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Homorodean C, Ober MC, Spinu M, Olinic M, Tataru DA, Onea HL, Achim A, Lazar LF, Homorodean R, Deak B, Olinic DM. Outcomes after stenting of renal artery stenosis in patients with high-risk clinical features. Egypt Heart J 2024; 76:4. [PMID: 38236490 PMCID: PMC10796309 DOI: 10.1186/s43044-024-00435-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/11/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND In patients with renal artery stenosis, revascularization was seen as a mean to improve outcomes, but large studies failed to show significant benefit in general population. However, data on benefits of renal artery stenting in patients with high-risk features, such as rapidly declining renal function and cardiac destabilization syndromes, are limited, as they were excluded from trials. In this descriptive study, we aimed to evaluate short- and long-term outcomes in high-risk patients with renal artery stenosis, treated by angioplasty and stenting. We have retrospectively interrogated our local databases for renal artery percutaneous interventions; patients at high-risk (rapidly declining renal function; stable chronic renal failure and bilateral renal artery disease; severe hypertensive crisis) were selected for the current analysis. RESULTS Of 30 patients undergoing renal artery stenting, 18 patients were deemed "high-risk." On short term, good in-hospital control of hypertension and cardiac stabilization were obtained in all patients. Renal function improved significantly only in patients admitted with rapidly declining renal function, with significant creatinine level fall from median 3.98 mg/dL to 2.02 mg/dL, p = 0.023. However, for the whole group, creatinine change was non-significant (- 0.12 mg/dL, p = NS). On the long term, five patients (27.8%) ended-up on chronic hemodialysis and six patients died (33.3%) after a median of 20 months. No death occurred during the first year after the procedure. CONCLUSIONS Percutaneous procedures are feasible and safe in patients with high-risk renal artery stenosis, especially in those with rapidly declining renal function, probably saving some of them from the immediate need for renal replacement therapy, but long-term results are negatively influenced by the precarious general and cardio-vascular status of these patients and by the pre-existing significant renal parenchymal disease, non-related to the renal artery stenosis.
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Affiliation(s)
- Calin Homorodean
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
| | - Mihai Claudiu Ober
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania.
| | - Mihail Spinu
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
| | - Maria Olinic
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
| | - Dan-Alexandru Tataru
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
| | - Horea Laurentiu Onea
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
| | - Alexandru Achim
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
| | - Leontin Florin Lazar
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
| | - Romana Homorodean
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
| | - Balasz Deak
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
| | - Dan Mircea Olinic
- Medical Clinic No. 1, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Cluj, Romania
- Cluj County Emergency Clinical Hospital, 3-5, Clinicilor Street, 400006, Cluj-Napoca, Cluj, Romania
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Bhalla V, Textor SC, Beckman JA, Casanegra AI, Cooper CJ, Kim ESH, Luther JM, Misra S, Oderich GS. Revascularization for Renovascular Disease: A Scientific Statement From the American Heart Association. Hypertension 2022; 79:e128-e143. [PMID: 35708012 DOI: 10.1161/hyp.0000000000000217] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Renovascular disease is a major causal factor for secondary hypertension and renal ischemic disease. However, several prospective, randomized trials for atherosclerotic disease failed to demonstrate that renal revascularization is more effective than medical therapy for most patients. These results have greatly reduced the generalized diagnostic workup and use of renal revascularization. Most guidelines and review articles emphasize the limited average improvement and fail to identify those clinical populations that do benefit from revascularization. On the basis of the clinical experience of hypertension centers, specialists have continued selective revascularization, albeit without a summary statement by a major, multidisciplinary, national organization that identifies specific populations that may benefit. In this scientific statement for health care professionals and the public-at-large, we review the strengths and weaknesses of randomized trials in revascularization and highlight (1) when referral for consideration of diagnostic workup and therapy may be warranted, (2) the evidence/rationale for these selective scenarios, (3) interventional and surgical techniques for effective revascularization, and (4) areas of research with unmet need.
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Stanley JC. Renal Artery Occlusive Disease, Renin-Angiotensin-Aldosterone, Inflammation and Refractory Arterial Hypertension, A Half-Century’s Perspective. J Vasc Surg 2022; 76:46-52. [DOI: 10.1016/j.jvs.2022.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 02/19/2022] [Indexed: 10/18/2022]
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Textor SC. Mortality After Renal Artery Revascularization. Am J Hypertens 2021; 34:795-798. [PMID: 33609351 DOI: 10.1093/ajh/hpab039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 02/17/2021] [Indexed: 12/31/2022] Open
Affiliation(s)
- Stephen C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
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Khan Z, Tolia S, Sanam K, Gholkar G, Zughaib M, Naik S, Zughaib M. Is there still a role for renal artery stenting in the management of renovascular hypertension - A single-center experience and where do we stand? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:202-206. [PMID: 29934065 DOI: 10.1016/j.carrev.2018.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 05/20/2018] [Accepted: 06/08/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Renal artery (RA) stenosis has been implicated in the pathophysiological mechanism for resistant hypertension. Despite the increasingly diagnosed frequency of hemodynamically significant lesions, the value of RA revascularization remains controversial. Our group had previously demonstrated significant blood pressure (BP) reduction in a retrospective cohort of appropriately selected patients undergoing RA stenting up to 18-months of follow-up. We herein present long-term clinical outcomes data 5-years post revascularization on 26 subjects who continued follow-up at our institution. METHODS Retrospective analysis was performed on subjects who underwent RA stenting at our institution for hemodynamically significant (≥70%) RA stenosis and systolic hypertension on ≥3 antihypertensive agents. Clinical outcome data for systolic blood pressure (SBP), diastolic blood pressure (DBP), creatinine level and number of antihypertensive drugs was assessed prior to and then later at 6-12 months and 3-5 years post RA stenting. RESULTS Mean age was 69 ± 9 years; 27% (7/26) were male. Median follow-up was 5.1 years. Blood pressure reduction was sustained at long-term follow-up (135/70 ± 18/11 mmHg) compared to initial reduction noted at 6-months (136/69 ± 16/8 mmHg; p ≤0.01 for both) and from baseline (162/80 ± 24/18 mmHg; p ≤0.001 for both). The number of antihypertensive agents also decreased from 4.1 ± 1.0 to 2.7 ± 2.1 (p = 0.002) at 6-months and was sustained at long-term follow-up, 3.4 ± 1.2 (p = 0.03) with no difference in renal function between short- and long-term follow-up compared to baseline. CONCLUSIONS This study shows sustained benefit of RA stenting in BP reduction in an appropriately selected cohort with significant stenosis ≥70% and uncontrolled hypertension on multiple medications on long-term follow-up.
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Affiliation(s)
- Zubair Khan
- Providence-Providence Park Hospital, Southfield, Michigan, USA.
| | - Sunit Tolia
- Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Kumar Sanam
- Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Gunjan Gholkar
- Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Marc Zughaib
- Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Sunil Naik
- Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Marcel Zughaib
- Providence-Providence Park Hospital, Southfield, Michigan, USA
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Sag AA, Afsar B, Kanbay M. Renal artery intervention utilizing carbon dioxide angiography. Clin Kidney J 2017; 10:776-777. [PMID: 29225806 PMCID: PMC5716060 DOI: 10.1093/ckj/sfx095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 07/16/2017] [Indexed: 11/19/2022] Open
Abstract
Carbon dioxide angiography is an established non-nephrotoxic option for imaging of the infradiaphragmatic arteries and veins. Safe performance of the technique once required a somewhat cumbersome system, however, recent innovations have simplified implementation and expanded the user base for this technique. As such, patient access has also increased. In this issue, Hameed et al. provide initial feasibility data regarding carbon dioxide angiography and renal denervation therapy. This experience may be translated into future renovascular interventions in patients with limited renal reserve.
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Affiliation(s)
- Alan A Sag
- Division of Interventional Radiology, Department of Radiology, Koc University School of Medicine, Istanbul, Turkey
| | - Baris Afsar
- Division of Nephrology, Department of Medicine, Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
- Correspondence and offprint requests to: Mehmet Kanbay; E-mail: ,
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Saeed A, Fortuna EN, Jensen G. Split renal function in patients with unilateral atherosclerotic renal artery stenosis-effect of renal angioplasty. Clin Kidney J 2017; 10:496-502. [PMID: 28852489 PMCID: PMC5569696 DOI: 10.1093/ckj/sfx052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 05/05/2017] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To evaluate the effect of percutaneous transluminal renal angioplasty (PTRA) on split renal function (SRF) in patients with unilateral atherosclerotic renal artery stenosis (ARAS). METHODS We performed a retrospective analysis of all consecutively examined patients at our centre with significant ARAS undergoing PTRA during 2002-07. A significant ARAS was defined as a lesion with a trans-stenotic mean arterial pressure gradient of at least 10 mmHg or a diameter stenosis >50% on angiography. Ambulatory (24 h) systolic and diastolic blood pressure (ASBP and ADBP, respectively) and calculated SRF using 99mTc-DTPA renal scintigraphy were evaluated before (baseline) and 4 weeks after PTRA. RESULTS ASBP and ADBP were significantly lower 4 weeks after PTRA compared with baseline levels. Although total estimated glomerular filtration rate (eGFR; four-variable Modification of Diet in Renal Disease equation) had not changed by PTRA, analysis of SRF showed significantly increased eGFR in stenotic kidneys and a comparable reduction in eGFR in non-stenotic kidneys 4 weeks after PTRA. CONCLUSIONS In patients with unilateral ARAS, PTRA significantly improved eGFR in stenotic kidneys and decreased filtration in contralateral, non-stenotic kidneys. These potentially beneficial effects may not be apparent when total renal function remains stable. The clinical significance of these findings needs to be evaluated further.
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Affiliation(s)
- Aso Saeed
- Institute of Medicine, Department of Molecular and Clinical Medicine/Nephrology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Elzbieta Nowakowska- Fortuna
- Institute of Medicine, Department of Molecular and Clinical Medicine/Nephrology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gert Jensen
- Institute of Medicine, Department of Molecular and Clinical Medicine/Nephrology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Sag AA, Kanbay M. Revisiting angioplasty for renovascular hypertension. Clin Kidney J 2017; 10:494-495. [PMID: 28852488 PMCID: PMC5570010 DOI: 10.1093/ckj/sfx065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 05/29/2017] [Indexed: 11/26/2022] Open
Abstract
Following contemporary trends in arterial endovascular therapy of the lower extremities, recent major trials in anti-hypertensive renovascular revascularization have focused on outcomes after primary stenting of the renal artery. Angioplasty-only therapy has not been studied in a major trial since the year 2000. As such, the current study by Saeed et al. presents an updated data set on the technique with one unique aspect: patients underwent post-procedural physiologic scintigraphy to document the effects of unilateral intervention in patients with two kidneys. Although these physiologic changes should not supersede the clinically relevant outcome of blood pressure reduction (which was also accomplished in this study albeit to a modest but statistically significant degree), the physiologic consequences of unilateral intervention are elegantly presented in this short-term follow-up study. Furthermore, while current renovascular intervention is trending towards treatment of global renal ischemia (i.e. bilateral renal artery stenosis or renal artery stenosis in a congenitally or acquired solitary functional kidney scenario), the current study provides a useful data set for reference in guiding future renovascular revascularization studies and treatment algorithms.
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Affiliation(s)
- Alan A Sag
- Department of Radiology, Koc University School of Medicine, Istanbul, Turkey
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
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Hameed MA, Freedman JS, Watkin R, Ganeshan A, Dasgupta I. Renal denervation using carbon dioxide renal angiography in patients with uncontrolled hypertension and moderate to severe chronic kidney disease. Clin Kidney J 2017; 10:778-782. [PMID: 29225807 PMCID: PMC5716068 DOI: 10.1093/ckj/sfx066] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 05/31/2017] [Indexed: 12/18/2022] Open
Abstract
Background Chronic kidney disease (CKD) is the most common cause of secondary hypertension. More than half of the patients have uncontrolled hypertension (≥140/90 mmHg on three or more antihypertensive agents at optimum doses). Renal sympathetic denervation (RSDN) has been shown to reduce blood pressure (BP) in patients with resistant hypertension. Although patients with CKD have high sympathetic drive, all major clinical trials have excluded patients with estimated glomerular filtration rates (eGFRs) <45 mL/min/1.73m2 for risk of contrast-induced nephropathy. Methods In this pilot study, carbon dioxide (CO2) was used as the sole contrast agent to carry out renal angiography and RSDN in patients with moderate to severe CKD (eGFR 15–44 mL/min/1.73m2) and uncontrolled hypertension. Results Eleven patients (eight males) underwent RSDN. The median age was 57 years [interquartile range (IQR) 49–66]. The median number of antihypertensives being taken at baseline was 4 (IQR 3–4). No statistically significant difference was observed in serum creatinine in the serial follow-ups until at 6 months[median difference 0.25 mg/dL (IQR 0.09–0.53); P = 0.008]. There was a non-significant reduction in median clinic BP from baseline to 6 months [−14 mmHg (IQR −24–5)] and a significant increase in daytime ambulatory systolic BP [7 mmHg (IQR −2–12); P= 0.045]. A trend towards a serial reduction in albuminuria was observed. Procedure-related complications included a groin haematoma (n = 1) and reported flank (n = 1) and groin pain (n = 1). Conclusions This pilot study shows that CO2 renal angiography can be used to perform RSDN in patients with significant renal impairment and may lead to associated improvements in clinic BP and albuminuria.
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Affiliation(s)
- Mohammed Awais Hameed
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Heart of England NHS Foundation Trust, Birmingham, UK
| | | | | | - Arul Ganeshan
- Heart of England NHS Foundation Trust, Birmingham, UK
| | - Indranil Dasgupta
- Heart of England NHS Foundation Trust, Birmingham, UK.,Aston Medical School, Aston University, Birmingham, UK
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Sag AA, Sal O, Kilic Y, Onal EM, Kanbay M. The concept of crosstalk-directed embryological target mining and its application to essential hypertension treatment failures. J Clin Hypertens (Greenwich) 2017; 19:530-533. [PMID: 28224730 DOI: 10.1111/jch.12978] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 11/14/2016] [Accepted: 11/19/2016] [Indexed: 01/11/2023]
Abstract
This review aims to introduce the novel concept of embryological target mining applied to interorgan crosstalk network genesis, and applies embryological target mining to multidrug-resistant essential hypertension (a prototype, complex, undertreated, multiorgan systemic syndrome) to uncover new treatment targets and critique why existing strategies fail. Briefly, interorgan crosstalk pathways represent the next frontier for target mining in molecular medicine. This is because stereotyped stepwise organogenesis presents a unique opportunity to infer interorgan crosstalk pathways that may be crucial to discovering novel treatment targets. Insights gained from this review will be applied to patient management in a clinician-directed fashion.
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Affiliation(s)
- Alan Alper Sag
- Division of Interventional Radiology, Department of Radiology, Koç University School of Medicine, Istanbul, Turkey
| | - Oguzhan Sal
- School of Medicine, Koç University, Istanbul, Turkey
| | - Yagmur Kilic
- School of Medicine, Koç University, Istanbul, Turkey
| | | | - Mehmet Kanbay
- Division of Nephrology, Department of Internal Medicine, Koç University School of Medicine, Istanbul, Turkey
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Afsar B, Sag AA, Yalcin CE, Kaya E, Siriopol D, Goldsmith D, Covic A, Kanbay M. Brain-kidney cross-talk: Definition and emerging evidence. Eur J Intern Med 2016; 36:7-12. [PMID: 27531628 DOI: 10.1016/j.ejim.2016.07.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 07/29/2016] [Accepted: 07/31/2016] [Indexed: 12/12/2022]
Abstract
Cross-talk is broadly defined as endogenous homeostatic signaling between vital organs such as the heart, kidneys and brain. Kidney-brain cross-talk remains an area with excitingly few publications despite its purported clinical relevance in the management of currently undertreated conditions such as resistant hypertension. Therefore, this review aims to establish an organ-specific definition for kidney-brain cross-talk and review the available and forthcoming literature on this topic.
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Affiliation(s)
- Baris Afsar
- Department of Medicine, Division of Nephrology, Konya Numune State Hospital, Konya, Turkey
| | - Alan A Sag
- Department of Radiology, Division of Interventional Radiology, Koc University School of Medicine, Istanbul, Turkey
| | - Can Ege Yalcin
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Eren Kaya
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Dimitrie Siriopol
- Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. PARHON' University Hospital, and 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - David Goldsmith
- Renal and Transplantation Department, Guy's and St Thomas' Hospitals, London, UK
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center, 'C.I. PARHON' University Hospital, and 'Grigore T. Popa' University of Medicine, Iasi, Romania
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey.
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Affiliation(s)
| | - Sanjay Misra
- Interventional Radiology, Mayo Clinic, Rochester, Minnesota
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