1
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Oruc A, Sumnu A, Turkmen A, Basturk T, Cebeci E, Turgutalp K, Cetinkaya H, Uzerk Kibar M, Seyahi N, Tatar E, Ergul M, Derici Ü, Aylı MD, Pınar M, Bakar B, Kazancıoglu R, Yıldız A, Dirim AB, Yılmaz Z, Turkmen K, Tunca O, Koc M, Kutlay S, Micozkadıoglu H, Azak A, Boztepe B, Ustundag S, Şafak Ozturk S, Unsal A, Karadag S, Sahin G, Yenigun EC, Eren N, Gullulu M, Gursu M, Ozturk S. Immunosuppressive treatment results in patients with primary IgA nephropathy in Turkiye; the data from TSN-GOLD working group. Ren Fail 2024; 46:2341787. [PMID: 38637275 PMCID: PMC11028022 DOI: 10.1080/0886022x.2024.2341787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/06/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Immunoglobulin A (IgA) nephropathy (IgAN) treatment consists of maximal supportive care and, for high-risk individuals, immunosuppressive treatment (IST). There are conflicting results regarding IST. Therefore, we aimed to investigate IST results among IgAN patients in Turkiye. METHOD The data of 1656 IgAN patients in the Primary Glomerular Diseases Study of the Turkish Society of Nephrology Glomerular Diseases Study Group were analyzed. A total of 408 primary IgAN patients treated with IST (65.4% male, mean age 38.4 ± 12.5 years, follow-up 30 (3-218) months) were included and divided into two groups according to treatment protocols (isolated corticosteroid [CS] 70.6% and combined IST 29.4%). Treatment responses, associated factors were analyzed. RESULTS Remission (66.7% partial, 33.7% complete) was achieved in 74.7% of patients. Baseline systolic blood pressure, mean arterial pressure, and proteinuria levels were lower in responsives. Remission was achieved at significantly higher rates in the CS group (78% vs. 66.7%, p = 0.016). Partial remission was the prominent remission type. The remission rate was significantly higher among patients with segmental sclerosis compared to those without (60.4% vs. 49%, p = 0.047). In the multivariate analysis, MEST-C S1 (HR 1.43, 95% CI 1.08-1.89, p = 0.013), MEST-C T1 (HR 0.68, 95% CI 0.51-0.91, p = 0.008) and combined IST (HR 0.66, 95% CI 0.49-0.91, p = 0.009) were found to be significant regarding remission. CONCLUSION CS can significantly improve remission in high-risk Turkish IgAN patients, despite the reliance on non-quantitative endpoints for favorable renal outcomes. Key predictors of remission include baseline proteinuria and specific histological markers. It is crucial to carefully weigh the risks and benefits of immunosuppressive therapy for these patients.
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Affiliation(s)
- Aysegul Oruc
- Department of Nephrology, Bursa Uludag University Faculty of Medicine, Bursa, Turkiye
| | - Abdullah Sumnu
- Department of Nephrology, Medipol University Faculty of Medicine, Istanbul, Turkiye
| | - Aydın Turkmen
- Department of Nephrology, Istanbul University Faculty of Medicine, Istanbul, Turkiye
| | - Taner Basturk
- Department of Nephrology, University of Health Sciences, Etfal Hamidiye Training and Research Hospital, Istanbul, Turkiye
| | - Egemen Cebeci
- Department of Nephrology, Istanbul Provincial Directorate of Health Istanbul Haseki Training and Research Hospital, Istanbul, Turkiye
| | - Kenan Turgutalp
- Department of Nephrology, Mersin University Faculty of Medicine, Training and Educational Hospital, Mersin, Turkiye
| | - Hakkı Cetinkaya
- Department of Nephrology, University of Health Sciences, Sultan 2. Abdülhamid Han Training and Research Hospital, Istanbul, Turkiye
| | - Müge Uzerk Kibar
- Department of Nephrology, Health Ministry of Turkiye Republic Ankara Bilkent City Hospital, Ankara, Turkiye
| | - Nurhan Seyahi
- Department of Nephrology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkiye
| | - Erhan Tatar
- Department of Nephrology, Izmir Provincial Directorate of Health Bozyaka Education and Research Hospital, Izmir, Turkiye
| | - Metin Ergul
- Department of Nephrology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkiye
| | - Ülver Derici
- Department of Nephrology, Faculty of Medicine, Gazi University, Ankara, Turkiye
| | - Mehmet Deniz Aylı
- Department of Nephrology, Mınıstry Of Health Dıskapı Yıldırım Beyazıt Traınıng And Research Hospıtal, Ankara, Turkiye
| | - Musa Pınar
- Department of Nephrology, Faculty of Medicine, Sakarya University, Sakarya, Turkiye
| | - Betül Bakar
- Department of Nephrology, Ankara Provincial Health Directorate Ankara Training and Research Hospital, Ankara, Turkiye
| | - Rümeyza Kazancıoglu
- Department of Nephrology, Faculty of Medicine, Bezmialem Vakif Univeristy, Istanbul, Turkiye
| | - Abdülmecit Yıldız
- Department of Nephrology, Bursa Uludag University Faculty of Medicine, Bursa, Turkiye
| | - Ahmet Burak Dirim
- Department of Nephrology, Istanbul Provincial Health Directorate ˙Istanbul Bakirköy Dr. Sadi Konuk Education And Research Hospital, Istanbul, Turkiye
| | - Zülfükar Yılmaz
- Department of Nephrology, Dicle University Faculty of Medicine, Diyarbakır, Turkiye
| | - Kültigin Turkmen
- Department of Nephrology, Faculty of Medicine Hospital, Necmettin Erbakan University Meram, Konya, Turkiye
| | - Onur Tunca
- Department of Nephrology, Faculty of Medicine, Afyonkarahisar University of Health Sciences, Afyonkarahisar, Turkiye
| | - Mehmet Koc
- Department of Nephrology, Faculty of Medicine, Marmara University, Istanbul, Turkiye
| | - Sim Kutlay
- Department of Nephrology, Faculty of Medicine, Ankara University, Ankara, Turkiye
| | - Hasan Micozkadıoglu
- Department of Nephrology, Baskent University Faculty of Medicine, Dr. Turgut Noyan Adana Application and Research Hospital, Adana, Turkiye
| | - Alper Azak
- Department of Nephrology, Balikesir Provincial Health Directorate Atatürk City Hospital, Balıkesir, Turkiye
| | - Burcu Boztepe
- Department of Nephrology, Istanbul Provincial Health Directorate Haydarpasa Numune Traınıng And Research Hospıtal, Istanbul, Turkiye
| | - Sedat Ustundag
- Department of Nephrology, Faculty of Medicine, Trakya University, Edirne, Turkiye
| | - Seda Şafak Ozturk
- Department of Nephrology, Istanbul University Faculty of Medicine, Istanbul, Turkiye
| | - Abdulkadir Unsal
- Department of Nephrology, University of Health Sciences, Etfal Hamidiye Training and Research Hospital, Istanbul, Turkiye
| | - Serhat Karadag
- Department of Nephrology, Istanbul Provincial Directorate of Health Istanbul Haseki Training and Research Hospital, Istanbul, Turkiye
| | - Gülizar Sahin
- Department of Nephrology, University of Health Sciences, Sultan 2. Abdülhamid Han Training and Research Hospital, Istanbul, Turkiye
| | - Ezgi Coşgun Yenigun
- Department of Nephrology, Ankara Provincial Health Directorate Ankara Training and Research Hospital, Ankara, Turkiye
| | - Necmi Eren
- Department of Nephrology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkiye
| | - Mustafa Gullulu
- Department of Nephrology, Bursa Uludag University Faculty of Medicine, Bursa, Turkiye
| | - Meltem Gursu
- Department of Nephrology, Faculty of Medicine, Bezmialem Vakif Univeristy, Istanbul, Turkiye
| | - Savaş Ozturk
- Department of Nephrology, Istanbul University Faculty of Medicine, Istanbul, Turkiye
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2
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Zhang Y, Zhang H. Current understanding and new insights in the treatment of IgA nephropathy. Nephrology (Carlton) 2024. [PMID: 38958055 DOI: 10.1111/nep.14340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 06/24/2024] [Indexed: 07/04/2024]
Abstract
IgA nephropathy (IgAN) is the most common primary glomerulonephritis worldwide, and almost all patients are at risk of progression to end-stage kidney disease within their lifetime. The mechanisms responsible for the presentation and development of IgAN are required for the development of highly targeted therapies for this disease. In this review, we first demonstrate the current treatment strategy of IgAN recommended by the 2021 KDIGO guideline. Then, we update the new insights into disease pathogenesis based on the well acknowledged 'multiple-hit hypothesis' and provide the potential therapeutic targets involved in the upstream production of pathogenic IgA1 and the downstream complement activation. Finally, the recent large randomized controlled trials focusing on these novel targets have been summarized, among which Nefecon and Sparsentan have received approval and Telitacicept have been used off-label for IgAN. In the future, emerging treatment approaches for IgAN is likely to evolve, which will signify a shift in the management of the IgAN from traditional immunosuppressive approaches to an era of targeted treatment based on the understanding of the pathogenic mechanisms.
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Affiliation(s)
- Yuemiao Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
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3
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Hu Y, Zhang Y. Targeted release of budesonide in primary IgA nephropathy. Lancet 2024; 403:2785. [PMID: 38944524 DOI: 10.1016/s0140-6736(24)00794-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 04/12/2024] [Indexed: 07/01/2024]
Affiliation(s)
- Yitong Hu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China; Peking University Health Science Center, Beijing, China
| | - Yuemiao Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.
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El Karoui K, Fervenza FC, De Vriese AS. Treatment of IgA Nephropathy: A Rapidly Evolving Field. J Am Soc Nephrol 2024; 35:103-116. [PMID: 37772889 PMCID: PMC10786616 DOI: 10.1681/asn.0000000000000242] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 09/19/2023] [Indexed: 09/30/2023] Open
Abstract
The pivotal event in the pathophysiology of IgA nephropathy is the binding of circulating IgA-containing immune complexes to mesangial cells, with secondary glomerular and tubulointerstitial inflammation and fibrosis. The paramount difficulty in the management of IgA nephropathy is the heterogeneity in its clinical presentation and prognosis, requiring an individualized treatment approach. Goal-directed supportive care remains the bedrock of therapy for all patients, regardless of risk of progression. Sodium-glucose transporter 2 inhibitors and sparsentan should be integral to contemporary supportive care, particularly in patients with chronic kidney damage. Pending the development of reliable biomarkers, it remains a challenge to identify patients prone to progression due to active disease and most likely to derive a net benefit from immunosuppression. The use of clinical parameters, including the degree of proteinuria, the presence of persistent microscopic hematuria, and the rate of eGFR loss, combined with the mesangial hypercellularity, endocapillary hypercellularity, segmental glomerulosclerosis, tubular atrophy/interstitial fibrosis, crescents score, is currently the best approach. Systemic glucocorticoids are indicated in high-risk patients, but the beneficial effects wane after withdrawal and come at the price of substantial treatment-associated toxicity. Therapies with direct effect on disease pathogenesis are increasingly becoming available. While targeted-release budesonide has garnered the most attention, anti-B-cell strategies and selective complement inhibition will most likely prove their added value. We propose a comprehensive approach that tackles the different targets in the pathophysiology of IgA nephropathy according to their relevance in the individual patient.
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Affiliation(s)
- Khalil El Karoui
- Department of Nephrology, Hôpital Tenon, Sorbonne Université, Paris, France
| | | | - An S. De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium
- Department of Internal Medicine, Ghent University, Ghent, Belgium
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5
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Yeo SC, Barratt J. The contribution of a proliferation-inducing ligand (APRIL) and other TNF superfamily members in pathogenesis and progression of IgA nephropathy. Clin Kidney J 2023; 16:ii9-ii18. [PMID: 38053976 PMCID: PMC10695512 DOI: 10.1093/ckj/sfad200] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Indexed: 12/07/2023] Open
Abstract
Advances in our understanding of the pathogenesis of immunoglobulin A nephropathy (IgAN) have led to the identification of novel therapeutic targets and potential disease-specific treatments. Specifically, a proliferation-inducing ligand (APRIL) has been implicated in the pathogenesis of IgAN, mediating B-cell dysregulation and overproduction of pathogenic galactose-deficient IgA1 (Gd-IgA1). Animal and clinical studies support the involvement of APRIL in the pathogenesis and progression of IgAN. An elevated level of APRIL is found in IgAN when compared with controls, which correlates with the level of Gd-IgA1 and associates with more severe disease presentation and worse outcomes. Conversely, anti-APRIL therapy reduces pathogenic Gd-IgA1 and IgA immune complex formation and ameliorates the severity of kidney inflammation and injury. Genome-wide association studies in IgAN have identified TNFSF13 and TNFRSF13B, a cytokine ligand-receptor gene pair encoding APRIL and its receptor, respectively, as risk susceptibility loci in IgAN, further supporting the causal role of the APRIL signalling pathway in IgAN. Several novel experimental agents targeting APRIL, including atacicept, telitacicept, zigakibart and sibeprenlimab, are currently under investigation as potential therapies in IgAN. Preliminary results suggest that these agents are well-tolerated, and reduce levels of Gd-IgA1, with corresponding improvement in proteinuria. Further studies are ongoing to confirm the safety and efficacy of anti-APRIL approaches as an effective therapeutic strategy in IgAN.
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Affiliation(s)
- See Cheng Yeo
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
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6
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Stamellou E, Seikrit C, Tang SCW, Boor P, Tesař V, Floege J, Barratt J, Kramann R. IgA nephropathy. Nat Rev Dis Primers 2023; 9:67. [PMID: 38036542 DOI: 10.1038/s41572-023-00476-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 12/02/2023]
Abstract
IgA nephropathy (IgAN), the most prevalent primary glomerulonephritis worldwide, carries a considerable lifetime risk of kidney failure. Clinical manifestations of IgAN vary from asymptomatic with microscopic or intermittent macroscopic haematuria and stable kidney function to rapidly progressive glomerulonephritis. IgAN has been proposed to develop through a 'four-hit' process, commencing with overproduction and increased systemic presence of poorly O-glycosylated galactose-deficient IgA1 (Gd-IgA1), followed by recognition of Gd-IgA1 by antiglycan autoantibodies, aggregation of Gd-IgA1 and formation of polymeric IgA1 immune complexes and, lastly, deposition of these immune complexes in the glomerular mesangium, leading to kidney inflammation and scarring. IgAN can only be diagnosed by kidney biopsy. Extensive, optimized supportive care is the mainstay of therapy for patients with IgAN. For those at high risk of disease progression, the 2021 KDIGO Clinical Practice Guideline suggests considering a 6-month course of systemic corticosteroid therapy; however, the efficacy of systemic steroid treatment is under debate and serious adverse effects are common. Advances in understanding the pathophysiology of IgAN have led to clinical trials of novel targeted therapies with acceptable safety profiles, including SGLT2 inhibitors, endothelin receptor blockers, targeted-release budesonide, B cell proliferation and differentiation inhibitors, as well as blockade of complement components.
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Affiliation(s)
- Eleni Stamellou
- Department of Nephrology, School of Medicine, University of Ioannina, Ioannina, Greece
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Claudia Seikrit
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Sydney C W Tang
- Division of Nephrology, Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Peter Boor
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
- Department of Pathology, RWTH Aachen University, Aachen, Germany
| | - Vladimir Tesař
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Jürgen Floege
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Rafael Kramann
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany.
- Department of Internal Medicine, Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, Netherlands.
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7
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Kohan DE, Barratt J, Heerspink HJ, Campbell KN, Camargo M, Ogbaa I, Haile-Meskale R, Rizk DV, King A. Targeting the Endothelin A Receptor in IgA Nephropathy. Kidney Int Rep 2023; 8:2198-2210. [PMID: 38025243 PMCID: PMC10658204 DOI: 10.1016/j.ekir.2023.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/09/2023] [Accepted: 07/24/2023] [Indexed: 12/01/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis worldwide and carries a substantial risk of kidney failure. New agency-approved therapies, either specifically for IgAN or for chronic kidney disease (CKD) in general, hold out hope for mitigating renal deterioration in patients with IgAN. The latest addition to this therapeutic armamentarium targets the endothelin-A receptor (ETAR). Activation of ETAR on multiple renal cell types elicits a host of pathophysiological effects, including vasoconstriction, cell proliferation, inflammation, apoptosis, and fibrosis. Blockade of ETAR is renoprotective in experimental models of IgAN and reduces proteinuria in patients with IgAN. This review discusses the evidence supporting the use of ETAR blockade in IgAN as well as addressing the potential role for this class of agents among the current and emerging therapies for treating this disorder.
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Affiliation(s)
- Donald E. Kohan
- Division of Nephrology, University of Utah Health, Salt Lake City, Utah, USA
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Kirk N. Campbell
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Ike Ogbaa
- Chinook Therapeutics, Seattle, Washington, USA
| | | | - Dana V. Rizk
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrew King
- Chinook Therapeutics, Seattle, Washington, USA
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8
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Rovin BH. IgA nephropathy and glucocorticoids-a limbo dance? Kidney Int 2023; 103:673. [PMID: 36948770 DOI: 10.1016/j.kint.2023.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/23/2023] [Indexed: 03/24/2023]
Affiliation(s)
- Brad H Rovin
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
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