1
|
Araujo-Castro M, Paja Fano M, González-Boillos M, Pascual-Corrales E, Martín Rojas-Marcos P, García-Cano A, Ruiz-Sanchez JG, Vicente A, Gómez-Hoyos E, Casterás A, Puig-Pérez A, García Sanz I, Recasens M, Barahona San Millan R, Picón César MJ, Díaz Guardiola P, Perdomo CM, Manjón-Miguélez L, Rebollo Román A, Robles Lázaro C, María Recio J, Morales-Ruiz M, Calatayud M, Jiménez López N, Meneses D, Sampedro Nuñez M, Mena Ribas E, Sanmartín Sánchez A, Gonzalvo Diaz C, Lamas C, Castillo Tous MD, Serrano J, Michalopoulou T, Tenés Rodrigo S, Roa Chamorro R, Jaén Aguila F, Moya Mateo EM, Gutiérrez-Medina S, Hanzu FA, Parra Ramírez P. Impact of primary aldosteronism on kidney function: results from the SPAIN-ALDO registry. J Hypertens 2024:00004872-990000000-00503. [PMID: 39051487 DOI: 10.1097/hjh.0000000000003813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
AIM To evaluate the impact of aldosterone excess on renal function in individuals with primary aldosteronism and to compare its evolution after surgery or mineralocorticoid receptor antagonist (MRA) treatment. METHODS A multicentre, retrospective cohort study of primary aldosteronism patients in follow-up in 36 Spanish tertiary hospitals, who underwent specific treatment for primary aldosteronism (MRA or adrenalectomy). RESULTS A total of 789 patients with primary aldosteronism were included, with a median age of 57.5 years and 41.8% being women. At primary aldosteronism diagnosis, the prevalence of chronic kidney disease (CKD) was 10.7% (n = 84), with 75% of cases classified as state 3a (n = 63). Primary aldosteronism patients with CKD had a longer duration of hypertension, a higher prevalence of type 2 diabetes, dyslipidaemia, cardiovascular events, hypokalaemia, and albuminuria. Unilateral adrenalectomy was performed in 41.8% of cases (n = 330), and 459 patients were treated with MRA. After a median follow-up of 30.7 months (range 13.3-68.4), there was a significant decline in the estimated glomerular filtration rate (eGFR) in operated patients and those receiving MRA. During follow-up, 24.4% of patients with CKD at the time of primary aldosteronism diagnosis had normalized renal function, and 39% of those with albuminuria had albuminuria remission. There were no differences in renal function or albuminuria regression between the two therapy groups. However, development of albuminuria was less common in operated than in medically treated patients (0 vs. 6.0%, P = 0.009). CONCLUSION CKD affects around 10% of the patients with primary aldosteronism, with a higher risk in individuals with long-term hypertension, type 2 diabetes, dyslipidaemia, cardiovascular events, hypokalaemia, and albuminuria. At short-term, both MRA and surgical treatment lead to a reduction of renal function, but adrenalectomy led to higher renal protection.
Collapse
Affiliation(s)
- Marta Araujo-Castro
- Endocrinology & Nutrition Department, Hospital Universitario Ramón y Cajal Madrid
- Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid
| | - Miguel Paja Fano
- Endocrinology & Nutrition Department, OSI Bilbao-Basurto, Hospital Universitario de Basurto
- University of the Basque Country UPV/EHU, Bilbao
| | | | | | | | - Ana García-Cano
- Biochemistry Department, Hospital Universitario Ramón y Cajal
| | | | - Almudena Vicente
- Endocrinology & Nutrition Department, Hospital Universitario de Toledo, Toledo
| | - Emilia Gómez-Hoyos
- Endocrinology & Nutrition Department, Hospital Universitario de Valladolid, Valladolid
| | - Anna Casterás
- Endocrinology & Nutrition Department, Hospital Vall d'Hebrón, Barcelona
| | - Albert Puig-Pérez
- Endocrinology & Nutrition Department, Hospital Vall d'Hebrón, Barcelona
| | - Iñigo García Sanz
- General & Digestive Surgery Department, Hospital Universitario de La Princesa, Madrid
| | - Mónica Recasens
- Endocrinology & Nutrition Department, Hospital De Girona Doctor Josep Trueta, Girona
| | | | - María José Picón César
- Endocrinology & Nutrition Department, Hospital Universitario Virgen de la Victoria de Málaga, IBIMA Málaga
- CIBEROBN
| | | | - Carolina M Perdomo
- Endocrinology & Nutrition Department, Clínica Universidad de Navarra, Pamplona
| | - Laura Manjón-Miguélez
- Endocrinology & Nutrition Department, Hospital Universitario Central de Asturias, Oviedo
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA)
| | | | - Cristina Robles Lázaro
- Endocrinology & Nutrition Department, Hospital Clínico Universitario de Salamanca, Salamanca
| | - José María Recio
- Endocrinology & Nutrition Department, Hospital Clínico Universitario de Salamanca, Salamanca
| | - Manuel Morales-Ruiz
- Biochemistry and Molecular Genetics Department-CDB, Hospital Clinic, IDIBAPS, CIBERehd, Barcelona
| | - María Calatayud
- Endocrinology & Nutrition Department, Hospital Doce de Octubre, Madrid
| | | | - Diego Meneses
- Endocrinology & Nutrition Department, Hospital Universitario La Paz
| | | | - Elena Mena Ribas
- Endocrinology & Nutrition Department, Hospital Universitario Son Espases, Islas Baleares
| | | | - Cesar Gonzalvo Diaz
- Endocrinology & Nutrition Department, Complejo Hospitalario Universitario de Albacete, Albacete
| | - Cristina Lamas
- Endocrinology & Nutrition Department, Complejo Hospitalario Universitario de Albacete, Albacete
| | | | - Joaquín Serrano
- Endocrinology & Nutrition Department, Hospital General Universitario de Alicante, Alicante
| | | | | | - Ricardo Roa Chamorro
- Internal Medicine Department, Hospital Universitario Virgen de las Nieves, Granada
| | - Fernando Jaén Aguila
- Internal Medicine Department, Hospital Universitario Virgen de las Nieves, Granada
| | | | | | - Felicia Alexandra Hanzu
- Endocrinology & Nutrition Department, Hospital Clinic, University of Barcelona, IDIPAS, Barcelona, Spain
| | | |
Collapse
|
2
|
Lu YC, Liu KL, Wu VC, Wang SM, Lin YH, Chueh SCJ, Wu KD, Su YR, Huang KH. Unilateral adrenalectomy in bilateral adrenal hyperplasia with primary aldosteronism. J Formos Med Assoc 2023; 122:393-399. [PMID: 36813699 DOI: 10.1016/j.jfma.2022.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 10/08/2022] [Accepted: 12/22/2022] [Indexed: 02/22/2023] Open
Abstract
PURPOSE Mineralocorticoid receptor antagonists are the first-line treatment for bilateral adrenal hyperplasia (BAH) with primary aldosteronism (PA), while unilateral adrenalectomy is the standard treatment for aldosterone-producing adenoma (APA). In this study, we investigated the outcomes of patients with BAH after unilateral adrenalectomy and compared them with those of patients with APA. METHODS From January 2010 to November 2018, 102 patients with a diagnosis of PA confirmed by adrenal vein sampling (AVS) and available NP-59 scans were enrolled. All patients underwent unilateral adrenalectomy based on the lateralization test results. We prospectively collected the clinical parameters over 12 months and compared the outcomes of BAH and APA. RESULTS A total of 102 patients were enrolled in this study: 20 (19.6%) had BAH and 82 (80.4%) had APA. Significant improvements in serum aldosterone-renin ratio (ARR), potassium level, and reduction of antihypertensive drugs were observed in both groups at 12 months after surgery (all p < 0.05). Patients with APA showed a significant decrease in blood pressure after surgery (p < 0.001) than those with BAH. Additionally, multivariate logistic regression analysis indicated that APA was associated with biochemical success (odds ratio: 4.32, p = 0.024) compared to BAH. CONCLUSION Patients with BAH had a higher failure rate in clinical outcomes, and APA was associated with biochemical success after unilateral adrenalectomy. However, significant improvements in ARR, hypokalemia, and a decreased use of antihypertensive drugs were noted in patients with BAH after surgery. Unilateral adrenalectomy is feasible and beneficial in selected patients, and could potentially serve as a treatment option.
Collapse
Affiliation(s)
- Yu-Cheng Lu
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kao-Lang Liu
- Department of Medical Imagine, National Taiwan University Hospital, Taipei, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shuo-Meng Wang
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yann-Rong Su
- Department of Urology, National Taiwan University BioMedical Park Hospital, Hsin-Chu, Taiwan
| | - Kuo-How Huang
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan; Department of Urology, National Taiwan University BioMedical Park Hospital, Hsin-Chu, Taiwan.
| | -
- TAIPAI, Taiwan Primary Aldosteronism Investigator
| |
Collapse
|
3
|
Lu YC, Liu KL, Wu VC, Wang SM, Lin YH, Chueh SCJ, Wu KD, Huang KH. Factors associated with renal function change after unilateral adrenalectomy in patients with primary aldosteronism. Int J Urol 2022; 29:831-837. [PMID: 35474521 DOI: 10.1111/iju.14905] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 03/31/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Decreased glomerular filtration rate has been reported in patients with primary aldosteronism after unilateral adrenalectomy. Glomerular hyperfiltration has been assumed to mask the preoperative subtle renal impairment. In this study, we investigated predictors for decreased estimated glomerular filtration rate after adrenalectomy in patients with primary aldosteronism. METHODS From January 2006 through September 2018, 328 patients with confirmatory diagnoses of primary aldosteronism received unilateral laparoscopic adrenalectomy and subsequent follow-up for 12 months. We prospectively collected related parameters of the clinical outcomes and renal function to identify predictors of renal function impairment at 12 months after surgery. RESULTS Patients were stratified into three groups by preoperative estimated glomerular filtration rate level: 144 (43.9%) with estimated glomerular filtration rate ≥90, 130 (39.6%) with estimated glomerular filtration rate within 60-89.9, and 54 (16.5%) with estimated glomerular filtration rate <60 mL/min/1.73 m2 . The estimated glomerular filtration rate decreased significantly at the 6th month and remained stable at the 12th month, postoperatively. Patients with estimated glomerular filtration rate ≥90 had better clinical outcome with 59.6% success rate (P = 0.006) among three groups. Multivariate logistic regression analysis indicated that preoperative estimated glomerular filtration rate (odds ratio 1.012, P = 0.02) and hypokalemia (odds ratio 2.018, P = 0.024) were associated with renal impairment at 12th month after adrenalectomy. Multivariate linear regression analysis revealed high preoperative estimated glomerular filtration rate (β = 0.261, P < 0.001), high preoperative systolic blood pressure (β = 0.168, P = 0.003), high level of microalbuminuria (β = 0.024, P = 0.001), and low level of serum potassium (β = -4.883, P = 0.007) were associated with estimated glomerular filtration rate percentage decline at 12th month after adrenalectomy. CONCLUSIONS Estimated glomerular filtration rate declined significantly after adrenalectomy in patients with estimated glomerular filtration rate ≥90. The study provided important information to identify primary aldosteronism patients with higher risk of estimated glomerular filtration rate decline after adrenalectomy and might help to adopt early interventions to improve the outcomes.
Collapse
Affiliation(s)
- Yu-Cheng Lu
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
| | - Kao-Lang Liu
- Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shuo-Meng Wang
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuo-How Huang
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
| | | |
Collapse
|
4
|
安 文, 闫 慧, 邓 正, 陈 芳, 欧 小, 金 红, 黄 薇. [Chronic kidney disease after adrenalectomy in a patient with primary aldosteronism]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2021; 53:1201-1204. [PMID: 34916706 PMCID: PMC8695166 DOI: 10.19723/j.issn.1671-167x.2021.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Indexed: 06/14/2023]
Abstract
We report one case of estimated glomerular filtration rate (eGFR) decline after taking unilateral adrenalectomy due to aldosterone adenoma. A 60-year-old male with 23-year history of hypertension was reported to the endocrinologist due to hypokalemia (serum potassium 3.01 mmol/L). Urine microalbumin/creatinine (ALB/CR) was 70.15 mg/g, serum creatinine was 82 μmol/L and eGFR was 89.79 mL/(min·1.73 m2). Random serum aldosterone was 172.2-203.5 ng/L, and random plasma rennin activity was 0-0.17 μg/(L·h). His captopril challenge test suggested that his aldosterone le-vels were suppressed by 8% (< 30%) and the adrenal enhanced computed tomography scan revealed a left adrenal tumor. The patient was diagnosed with primary hyperaldosteronism (PA), aldosterone adenoma and underwent left laparoscopic adrenalectomy. Histological examination confirmed adrenal cortical adenoma. One week after the operation, his serum creatinine was increased to 127 μmol/L compared with preoperative level; eGFR was 32.34 mL/(min·1.73 m2). His systolic blood pressure (SBP) was 110 mmHg and diastolic blood pressure (DBP) was 60 mmHg (hypotensive drugs discontinued), and serum potassium level was 5.22 mmol/L. At the end of the 2-year follow up, the serum creatinine of this patient remained at 109-158 μmol/L and eGFR fluctuated from 63.28-40.12 mL/(min·1.73 m2). PA is one of the most common causes of secondary hypertension. Several studies have reported renal function deterioration of PA patients after unilateral adrenalectomy, like the patient in this article. Age, preoperative plasma aldosterone concentration, albuminuria and preoperative potassium level might be significant predictors of a decrease in the eGFR. Growing evidence suggests that aldosterone could contribute to structural kidney damage, arterial injury and hemodynamic disorder. At the same time, patients with PA exhibit glomerular hyperfiltration and glomerular vascular hypertension, leading to the misinterpretation of renal function in PA patients as subtle kidney damage may be masked by the glomerular hyperfiltration before treatment. After a unilateral adrenalectomy, glomerular hyperfiltration by aldosterone excess is resolved and renal damage can be unmasked. In conclusion, kidney function deterioration after adrenalectomy can be detected in some patients with PA. Thus, accurate evaluation of kidney function in patients with PA may be essential, especially for those with preoperative risk factors for postoperative renal impairment. After unilateral adrenalectomy, close monitoring of renal function and adequate management are required for PA patients.
Collapse
Affiliation(s)
- 文成 安
- 北京市海淀医院,北京大学第三医院海淀院区内分泌科,北京 100080Department of Endocrinology, Beijing Haidian Hospital, Peking University Third Hospital (Haidian District), Beijing 100080, China
| | - 慧娴 闫
- 北京市海淀医院,北京大学第三医院海淀院区内分泌科,北京 100080Department of Endocrinology, Beijing Haidian Hospital, Peking University Third Hospital (Haidian District), Beijing 100080, China
| | - 正照 邓
- 北京大学第三医院内分泌科,北京 100191Department of Endocrinology, Peking University Third Hospital, Beijing 100191, China
| | - 芳 陈
- 北京市海淀医院,北京大学第三医院海淀院区内分泌科,北京 100080Department of Endocrinology, Beijing Haidian Hospital, Peking University Third Hospital (Haidian District), Beijing 100080, China
| | - 小虹 欧
- 北京市海淀医院,北京大学第三医院海淀院区内分泌科,北京 100080Department of Endocrinology, Beijing Haidian Hospital, Peking University Third Hospital (Haidian District), Beijing 100080, China
| | - 红心 金
- 北京市海淀医院,北京大学第三医院海淀院区内分泌科,北京 100080Department of Endocrinology, Beijing Haidian Hospital, Peking University Third Hospital (Haidian District), Beijing 100080, China
| | - 薇 黄
- 北京市海淀医院,北京大学第三医院海淀院区内分泌科,北京 100080Department of Endocrinology, Beijing Haidian Hospital, Peking University Third Hospital (Haidian District), Beijing 100080, China
| |
Collapse
|
5
|
Liu Y, Zhou L, Liu Z, Ma Y, Lin L, Zhu Y, Wang K, Li H. Higher Blood Urea Nitrogen and Urinary Calcium: New Risk Factors for Diabetes Mellitus in Primary Aldosteronism Patients. Front Endocrinol (Lausanne) 2020; 11:23. [PMID: 32117054 PMCID: PMC7011190 DOI: 10.3389/fendo.2020.00023] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 01/14/2020] [Indexed: 02/05/2023] Open
Abstract
Purpose: The aim of the study was to investigate the prevalence and risk factors of diabetes mellitus (DM) in primary aldosteronism (PA) patients. Methods: This case-control study enrolled 259 PA patients in West China Hospital, China from January 2016 to January 2019. Patients were divided into three groups: PA group, PA + impaired fasting glucose (IFG)/impaired glucose tolerance (IGT) group and PA + DM group. Clinical characteristics (like age and sex) and laboratory variables (like plasma aldosterone concentration and plasma renin activity) were compared between three groups. Univariate and multivariate logistic regression analyses were performed to determine risk factors for DM in PA patients. The association of random blood glucose with the above-mentioned factors were also investigated by Pearson correlation analyses. Nomogram model was developed to predict the probability of DM in PA patients. Results: 49 (18.9%) patients were diagnosed with DM and 22 (8.5%) with IFG/IGT in 259 PA patients. Apart from older age, male, higher body mass index, higher triglycerides and lower cholesterol, we found that higher blood urea nitrogen (BUN) and higher 24 h urinary calcium (Ca) might be potential new risk factors for dysglycemia. The nomogram model for DM in PA patients had a good predictive accuracy, with the area under the curve of receiver operating characteristic of 0.839 (95% CI 0.784-0.893). Conclusions: PA patients were more likely to have DM compared with general population. Apart from older age, overweight and dyslipidemia, higher BUN and excessive excretion of urinary Ca may also be the new potential risk factors for DM in PA patients.
Collapse
|
6
|
Onohara T, Takagi T, Yoshida K, Iizuka J, Okumi M, Kondo T, Ishida H, Tanabe K. Assessment of postoperative renal function after adrenalectomy in patients with primary aldosteronism. Int J Urol 2018; 26:229-233. [DOI: 10.1111/iju.13844] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 10/08/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Tadashi Onohara
- Department of Urology Tokyo Women's Medical University Tokyo Japan
| | - Toshio Takagi
- Department of Urology Tokyo Women's Medical University Tokyo Japan
| | - Kazuhiko Yoshida
- Department of Urology Tokyo Women's Medical University Tokyo Japan
| | - Junpei Iizuka
- Department of Urology Tokyo Women's Medical University Tokyo Japan
| | - Masayoshi Okumi
- Department of Urology Tokyo Women's Medical University Tokyo Japan
| | - Tsunenori Kondo
- Department of Urology Tokyo Women's Medical University Medical Center East Tokyo Japan
| | - Hideki Ishida
- Department of Urology Tokyo Women's Medical University Tokyo Japan
| | - Kazunari Tanabe
- Department of Urology Tokyo Women's Medical University Tokyo Japan
| |
Collapse
|
7
|
Kim IY, Park IS, Kim MJ, Han M, Rhee H, Seong EY, Lee DW, Lee SB, Kwak IS, Song SH, Chung HC. Change in kidney function after unilateral adrenalectomy in patients with primary aldosteronism: identification of risk factors for decreased kidney function. Int Urol Nephrol 2018; 50:1887-1895. [PMID: 29779118 DOI: 10.1007/s11255-018-1887-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 05/06/2018] [Indexed: 10/16/2022]
Abstract
PURPOSE Glomerular filtration rate (GFR) has been reported to decrease after unilateral adrenalectomy in patients with primary aldosteronism (PA). The aim of this study was to identify clinical predictors for decreased GFR after adrenalectomy in patients with PA. METHODS The records of 187 patients (98 patients with PA and 89 with non-PA adrenal disease) who were followed up for at least 6 months after unilateral adrenalectomy were retrospectively analyzed. Estimated GFR (eGFR) was investigated at 1, 3, and 6 months postoperatively. Preoperative risk factors for eGFR% decline at 1 month ([preoperative eGFR-eGFR at 1 month]/preoperative eGFR × 100) and postoperative CKD development were investigated. RESULTS The eGFR decreased significantly at 1 month and remained stable in the PA group. However, there were no significant changes in eGFR in the non-PA group over the 6-month period. In the PA group, a high preoperative eGFR and high aldosterone to renin ratio (ARR) were independently associated with eGFR% decline at 1 month. In patients with PA but without preoperative CKD (n = 68), a low preoperative eGFR and high ARR were independent risk factors for developing postoperative CKD. The best preoperative cut-off values of eGFR and ARR for predicting the development of postoperative CKD were ≤ 102 ml/min/1.73 m2 and ≥ 448 ng/dl:ng/ml/h, respectively. CONCLUSIONS Renal function deteriorated significantly after unilateral adrenalectomy in patients with PA. Clinicians must pay attention to postoperative renal function in PA patients at elevated risk of developing decreased kidney function.
Collapse
Affiliation(s)
- Il Young Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Gyeongsangnamdo, Republic of Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnamdo, Republic of Korea
| | - In Seong Park
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Gyeongsangnamdo, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Min Jeong Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Gyeongsangnamdo, Republic of Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnamdo, Republic of Korea
| | - Miyeun Han
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Gyeongsangnamdo, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Harin Rhee
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Gyeongsangnamdo, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Eun Young Seong
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Gyeongsangnamdo, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Dong Won Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Gyeongsangnamdo, Republic of Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnamdo, Republic of Korea
| | - Soo Bong Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Gyeongsangnamdo, Republic of Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Gyeongsangnamdo, Republic of Korea
| | - Ihm Soo Kwak
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Gyeongsangnamdo, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Sang Heon Song
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Gyeongsangnamdo, Republic of Korea. .,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea. .,Department of Internal Medicine, Pusan National University Hospital, Gudeok-ro 179, Seo-gu, Busan, 49241, Republic of Korea.
| | - Hyun Chul Chung
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea.
| |
Collapse
|