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Yang Q, Zou Y, Lang Y, Yang J, Wu Y, Xiao X, Qin C, Zhao Y, Liu F. Estimated small dense low-density lipoprotein-cholesterol and the risk of kidney and cardiovascular outcomes in diabetic kidney disease. Ren Fail 2024; 46:2369701. [PMID: 38952279 PMCID: PMC467091 DOI: 10.1080/0886022x.2024.2369701] [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: 07/31/2023] [Accepted: 06/13/2024] [Indexed: 07/03/2024] Open
Abstract
AIMS This study aimed to investigate the correlations between estimated small dense low-density lipoprotein-cholesterol (esd-LDL-c) and the development of end-stage kidney disease (ESKD), cardiovascular mortality, and all-cause mortality in individuals with diabetic kidney disease (DKD) or diabetes mellitus (DM) concomitant chronic kidney disease (CKD). METHODS We analyzed the data from a biopsy-proven DKD cohort conducted at West China Hospital of Sichuan University between 2009 and 2021 (the DKD cohort) and participants with DM and CKD in the National Health and Nutrition Examination Survey (NHANES) 2011-2014 (the NHANES DM-CKD cohort). Cox regression analysis was also used to estimate associations between esd-LDL-c and the incidence of ESKD, cardiovascular mortality, and all-cause mortality. RESULTS There were 175 ESKD events among 338 participants in the DKD cohort. Patients were divided into three groups based on esd-LDL-c tertiles (T1 < 33.7 mg/dL, T2 ≥ 33.7 mg/dL to <45.9 mg/dL, T3 ≥ 45.9 mg/dL). The highest tertile of esd-LDL-c was associated with ESKD (adjusted HR 2.016, 95% CI 1.144-3.554, p = .015). Furthermore, there were 99 deaths (39 cardiovascular) among 293 participants in the NHANES DM-CKD cohort. Participants were classified into three groups in line with the tertile values of esd-LDL-c in the DKD cohort. The highest tertile of esd-LDL-c was associated with cardiovascular mortality (adjusted HR 3.95, 95% CI 1.3-12, p = .016) and all-cause mortality (adjusted HR 2.37, 95% CI 1.06-5.32, p = .036). CONCLUSIONS Higher esd-LDL-c was associated with increased risk of ESKD in people with biopsy-proven DKD, and higher cardiovascular and all-cause mortality risk among those with DM-CKD.
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Affiliation(s)
- Qing Yang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Yutong Zou
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Yanlin Lang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Jia Yang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Yucheng Wu
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Xiang Xiao
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Chunmei Qin
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Yuancheng Zhao
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
| | - Fang Liu
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
- Laboratory of Diabetic Kidney Disease, Centre of Diabetes and Metabolism Research, West China Hospital of Sichuan University, Chengdu, China
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Chu M, Wang AYM, Chan IHS, Chui SH, Lam CWK. Serum small-dense LDL abnormalities in chronic renal disease patients. Br J Biomed Sci 2019. [DOI: 10.1080/09674845.2012.12069133] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- M. Chu
- Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau
- Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, Guangzhou, China
| | - A. Y. M. Wang
- Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau
- Department of Medicine, Queen Mary Hospital, University of Hong Kong
| | - I. H. S. Chan
- Department of Chemical Pathology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong
| | - S. H. Chui
- Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau
| | - C. W. K. Lam
- Macau Institute for Applied Research in Medicine and Health, Macau University of Science and Technology, Macau
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Hou Q, Yu C, Li S, Li Y, Zhang R, Zheng T, Ma Y, Wang M, Su N, Wu T, Liu Z, Sheng X, Li N, Liu G, Huang Y, Xu T, Sun X, Tian H. Characteristics of lipid profiles and lipid control in patients with diabetes in a tertiary hospital in Southwest China: an observational study based on electronic medical records. Lipids Health Dis 2019; 18:13. [PMID: 30636643 PMCID: PMC6330454 DOI: 10.1186/s12944-018-0945-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 12/11/2018] [Indexed: 02/07/2023] Open
Abstract
Background Diabetes is often accompanied by dyslipidemia. Lipid control is very important in the management of diabetes. There are limited real world data on the lipid control in diabetic inpatients in southwest China. Methods An observational study was conducted to assess the characteristics of lipid profiles and lipid control. Diabetic patients from February 2009 to December 2013 at West China Hospital of Sichuan University were identified. Results A total of 56,784 inpatients were included and 85.9% of them had at least one lipid panel. The proportions of inpatients with optimal low-density lipoprotein cholesterol (LDL-C) level (< 2.59 mmol/L), optimal triglyceride (TG) level (< 1.70 mmol/L), optimal high-density lipoprotein cholesterol (HDL-C) level (men ≥1.04 mmol/L; women ≥1.30 mmol/L) and optimal non-high-density lipoprotein cholesterol (non-HDL-C) level (< 3.37 mmol/L) were 61.1, 64.6, 49.9 and 64.5%, respectively. Only 23.1% of inpatients obtained optimal levels for all the above four lipid parameters. Of diabetic inpatients with ischemic heart disease, the proportions of inpatients with optimal LDL-C level (< 1.81 mmol/L), optimal TG level (< 1.70 mmol/L), optimal HDL-C level (men ≥1.04 mmol/L; women ≥1.30 mmol/L) and optimal non-HDL-C level (< 2.59 mmol/L) were 38.0, 66.3, 48.1 and 48.7%, respectively. Of diabetic inpatients with cerebrovascular disease, the proportions were 28.3, 64.8, 49.9 and 38.1%, respectively. Older people and men were more likely to obtain optimal lipid levels. However, inpatients between 46 and 64 years were least likely to obtain optimal LDL-C levels. Conclusions The lipid control of diabetic inpatients in southwest China is worrisome. Individualized strategies of lipid management should be taken to bridge the gap between the recommendations of clinical guidelines and the real situation of clinical practice. Electronic supplementary material The online version of this article (10.1186/s12944-018-0945-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Qingtao Hou
- West China School of Medicine, Sichuan University, Chengdu, 610041, China.,Department of Geriatrics, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Chuan Yu
- Department of Health-Related Social and Behavioral Science, West China School of Public Health, Sichuan University, Chengdu, 610041, China.,CREAT Group, Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yun Li
- Department of Endocrinology and Metabolism, Deyang People's Hospital, Deyang, 618000, China
| | - Rui Zhang
- Health Informatics Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Tao Zheng
- Health Informatics Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yi Ma
- Health Informatics Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Miye Wang
- Health Informatics Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Na Su
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ting Wu
- Epidemiology Asia Pacific Unit, Merck Research Laboratories, Merck Sharp and Dohme Corp, Chengdu, 610041, China
| | - Zhiwen Liu
- Department of Pharmacoepidemiology, Merck Research Laboratories, Merck Sharp and Dohme Corp, Chengdu, 610041, China
| | - Xia Sheng
- Informatics IT Asia Pacific Unit, Merck Research Laboratories, Merck Sharp and Dohme Corp, Beijing, 100000, China
| | - Nan Li
- Health Informatics Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Guanjian Liu
- CREAT Group, Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yong Huang
- Health Informatics Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ting Xu
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin Sun
- CREAT Group, Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Haoming Tian
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Abstract
BACKGROUND Calcineurin inhibitors used in kidney transplantation for immunosuppression have adverse effects that may contribute to nephrotoxicity and increased cardiovascular risk profile. Fish oils are rich in very long chain omega-3 fatty acids, which may reduce nephrotoxicity by improving endothelial function and reduce rejection rates through their immuno-modulatory effects. They may also modify the cardiovascular risk profile. Hence, fish oils may potentially prolong graft survival and reduce cardiovascular mortality. OBJECTIVES This review aimed to look at the benefits and harms of fish oil treatment in ameliorating the kidney and cardiovascular adverse effects of CNI-based immunosuppressive therapy in kidney transplant recipients. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register (up to 17 March 2016) through contact with the Information Specialist using search terms relevant to this review. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs of fish oils in kidney transplant recipients on a calcineurin inhibitor-based immunosuppressive regimen. RCTs of fish oil versus statins were included. DATA COLLECTION AND ANALYSIS Data was extracted and the quality of studies assessed by two authors, with differences resolved by discussion with a third independent author. Dichotomous outcomes were reported as risk ratio (RR) and continuous outcome measures were reported as the mean difference (MD) with 95% confidence intervals using the random effects model. Heterogeneity was assessed using a Chi(2) test on n-1 degrees of freedom and the I(2) statistic. Data not suitable for pooling were tabulated and described. MAIN RESULTS Fifteen studies (733 patients) were suitable for analysis. All studies were small and had variable methodology. Fish oil did not significantly affect patient or graft survival, acute rejection rates, or calcineurin inhibitor toxicity when compared to placebo. Overall SCr was significantly lower in the fish oil group compared to placebo (5 studies, 237 participants: MD -30.63 µmol/L, 95% CI -59.74 to -1.53; I(2) = 88%). In the subgroup analysis, this was only significant in the long-course (six months or more) group (4 studies, 157 participants: MD -37.41 µmol/L, 95% CI -69.89 to -4.94; I(2) = 82%). Fish oil treatment was associated with a lower diastolic blood pressure (4 studies, 200 participants: MD -4.53 mm Hg, 95% CI -7.60 to -1.45) compared to placebo. Patients receiving fish oil for more than six months had a modest increase in HDL (5 studies, 178 participants: MD 0.12 mmol/L, 95% CI 0.03 to 0.21; I(2) = 47%) compared to placebo. Fish oil effects on lipids were not significantly different from low-dose statins. There was insufficient data to analyse cardiovascular outcomes. Fishy aftertaste and gastrointestinal upset were common but did not result in significant patient drop-out. AUTHORS' CONCLUSIONS There is insufficient evidence from currently available RCTs to recommend fish oil therapy to improve kidney function, rejection rates, patient survival or graft survival. The improvements in HDL cholesterol and diastolic blood pressure were too modest to recommend routine use. To determine a benefit in clinical outcomes, future RCTs will need to be adequately powered with these outcomes in mind.
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Affiliation(s)
- Andy KH Lim
- Monash Medical CentreDepartment of Nephrology246 Clayton RdClaytonVICAustralia3168
| | - Karen J Manley
- Austin HealthDepartment of Nutrition and DieteticsPO Box 5555HeidelbergVICAustralia3084
| | - Matthew A Roberts
- Monash UniversityEastern Health Clinical SchoolBox HillVICAustralia3128
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Suszyńska-Zajczyk J, Sikora M, Jakubowski H. Paraoxonase 1 deficiency and hyperhomocysteinemia alter the expression of mouse kidney proteins involved in renal disease. Mol Genet Metab 2014; 113:200-6. [PMID: 25069821 DOI: 10.1016/j.ymgme.2014.07.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 07/09/2014] [Accepted: 07/10/2014] [Indexed: 01/19/2023]
Abstract
SCOPE Hyperhomocysteinemia (HHcy) is associated with kidney disease and leads to atherosclerosis and thrombosis. Paraoxonase 1 (Pon1), a hydrolase that participates in homocysteine (Hcy) metabolism and is carried in the circulation on high-density lipoprotein, has also been linked to kidney disease and atherothrombosis. Pon1-knockout mice are susceptible to atherosclerosis and exhibit a kidney-associated phenotype, polyuria or urine dilution. We hypothesize that HHcy and Pon1 deficiency are toxic to kidney function because they impair metabolic pathways important for normal kidney homeostasis. METHODS AND RESULTS We examined changes in the mouse kidney proteome induced by Pon1 gene deletion and dietary HHcy, using 2D IEF/SDS-PAGE gel electrophoresis and MALDI-TOF mass spectrometry. We found that the expression of ten mouse kidney proteins was altered by the Pon1(-/-) genotype or HHcy. Proteins involved in metabolism of lipid (ApoA-I), protein (Hspd1), carbohydrate (Pdhb, Fbp1-isoform2, Eno1), and energy (Ndufs8, Ldhd) were down-regulated. Proteins involved in lipid transport (Pebp1), oxidative stress response (Prdx2), and cellular detoxification (Glo1) were up-regulated. The kidney proteins altered by HHcy or Pon1 are also altered in renal disease. CONCLUSION Our findings suggest that excess Hcy is toxic because it deregulates the expression of proteins involved in diverse cellular processes-from lipid, protein, carbohydrate, and energy metabolisms to detoxification and antioxidant defenses-that are essential for normal kidney homeostasis. Dysregulation of these processes can account for the involvement of HHcy and reduced Pon1 in kidney disease. Our findings also show that Pon1 plays an important role in maintaining normal kidney homeostasis.
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Affiliation(s)
| | - Marta Sikora
- Institute of Bioorganic Chemistry, Poznań, Poland
| | - Hieronim Jakubowski
- Institute of Bioorganic Chemistry, Poznań, Poland; Department of Biochemistry and Biotechnology, University of Life Sciences, Poznań, Poland; Department of Microbiology & Molecular Genetics, Rutgers-New Jersey Medical School, International Center for Public Health, Newark, NJ, USA.
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Suszyńska-Zajczyk J, Utyro O, Jakubowski H. Methionine-induced hyperhomocysteinemia and bleomycin hydrolase deficiency alter the expression of mouse kidney proteins involved in renal disease. Mol Genet Metab 2014; 112:339-46. [PMID: 24913063 DOI: 10.1016/j.ymgme.2014.05.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 05/18/2014] [Accepted: 05/18/2014] [Indexed: 02/07/2023]
Abstract
SCOPE Hyperhomocysteinemia (HHcy) induced by dietary or genetic factors is linked to kidney disease. Bleomycin hydrolase (Blmh) metabolizes Hcy-thiolactone to Hcy. We aimed to explain the role of dietary HHcy in kidney disease. METHODS AND RESULTS We examined kidney proteome in dietary HHcy and Blmh-knockout mouse models using 2D IEF/SDS-PAGE gel electrophoresis and MALDI-TOF mass spectrometry. We found that the kidney proteome was altered by dietary HHcy and the Blmh(-/-) genotype. Proteins involved in metabolism of lipoprotein (ApoA1), amino acid and protein (Acy1, Hspd1), carbohydrate (Pdhb, Fbp1-isoform 1, Eno1), and energy metabolism (Ndufs8, Ldhd) were down-regulated. Proteins involved in carbohydrate metabolism (Fbp1-isoform 2), oxidative stress response (Prdx2), and detoxification (Glod4) were up-regulated. The Blmh(-/-) genotype down-regulated Glod4 isoform 3 mRNA but did not affect isoform 1 mRNA expression in mouse kidneys, suggesting post-transcriptional regulation of the Glod4 protein by the Blmh(+/+) genotype. Responses of ApoA1, Acy1, Hspd1, Ndufs8, Fbp1, Eno1, and Prdx2 to HHcy and/or Blmh deficiency mimic their responses to renal disease. CONCLUSION Our findings indicate that Blmh interacts with diverse cellular processes--lipoprotein, amino acid and protein, carbohydrate, and energy metabolisms, detoxification, antioxidant defenses--that are essential for normal kidney homeostasis and that deregulation of these processes can account for the involvement of HHcy in kidney disease.
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Affiliation(s)
| | - Olga Utyro
- Institute of Bioorganic Chemistry, Poznan, Poland; Department of Biochemistry and Biotechnology, University of Life Sciences, Poznan, Poland
| | - Hieronim Jakubowski
- Institute of Bioorganic Chemistry, Poznan, Poland; Department of Biochemistry and Biotechnology, University of Life Sciences, Poznan, Poland; Department of Microbiology & Molecular Genetics, Rutgers-New Jersey Medical School, International Center for Public Health, Newark, NJ, USA.
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Hoshino T, Ookawara S, Miyazawa H, Ito K, Ueda Y, Kaku Y, Hirai K, Mori H, Yoshida I, Tabei K. Renoprotective effects of thiazides combined with loop diuretics in patients with type 2 diabetic kidney disease. Clin Exp Nephrol 2014; 19:247-53. [DOI: 10.1007/s10157-014-0981-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 04/26/2014] [Indexed: 10/25/2022]
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Okubo M, Hanada H, Matsui M, Hidaka Y, Masuda D, Sakata Y, Yamashita S. Serum Apolipoprotein B-48 Concentration Is Associated with a Reduced Estimated Glomerular Filtration Rate and Increased Proteinuria. J Atheroscler Thromb 2014; 21:974-82. [DOI: 10.5551/jat.23309] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Hung CC, Tsai JC, Kuo HT, Chang JM, Hwang SJ, Chen HC. Dyslipoproteinemia and impairment of renal function in diabetic kidney disease: an analysis of animal studies, observational studies, and clinical trials. Rev Diabet Stud 2013; 10:110-20. [PMID: 24380087 DOI: 10.1900/rds.2013.10.110] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Dyslipoproteinemia is highly prevalent in diabetes, chronic kidney disease, and diabetic kidney disease (DKD). Both diabetes and chronic kidney disease (CKD) are associated with hypertriglyceridemia, lower high-density lipoprotein, and higher small, dense low-density lipoprotein. A number of observational studies have reported that dyslipidemia may be associated with albuminuria, renal function impairment, and end-stage renal disease (ESRD) in the general population, and especially in CKD and DKD patients. Diabetic glomerulopathy and the related albuminuria are the main manifestations of DKD. Numerous animal studies support the finding that glomerular atherosclerosis is the main mechanism of glomerulosclerosis in CKD and DKD. Some randomized, controlled trials suggest the use of statins for the prevention of albuminuria and renal function impairment in CKD and DKD patients. However, a large clinical study, the Study of Heart and Renal Protection (SHARP), does not support that statins could reduce ESRD in CKD. In this article, we analyze the complex association of dyslipoproteinemia with DKD and deduce its relevance from animal studies, observational studies, and clinical trials. We show that special subgroups could benefit from the statin treatment.
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Affiliation(s)
- Chi-Chih Hung
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Taiwan
| | - Jer-Chia Tsai
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Taiwan
| | - Hung-Tien Kuo
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Taiwan
| | - Jer-Ming Chang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Taiwan
| | - Shang-Jyh Hwang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Taiwan
| | - Hung-Chun Chen
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Taiwan
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Rodrigues TC, Canani LH, Schvartzman P, Gross JL. Hypertension is the metabolic syndrome component most strongly associated with microvascular complications and coronary artery calcification in Type 1 diabetes. J Endocrinol Invest 2011; 34:e58-63. [PMID: 20855932 DOI: 10.1007/bf03347077] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To evaluate the association of metabolic syndrome (MetS) and its individual components with microvascular complications and coronary artery calcification (CAC) in patients with Type 1 diabetes. MATERIAL/SUBJECTS AND METHODS Cross-sectional study included 261 patients with Type 1 diabetes. Patients were assessed regarding the presence of MetS according to National Cholesterol Education Program (NCEP) criteria. CAC score was measured in a subset of 100 patients without known cardiovascular disease. RESULTS The prevalence of MetS was 13.4% according to the NCEP criteria. Microvascular complications and CAC were more frequent in patients with MetS. In a multiple logistic regression analysis, MetS remained associated with nephropathy [OR: 6.33 (95% CI 2.54-15.77), p<0.001], but not with retinopathy and CAC. Among the MetS components, hypertension was associated with presence of retinopathy [OR: 4.04 (95% CI 1.65- 9.90), p=0.002], nephropathy [OR: 5.92 (95% CI 2.42-14.4), p<0.001] and CAC [OR: 2.97 (95% CI 1.06-8.30), p=0.03]. CONCLUSIONS Hypertension was the only MetS component associated with retinopathy, nephropathy and the presence of CAC. Hypertension was better associated with CAC than MetS itself.
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Affiliation(s)
- T C Rodrigues
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
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Tsimihodimos V, Mitrogianni Z, Elisaf M. Dyslipidemia associated with chronic kidney disease. Open Cardiovasc Med J 2011; 5:41-8. [PMID: 21643500 PMCID: PMC3106357 DOI: 10.2174/1874192401105010041] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 01/06/2011] [Accepted: 01/06/2011] [Indexed: 12/13/2022] Open
Abstract
Cardiovascular disease is a major cause of morbidity and mortality in patients with impaired renal function. Dyslipidemia has been established as a well-known traditional risk factor for cardiovascular disease (CVD) in the general population and it is well known that patients with chronic kidney disease (CKD) exhibit significant alterations in lipoprotein metabolism. In this review, the pathogenesis and treatment of CKD-induced dyslipidemia are discussed. Studies on lipid abnormalities in predialysis, hemodialysis and peritoneal dialysis patients are analyzed. In addition, the results of the studies that tested the effects of the hypolipidemic drugs on cardiovascular morbidity and mortality in patients with CKD are reported.
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Affiliation(s)
- Vasilis Tsimihodimos
- Department of Internal Medicine, Medical School, University of Ioannina, Ioannina, Greece
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12
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Paraskevas KI, Tzovaras AA, Stathopoulos V, Mikhailidis DP. Statin use in patients with chronic kidney disease stages 2–4: targeting beyond improved mortality rates. Int Urol Nephrol 2010; 42:711-3. [DOI: 10.1007/s11255-009-9677-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Accepted: 11/05/2009] [Indexed: 10/20/2022]
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Notaro LA, Usman MH, Burke JF, Siddiqui A, Superdock KR, Ezekowitz MD. Secondary Prevention in Concurrent Coronary Artery, Cerebrovascular, and Chronic Kidney Disease: Focus on Pharmacological Therapy. Cardiovasc Ther 2009; 27:199-215. [DOI: 10.1111/j.1755-5922.2009.00087.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Ramirez-Cortes G, Fuentes-Velasco Y, García-Roca P, Guadarrama O, López M, Valverde-Rosas S, Velásquez-Jones L, Romero B, Toussaint G, Medeiros M. Prevalence of metabolic syndrome and obesity in renal transplanted Mexican children. Pediatr Transplant 2009; 13:579-84. [PMID: 18992053 DOI: 10.1111/j.1399-3046.2008.01032.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The purpose of the study was to evaluate the prevalence of MS and obesity in Mexican children with more than one yr post-renal transplantation. Thirty-two children transplanted between January 2004 and February 2006 were included in the study. The weight and height at the time of renal transplant were obtained. A fasting blood sample was drawn for serum creatinine, adiponectin, and complete lipid profile, and a three-h glucose tolerance test was also taken. A complete nutritional evaluation was performed including anthropometry. There was a statistically significant increase in BMI at one yr post-transplant that was maintained at two yr post-transplant. Three patients exhibited obesity and were overweight. Seventeen patients had hypertension, 14 patients had low HDL, 12 patients had hypertriglyceridemia, all had normal fasting glucose, six of them had glucose intolerance, and two had waist circumference higher than 90%. Eight patients (25%) had MS. Patients with MS had higher proportion of deceased donor grafts, acute rejection episodes, and received more methylprednisolone pulses; also they had a statistically significant higher pretransplant BMI than patients without MS. There was a significant relationship between BMI at one yr post-renal transplant and creatinine clearance estimated by Schwartz formula.
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Rysz J, Aronow WS, Stolarek RS, Hannam S, Mikhailidis DP, Banach M. Nephroprotective and clinical potential of statins in dialyzed patients. Expert Opin Ther Targets 2009; 13:541-50. [PMID: 19368496 DOI: 10.1517/14728220902882130] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Montague T, Murphy B. Lipid management in chronic kidney disease, hemodialysis, and transplantation. Endocrinol Metab Clin North Am 2009; 38:223-34. [PMID: 19217521 DOI: 10.1016/j.ecl.2008.11.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Recent studies have shown the spectrum of dyslipidemia in patients who have chronic kidney disease (CKD) or end-stage renal disease to be different from that of the general population. This article discusses the pathophysiology of dyslipidemia in CKD, dialysis, and renal transplant patients, the therapeutic options, and their association with clinical outcomes. Whenever possible, comparisons are made to outcomes in the general population.
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Affiliation(s)
- Terri Montague
- Division of Kidney Disease and Hypertension, 593 Eddy Street, APC 9, Brown Medical School, Providence, RI 02903, USA.
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17
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Dimethylarginines and inflammation markers in patients with chronic kidney disease undergoing dialysis. Clin Exp Med 2009; 9:235-41. [DOI: 10.1007/s10238-009-0035-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2008] [Accepted: 01/20/2009] [Indexed: 11/26/2022]
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18
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Kirino Y, Sato Y, Kamimoto T, Kawazoe K, Minakuchi K, Nakahori Y. Interrelationship of dipeptidyl peptidase IV (DPP4) with the development of diabetes, dyslipidaemia and nephropathy: a streptozotocin-induced model using wild-type and DPP4-deficient rats. J Endocrinol 2009; 200:53-61. [PMID: 18931022 DOI: 10.1677/joe-08-0424] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
We examined the role of dipeptidyl peptidase IV (DPP4) in the development of diabetes, dyslipidaemia and renal dysfunction induced by streptozotocin (STZ). F344/DuCrlCrlj rats, which lack DPP4 activity, and wild-type rats were treated with STZ. Plasma DPP4 activity and biochemical parameters were measured until 42 days after STZ treatment. At the end of the experiment, renal function and DPP4 expressions of the kidney, liver, pancreas and adipose tissues were determined. Increases in blood glucose, cholesterol and triglycerides were evoked by STZ in both rat strains; however, the onset of hyperglycaemia was delayed in DPP4-deficient rats as compared with wild-type rats. By contrast, more severe dyslipidaemia was observed in DPP4-deficient rats than in wild-type rats after STZ treatment. Plasma DPP4 activity increased progressively with time after STZ treatment in wild-type rats. The kidney of wild-type rats showed decreased DPP4 activity with increased Dpp4 mRNA after STZ treatment. In addition, kidney weight, serum creatinine and excreted amounts of urinary protein, glucose and DPP4 enzyme were enhanced by STZ. DPP4-deficient rats showed increased serum creatinine in accordance with decreased creatinine clearance as compared with wild-type rats after STZ treatment. In conclusion, plasma DPP4 activity increased after STZ treatment, positively correlating to blood glucose. DPP4-deficient rats were resistant to developing diabetes, while susceptible to dyslipidaemia and reduction of glomerular filtration rate by STZ. DPP4 activation may be responsible for hyperglycaemia, lipid metabolism and preservation of renal function.
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Affiliation(s)
- Yasushi Kirino
- Department of Human Genetics and Public Health, Institute of Health Biosciences, The University of Tokushima Graduate School, The University of Tokushima, Kuramoto-Cho, Tokushima, Japan
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19
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Shishehbor MH, Oliveira LPJ, Lauer MS, Sprecher DL, Wolski K, Cho L, Hoogwerf BJ, Hazen SL. Emerging cardiovascular risk factors that account for a significant portion of attributable mortality risk in chronic kidney disease. Am J Cardiol 2008; 101:1741-6. [PMID: 18549850 DOI: 10.1016/j.amjcard.2008.02.060] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2007] [Revised: 02/13/2008] [Accepted: 02/13/2008] [Indexed: 02/07/2023]
Abstract
Chronic kidney disease (CKD) increases cardiovascular risk and mortality. However, traditional cardiovascular risk factors do not adequately account for the substantial increase in mortality observed in CKD. The aim of this study was to examine the relative contributions of novel cardiovascular risk factors to the risk between CKD and mortality. The study population included 4,680 consecutive new patients from a tertiary care preventive cardiology program from 1996 to 2005. Estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease (MDRD) method. Baseline levels of traditional (low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, hypertension, triglycerides, total cholesterol, and fasting glucose) and emerging (apolipoproteins A-I and B, lipoprotein[a], fibrinogen, homocysteine, and high-sensitivity C-reactive protein) risk factors were examined. All-cause mortality was obtained from the Social Security Death Index. There were 278 deaths over a median follow-up period of 22 months. CKD (estimated glomerular filtration rate <or=60 ml/min/1.73 m(2)) was strongly associated with mortality after adjusting for traditional cardiovascular risk factors (hazard ratio 2.31, 95% confidence interval 1.77 to 3.11, p<0.001) and with the addition of propensity score (hazard ratio 2.33, 95% confidence interval 1.75 to 3.10, p<0.001). Of all the traditional and emerging risk factors monitored, only the addition of homocysteine and fibrinogen significantly attenuated the association between CKD and mortality (adjusted hazard ratio 1.73, 95% confidence interval 1.23 to 2.34, p<0.001), explaining 38% of the attributable mortality risk from CKD. A significant interaction (p=0.004) between homocysteine and estimated glomerular filtration rate was observed whereby the annual mortality rate in subjects with CKD with homocysteine <10 micromol/L (the bottom tertile) was similar to those with normal renal function (1% per year), whereas homocysteine levels >or=12.5 micromol/L (the top tertile) were associated with a sevenfold greater mortality risk. In conclusion, homocysteine and fibrinogen levels explain nearly 40% of the attributable mortality risk from CKD.
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Affiliation(s)
- Mehdi H Shishehbor
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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20
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Chan DT, Irish AB, Dogra GK, Watts GF. Dyslipidaemia and cardiorenal disease: mechanisms, therapeutic opportunities and clinical trials. Atherosclerosis 2008; 196:823-34. [PMID: 17343861 DOI: 10.1016/j.atherosclerosis.2007.01.023] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2006] [Revised: 12/13/2006] [Accepted: 01/22/2007] [Indexed: 02/02/2023]
Abstract
Dyslipidaemia is an important risk factor for the development of chronic kidney disease (CKD) and cardiovascular disease (CVD). CKD generates an atherogenic lipid profile, characterised by high triglycerides, low high-density lipoprotein (HDL) cholesterol and accumulation of small dense low-density lipoprotein (LDL) particles, comparable to that in the metabolic syndrome. These changes are due specifically to the effects of CKD on key enzymes, transfer proteins and receptors involved in lipid metabolism. Dyslipidaemia is further compounded by dialysis, immunosuppressive drugs, and concomitant diseases such as diabetes mellitus. Post hoc analyses from large intervention trials suggest the benefit of statins in patients with early CKD, but prospective clinical trials in haemodialysis (HD) and renal transplant recipients have not conclusively shown improvements in hard cardiovascular end-points. The lack of efficacy of statins in late-stage CKD could be a consequence of other disease processes, such as calcific arteriopathy and insulin resistance, which are not modified by lipid-lowering agents. Despite uncertainty and pending the results of ongoing statin trials such as Study of Heart and Renal Protection (SHARP) and AURORA (A study to evaluate the Use of Rosuvastatin in subjects On Regular haemodialysis: an Assessment of survival and cardiovascular events), major international guidelines continue to support statin therapy in CKD and renal transplant patients to reduce cardiovascular risk burden. Because of increased risk of toxicity, particularly myopathy, statins and other lipid-regulating agents should be used cautiously in CKD and renal transplant recipients.
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Affiliation(s)
- Doris T Chan
- Metabolic Research Centre, School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia 6000, Australia
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21
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Arora S, Andreassen A, Simonsen S, Gude E, Dahl C, Skaardal R, Hoel I, Geiran O, Gullestad L. Prognostic Importance of Renal Function 1 Year After Heart Transplantation for All-Cause and Cardiac Mortality and Development of Allograft Vasculopathy. Transplantation 2007; 84:149-54. [PMID: 17667805 DOI: 10.1097/01.tp.0000268810.61393.2c] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Impaired renal function is associated with increased mortality among heart failure patients. Although a significant proportion of heart transplant (HTx) recipients have reduced renal function at 1 year post-HTx, no previous study has evaluated the associated risk for both all-cause and cardiac mortality. Hence, we assessed the relationship between glomerular filtration rate (GFR) at 1 year post-HTx and all-cause and cardiac mortality and development of cardiac allograft vasculopathy (CAV). METHODS We evaluated 381 patients with a minimum survival of 1 year post-HTx and the Modification of Diet in Renal Disease Study formula was used to calculate estimated GFR. Mortality and angiographic CAV were defined as separate endpoints, and median follow-up was 7.4 and 4.0 years, respectively. RESULTS During the follow-up period, 122 patients died and 154 patients developed CAV. Reduced GFR pre-HTx was not a risk factor for either endpoint. Overall, 193 (51%) patients had GFR <60 ml/min/1.73 m at one year post-HTx and this was an independent predictor of all-cause mortality with an adjusted hazard ratio of 1.7 (P=0.01) for a GFR between 30-60 and 3.2 (P=0.006) for GFR <30 ml/min/1.73 m. GFR <60 ml/min/1.73 m at 1 year post-HTx was also associated with a higher risk of cardiac mortality (HR=1.9; P=0.04) but did not predict the development of CAV. CONCLUSIONS Renal impairment is evident in a majority of HTx recipients at 1 year post-HTx. It is an important risk factor for both all-cause and cardiac mortality but does not predict the development of angiographic CAV.
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Affiliation(s)
- Satish Arora
- Department of Cardiology, Rikshospitalet-Radiumhospitalet Medical Center, Oslo, Norway.
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Abstract
BACKGROUND Calcineurin inhibitors used in kidney transplantation for immunosuppression have adverse effects that may contribute to nephrotoxicity and increased cardiovascular risk profile. Fish oils are rich in very long chain omega-3 fatty acids, which may reduce nephrotoxicity by improving endothelial function and reduce rejection rates through their immuno-modulatory effects. They may also modify the cardiovascular risk profile. Hence, fish oils may potentially prolong graft survival and reduce cardiovascular mortality. OBJECTIVES To assess the benefits and harms of fish oil supplementation on kidney transplant recipients on a calcineurin inhibitor-based immunosuppressive regimen. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL in The Cochrane Library, issue 2 2005), MEDLINE (1966-April 2005) and EMBASE (1980-April 2005). SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs of fish oils in kidney transplant recipients on a calcineurin inhibitor-based immunosuppressive regimen. RCTs of fish oil versus statins were included. DATA COLLECTION AND ANALYSIS Data was extracted and the quality of studies assessed by two authors, with differences resolved by discussion with a third independent author. Dichotomous outcomes were reported as relative risk (RR) and continuous outcome measures were reported as the mean difference (MD) with 95% confidence intervals using the random effects model. Heterogeneity was assessed using a Chi(2) test on n-1 degrees of freedom and the I(2) statistic. Data not suitable for pooling were tabulated and described. MAIN RESULTS Sixteen studies (733 patients) were suitable for analysis. Fish oil did not significantly affect patient or graft survival, acute rejection rates, calcineurin inhibitor toxicity or renal function, when compared to placebo. Fish oil treatment was associated with a lower diastolic blood pressure (MD 4.5 mmHg; P = 0.004) compared to placebo. Patients receiving fish oil for more than six months had a modest increase in HDL (MD 0.12 mmol/L; P = 0.01) compared to placebo. Fish oil effects on lipids were not significantly different from low-dose statins. There was insufficient data to analyse cardiovascular outcomes. Fishy aftertaste and gastrointestinal upset were common but did not result in significant patient drop-out. AUTHORS' CONCLUSIONS There is insufficient evidence from currently available RCTs to recommend fish oil therapy to improve renal function, rejection rates, patient survival or graft survival. The improvements in HDL cholesterol and diastolic blood pressure were too modest to recommend routine use. To determine a benefit in clinical outcomes, future RCTs will need to be adequately powered with these outcomes in mind.
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Affiliation(s)
- A K H Lim
- Monash Medical Centre, Department of Nephrology, 246 Clayton Rd, Clayton, Victoria, Australia, 3168.
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Molitch ME. Management of dyslipidemias in patients with diabetes and chronic kidney disease. Clin J Am Soc Nephrol 2006; 1:1090-9. [PMID: 17699330 DOI: 10.2215/cjn.00780306] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Cardiovascular disease (CVD) is the leading cause of death in patients with stage 5 chronic kidney disease (CKD), and the mortality rate in stage 5 CKD is even higher in patients with diabetes. CVD risk reduction includes control of hyperglycemia, dyslipidemia, and BP. An LDL cholesterol goal of 70 mg/dl has been suggested for such high-risk patients. Most studies that have showed CVD risk reduction with statins have been in patients without CKD. However, some studies have had sufficient numbers of patients with CKD stages 2 to 3 to permit analysis, and these generally have shown CVD benefits similar to those found in patients without CKD. Studies that have shown benefit in patients who were on dialysis or after transplantation have been mixed, in part because CVD in such patients is far advanced and may not respond as well to intervention. As GFR falls, the dosages of many of the drugs that are used for the treatment of dyslipidemias need to be modified. In general, however, atorvastatin and fluvastatin dosages do not have to be modified. Drug interactions with cyclosporine also occur. In general, combinations of statins and fibrates should be avoided, and fenofibrate should be avoided in all patients with decreased GFR levels. Overall, on the basis of the very high risk for CVD in patients with diabetes and CKD, aggressive management of dyslipidemias is warranted, with an LDL goal of 70 mg/dl.
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MESH Headings
- Cardiovascular Diseases/blood
- Cardiovascular Diseases/etiology
- Cardiovascular Diseases/prevention & control
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/complications
- Diabetes Mellitus, Type 1/physiopathology
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/physiopathology
- Diabetic Nephropathies/blood
- Diabetic Nephropathies/complications
- Diabetic Nephropathies/etiology
- Diabetic Nephropathies/physiopathology
- Disease Progression
- Dyslipidemias/blood
- Dyslipidemias/complications
- Dyslipidemias/drug therapy
- Dyslipidemias/physiopathology
- Glomerular Filtration Rate
- Humans
- Hydroxymethylglutaryl-CoA Reductase Inhibitors/administration & dosage
- Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use
- Kidney Failure, Chronic/blood
- Kidney Failure, Chronic/complications
- Kidney Failure, Chronic/etiology
- Kidney Failure, Chronic/physiopathology
- Kidney Failure, Chronic/surgery
- Kidney Transplantation
- Lipoproteins, HDL/blood
- Treatment Outcome
- Triglycerides/blood
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Affiliation(s)
- Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 303 E. Chicago Avenue (Tarry 15-731), Chicago, IL 60611, USA.
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Abstract
PURPOSE OF REVIEW The treatment of dyslipidemia has been dynamic over the past several years. Of special importance is the impact of recent clinical trial data on management strategies of dyslipidemia in the elderly. People 65 years and older are living longer and are the fastest growing subset of the US population, necessitating more attention to chronic disease conditions that manifest in this age group. This review addresses guidelines of lipid management, discusses data that support their use, and examines the benefits of lipid-lowering therapy in the elderly with attention to the chronic conditions that are common in this population. RECENT FINDINGS Clinical trials completed since the publication of the 2001 National Cholesterol Education Program (NCEP) Adult Treatment Panel III guidelines support the use of lipid-lowering therapy in the elderly population. Lipid-lowering therapy has not only proven to be generally safe in the elderly, but has also proven effective in helping manage the chronic disease conditions that are common in this age group. SUMMARY The elderly segment of our population continues to grow. Along with this growth in population is a growth in incidence of cardiovascular disease, the metabolic syndrome, chronic kidney disease, cerebrovascular disease, and diabetes mellitus. There is no known panacea for managing these chronic disease conditions; however, lipid-lowering therapy has been shown to prevent or delay the progression of these diseases and the mortality and morbidity that accompanies them.
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Affiliation(s)
- Khan Pohlel
- Emory University School of Medicine, Atlanta, Georgia 30303, USA
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