1
|
Currie M, Leipzig M, Kaghazchi A, Zhu Y, Shudo Y, Woo YJ. Outcomes of Patients Undergoing Combined Heart-Kidney Transplantation With or Without Prior Ventricular Assist Device. Transplant Proc 2023; 55:1674-1680. [PMID: 37393169 DOI: 10.1016/j.transproceed.2023.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 04/14/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Both combined heart-kidney transplantation and ventricular assist devices (VADs) pose significant challenges, including sensitization, immunosuppressive treatment, and infrastructure demands. Despite these challenges, we hypothesized that the recipients of combined heart-kidney transplants with and without VADs would have equivalent survival. We aimed to compare the survival of heart-kidney transplant recipients with and without prior VAD placement. METHODS We retrospectively analyzed all patients enrolled in the United Network for Organ Sharing database who underwent heart-kidney transplants. We created a matched cohort of patients undergoing heart-kidney transplantation with or without prior VAD using 1:1 nearest propensity-score matching with preoperative variables. RESULTS In the propensity-matched cohort, 399 patients underwent heart-kidney transplantation with prior VAD, and 399 underwent heart-kidney transplantation without prior VAD. The estimated survival of heart--kidney recipients with prior VAD was 84.8% at one year, 81.2% at 3 years, and 75.3% at 5 years. The estimated survival of heart-kidney recipients without prior VAD was 86.8.7% at one year, 84.0% at 3 years, and 78.8% at 5 years. There was no statistically significant difference in the survival of heart-kidney transplant recipients with or without prior VAD at one year (P = .42; Figure 2), 3 years (P = .34), or 5 years (P = .30). CONCLUSION Despite the increased challenge of heart-kidney transplantation in recipients with prior VAD, we demonstrated that these patients have similar survival to those who underwent heart-kidney transplantation without previous VAD placement.
Collapse
Affiliation(s)
- Maria Currie
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California.
| | - Matthew Leipzig
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Aydin Kaghazchi
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Yasuhiro Shudo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
2
|
Atkins J, Hess NR, Fu S, Read JM, Hajj JM, Ramu B, Silverman DN, Inampudi C, Van Bakel AB, Hashmi ZA, Pope NH, Witer LP, Kanwar MK, Sauer AJ, Houston BA, Kilic A, Tedford RJ. Outcomes in LVAD Patients Undergoing Simultaneous Heart-Kidney Transplantation. J Card Fail 2022; 28:1584-1592. [PMID: 35597511 DOI: 10.1016/j.cardfail.2022.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 04/20/2022] [Accepted: 04/30/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Multiple studies have shown better outcomes for simultaneous heart kidney transplant (sHKT) compared with isolated orthotopic heart transplant (iOHT) in recipients with chronic kidney disease (CKD). However, outcomes in patients supported by durable LVAD have not been well studied. METHODS Patients with durable LVADs and stage 3 or greater CKD (eGFR <60ml/min/1.73m2) undergoing iOHT or sHKT between 2008-2020 were identified from the United Network for Organ Sharing (UNOS) registry. Kaplan Meier survival analysis with associated log-rank test was conducted to compare post-transplant survival. Multivariable modeling was used in order to identify risk adjusted predictors of one-year posttransplant mortality. RESULTS 4375 patients were identified, 366 underwent sHKT and 4009 iOHT. The frequency of sHKT increased over the study period. One-year post-transplant survival was worse in sHKT compared with iOHT (80.3% vs 88.3%, p<0.001), and persisted up to 5 years post-transplant (p=0.001). sHKT recipients were more likely to require dialysis after transplant and had longer hospital length of stay (p<0.001). Multivariable analysis showed sHKT remained an independent risk factor for mortality at 1 year (OR 1.58, p=0.002). CONCLUSIONS HKT is becoming more common in patients with durable LVADs. Compared with iOHT, sHKT have worse short and long-term survival are more likely to require posttransplant dialysis.
Collapse
Affiliation(s)
- Jessica Atkins
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Nicholas R Hess
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Sheng Fu
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Jacob M Read
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Jennifer M Hajj
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Bhavadharini Ramu
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Daniel N Silverman
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Chakradhari Inampudi
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Adrian B Van Bakel
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Z A Hashmi
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Nicholas H Pope
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Lucas P Witer
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Manreet K Kanwar
- Cardiovascular Institute at Allegheny Health Network, Pittsburgh, PA
| | - Andrew J Sauer
- Department of Cardiovascular Medicine, The University of Kansas School of Medicine, Kansas City, Kansas
| | - Brian A Houston
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC
| | - Ryan J Tedford
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, SC.
| |
Collapse
|
3
|
Chan JL, Patel DC, Megna D, Dimbil SJ, Levine R, Moriguchi J, Czer LS, Kobashigawa JA, Arabia F, Esmailian F. Use of durable mechanical circulatory support on outcomes of heart-kidney transplantation. Interact Cardiovasc Thorac Surg 2019; 27:773-777. [PMID: 29846594 DOI: 10.1093/icvts/ivy156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 04/10/2018] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES Previous studies have demonstrated that preheart transplant mechanical circulatory support (MCS) can lead to a small but significant increase in mortality. However, data on outcomes of patients with MCS who require simultaneous heart-kidney transplant are limited. METHODS A retrospective review of simultaneous heart-kidney transplantations (HKTxs) performed at a single institution over a 5-year period was performed. Patients were divided based on the preoperative use of durable MCS. Renal graft-related end points were evaluated, including glomerular filtration rate following transplantation, prevalence of delayed renal graft function and freedom from antibody and cellular-mediated graft rejection. Patient-specific outcomes, including survival and frequency of non-fatal major adverse cardiac events at 1 year, were additionally assessed. RESULTS During the study period, 50 HKTxs were performed, 14 of which had preoperative MCS. HKTx patients with and without MCS implantations had a similar prevalence of delayed graft function (57.1% vs 50.0%; P = 0.757). A numerical trend was observed towards a reduced glomerular filtration rate 1-month post-transplant in patients without an MCS device (81.2 ± 32.8 vs 64.4 ± 27.5; P = 0.072), but no significant difference was observed at 6 and 12 months. No significant difference was observed on the need for post-transplant renal replacement therapy, non-fatal major adverse cardiac events, freedom from graft rejection and overall survival at 1 year. CONCLUSIONS The use of preoperative MCS in patients undergoing combined HKTx was not found to affect renal graft function post-transplantation and does not seem to be associated with increase in morbidity or mortality.
Collapse
Affiliation(s)
- Joshua L Chan
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Deven C Patel
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Dominick Megna
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Ryan Levine
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA
| | | | | | | | - Francisco Arabia
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Fardad Esmailian
- Cedars-Sinai Heart Institute, Los Angeles, CA, USA.,Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
4
|
Givens RC, Topkara VK. Renal risk stratification in left ventricular assist device therapy. Expert Rev Med Devices 2017; 15:27-33. [DOI: 10.1080/17434440.2018.1418663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Raymond C. Givens
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| | - Veli K. Topkara
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY, USA
| |
Collapse
|
5
|
Awad M, Czer LSC, Esmailian F, Jordan S, De Robertis MA, Mirocha J, Patel J, Chang DH, Kittleson M, Ramzy D, Arabia F, Chung JS, Cohen JL, Trento A, Kobashigawa JA. Combined Heart and Kidney Transplantation: A 23-Year Experience. Transplant Proc 2017; 49:348-353. [PMID: 28219597 DOI: 10.1016/j.transproceed.2016.11.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/10/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND We report clinical experience with combined heart and kidney transplantation (HKTx) over a 23-year time period. METHODS From June 1992 to August 2015, we performed 83 combined HKTx procedures at our institution. We compared the more recent cohort of 53 HKTx recipients (group 2, March 2009 to August 2015) with the initial 30 previously reported HKTx recipients (group 1, June 1992 to February 2009). Pre-operative patient characteristics, peri-operative factors, and post-operative outcomes including survival were examined. RESULTS The baseline characteristics of the two groups were similar, except for a lower incidence of ethanol use and higher pre-operative left-ventricular ejection fraction, cardiac output, and cardiac index in group 2 when compared with group 1 (P = .007, .046, .037, respectively). The pump time was longer in group 2 compared with group 1 (153.30 ± 38.68 vs 129.60 ± 37.60 minutes; P = .007), whereas the graft ischemic time was not significantly different between the groups, with a trend to a longer graft ischemic time in group 2 versus group 1 (195.17 ± 45.06 vs 178.07 ± 52.77 minutes; P = .056, respectively). The lengths of intensive care unit (ICU) and hospital stay were similar between the groups (P = .083 and .39, respectively). In addition, pre-operative and post-operative creatinine levels at peak, discharge, 1 year, and 5 years and the number of people on post-operative dialysis were similar between the groups (P = .37, .75, .54, .87, .56, and P = .139, respectively). Overall survival was not significantly different between groups 2 and 1 for the first 5 years after transplant, with a trend toward higher survival in group 2 (P = .054). CONCLUSIONS The most recent cohort of combined heart and kidney transplant recipients had similar ICU and hospital lengths of stay and post-operative creatinine levels at peak, discharge, and 1 and 5 years and a similar number of patients on post-operative dialysis when compared with the initial cohort. Overall survival was not significantly different between the later and earlier groups, with a trend toward higher overall survival at 5 years in the more recent cohort of patients. In selected patients with co-existing heart and kidney failure, combined heart and kidney transplantation is safe to perform and has excellent outcomes.
Collapse
Affiliation(s)
- M Awad
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - L S C Czer
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California.
| | - F Esmailian
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - S Jordan
- Division of Pediatric Nephrology, Cedars-Sinai Medical Center, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - M A De Robertis
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
| | - J Mirocha
- Section of Biostatistics and Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - J Patel
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - D H Chang
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - M Kittleson
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - D Ramzy
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - F Arabia
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - J S Chung
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - J L Cohen
- Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - A Trento
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - J A Kobashigawa
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| |
Collapse
|
6
|
Gaffey AC, Chen CW, Chung J, Grandin EW, Porrett PM, Acker MA, Atluri P. Bridge with a left ventricular assist device to a simultaneous heart and kidney transplant: Review of the United Network for Organ Sharing database. J Card Surg 2017; 32:209-214. [PMID: 28176387 DOI: 10.1111/jocs.13105] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Left ventricular assist device (LVAD) implantation as a bridge to cardiac transplantation (BTT) is an effective treatment for end-stage heart failure patients. Currently, there is an increasing number of patients with a LVAD who need a heart and kidney transplant (HKT). Little is known of the prognostic outcomes in these patients. This study was undertaken to determine whether an equivalent outcome would be present in HKTs as compared to a non-LVAD primary HKT cohort. METHODS We reviewed the United Network for Organ Sharing database from 2004 to 2013. Orthotropic heart transplant recipients (n = 49 799) were subcategorized as dual organ HKT (n = 1 921) and then divided into cohorts of HKT following continuous flow left ventricular assist device placement (CF-VAD-HKT, n = 113) or no LVAD placement (HKT, n = 1 808). Survival after transplantation was analyzed. RESULTS For CF-LVAD-HKT and HKT cohorts, preoperative characteristics were similar regarding age (50.8 ± 13.7, 50.1 ± 13.7, p = 0.75) and panel reactive antibody (12.3 ± 18.4 vs 7.1 ± 18.4, p = 0.06). Donors were similar in age, gender, creatinine, and ejection fraction. Post-transplant, there was no difference in complications. Survival for CF-LVAD-HKT and HKT were similar at 1 year (77% vs 82%) and 3 years (75% vs 77%, log rank p = 0.2814). CONCLUSIONS For patients with advanced heart failure and persistent renal dysfunction, simultaneous HKT is a safe option. Survival after CF-LVAD-HKT is equivalent to conventional HKT.
Collapse
Affiliation(s)
- Ann C Gaffey
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, Philadelphia
| | - Carol W Chen
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, Philadelphia
| | - Jennifer Chung
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, Philadelphia
| | - Edward Wilson Grandin
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, Philadelphia
| | - Paige M Porrett
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, Philadelphia
| | - Michael A Acker
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, Philadelphia
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, Philadelphia
| |
Collapse
|
7
|
Mechanical circulatory support and simultaneous heart-kidney transplantation: An outcome analysis. J Heart Lung Transplant 2016; 35:203-12. [DOI: 10.1016/j.healun.2015.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 08/12/2015] [Accepted: 10/03/2015] [Indexed: 11/22/2022] Open
|
8
|
Ruzza A, Czer LSC, Ihnken KA, Sasevich M, Trento A, Ramzy D, Esmailian F, Moriguchi J, Kobashigawa J, Arabia F. Combined heart-kidney transplantation after total artificial heart insertion. Transplant Proc 2015; 47:210-2. [PMID: 25596961 DOI: 10.1016/j.transproceed.2014.09.106] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 09/17/2014] [Indexed: 11/25/2022]
Abstract
We present the first single-center report of 2 consecutive cases of combined heart and kidney transplantation after insertion of a total artificial heart (TAH). Both patients had advanced heart failure and developed dialysis-dependent renal failure after implantation of the TAH. The 2 patients underwent successful heart and kidney transplantation, with restoration of normal heart and kidney function. On the basis of this limited experience, we consider TAH a safe and feasible option for bridging carefully selected patients with heart and kidney failure to combined heart and kidney transplantation. Recent FDA approval of the Freedom driver may allow outpatient management at substantial cost savings. The TAH, by virtue of its capability of providing pulsatile flow at 6 to 10 L/min, may be the mechanical circulatory support device most likely to recover patients with marginal renal function and advanced heart failure.
Collapse
Affiliation(s)
- A Ruzza
- Cedars-Sinai Heart Institute, Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, Los Angeles, California, United States
| | - L S C Czer
- Cedars-Sinai Heart Institute, Division of Cardiology, Cedars Sinai Medical Center, Los Angeles, California, United States.
| | - K A Ihnken
- Cedars-Sinai Heart Institute, Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, Los Angeles, California, United States
| | - M Sasevich
- Cedars-Sinai Heart Institute, Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, Los Angeles, California, United States
| | - A Trento
- Cedars-Sinai Heart Institute, Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, Los Angeles, California, United States
| | - D Ramzy
- Cedars-Sinai Heart Institute, Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, Los Angeles, California, United States
| | - F Esmailian
- Cedars-Sinai Heart Institute, Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, Los Angeles, California, United States
| | - J Moriguchi
- Cedars-Sinai Heart Institute, Division of Cardiology, Cedars Sinai Medical Center, Los Angeles, California, United States
| | - J Kobashigawa
- Cedars-Sinai Heart Institute, Division of Cardiology, Cedars Sinai Medical Center, Los Angeles, California, United States
| | - F Arabia
- Cedars-Sinai Heart Institute, Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, Los Angeles, California, United States
| |
Collapse
|
9
|
El-Sayed Ahmed MM, Aftab M, Singh SK, Mallidi HR, Frazier OH. Triple Bridge to Simultaneous Heart and Kidney Transplantation. Ann Thorac Surg 2014; 98:e45-6. [DOI: 10.1016/j.athoracsur.2014.04.136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 04/09/2014] [Accepted: 04/23/2014] [Indexed: 11/30/2022]
|
10
|
Patel AM, Eduardo Rame J, Rudnick MR. How does the nephrologist manage an LVAD patient on chronic maintenance dialysis? Semin Dial 2014; 27:284-8. [PMID: 24650366 DOI: 10.1111/sdi.12229] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Ami M Patel
- Nephrology Division, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | | | | |
Collapse
|