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Agarwal A, Zeng X, Li S, Rayner D, Foroutan F, Aertgeerts B, Coyac F, Farhoumand PD, Demaine A, Heen AF, Jha V, Machuve E, Nagler E, Tunnicliffe DJ, Guyatt GH, Vandvik PO, Ponte B, Agoritsas T. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors for adults with chronic kidney disease: a clinical practice guideline. BMJ 2024; 387:e080257. [PMID: 39353639 DOI: 10.1136/bmj-2024-080257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2024]
Abstract
CLINICAL QUESTION What is the impact of sodium-glucose cotransporter-2 (SGLT-2) inhibitors on survival and on cardiovascular and kidneyoutcomes for adults living with chronic kidney disease (CKD)? CURRENT PRACTICE Few therapies slow kidney disease progression and improve long term prognosis for adults living with CKD. SGLT-2 inhibitors have demonstrated cardiovascular and kidney benefits in adults with CKD with and without type 2 diabetes. Existing guidance for SGLT-2 inhibitors does not account for the totality of current best evidence for adults with CKD and does not provide fully stratified treatment effects and recommendations across all risk groups based on risk of CKD progression and complications. RECOMMENDATIONS The guideline panel considered evidence regarding benefits and harms of SGLT-2 inhibitor therapy for adults with CKD over a five year period, along with contextual factors, and provided the following recommendations:1. For adults at low risk of CKD progression and complications, we suggest administering SGLT-2 inhibitors (weak recommendation in favour)2. For adults at moderate risk of CKD progression and complications, we suggest administering SGLT-2 inhibitors (weak recommendation in favour)3. For adults at high risk of CKD progression and complications, we recommend administering SGLT-2 inhibitors (strong recommendation in favour)4. For adults at very high risk of CKD progression and complications, we recommend administering SGLT-2 inhibitors (strong recommendation in favour).Recommendations are applicable to all adults with CKD, irrespective of type 2 diabetes status. HOW THIS GUIDELINE WAS CREATED An international panel including patients, clinicians, and methodologists produced these recommendations following standards for trustworthy guidelines and using the GRADE approach. The panel identified typical risk strata of adults with CKD (from low to very high risk of CKD progression and related complications) using the classification system developed by Kidney Disease Improving Global Outcomes (KDIGO), and applied an individual patient perspective in moving from evidence to recommendations. Effects of SGLT-2 inhibitors were interpreted in absolute terms applicable to different risk strata with varying baseline risks for outcomes of benefit over a five year period. The panel explicitly considered the balance of benefits, harms, and burdens of starting an SGLT-2 inhibitor, incorporating the values and preferences of adults with different risk profiles. Interactive evidence summaries and decision aids accompany multilayered recommendations, developed in an online authoring and publication platform (www.magicapp.org) that allows reuse and adaptation. THE EVIDENCE A linked systematic review and pairwise meta-analysis (13 trials including 29 614 participants) of benefits and harms associated with SGLT-2 inhibitors in adults with CKD with or without type 2 diabetes informed guidance. Among individuals at very high risk of CKD progression and complications, moderate to high certainty evidence shows SGLT-2 inhibitors (relative to placebo or standard care without SGLT-2 inhibitors) decrease all-cause and cardiovascular mortality, hospitalisation for heart failure, kidney failure, non-fatal myocardial infarction, and non-fatal stroke. Among individuals at high risk, moderate to high certainty evidence shows SGLT-2 inhibitors result in similar benefits across outcomes except demonstrating little or no effect on hospitalisation for heart failure and kidney failure. Among individuals at moderate and low risk, moderate to high certainty evidence shows SGLT-2 inhibitors probably reduce all-cause mortality and non-fatal stroke, with little or no effect for other outcomes of benefit. Risk-stratified estimates were unavailable for outcomes of harm; the panel therefore considered absolute effects summarised across risk strata. SGLT-2 inhibitors are associated with little or no effect on acute kidney injury requiring dialysis, bone fractures, lower limb amputations, ketoacidosis, genital infections, or symptomatic hypovolaemia, although a residual possibility of harms at the individual patient level remains. UNDERSTANDING THE RECOMMENDATION In order to apply recommendations, clinicians must appropriately identify adults with CKD, consider the underlying aetiology, and risk stratify them based on glomerular filtration rate (estimated or measured) and degree of albuminuria. In addition to classifying individuals into risk strata, further estimation of a given patient's risk based on the extent of their kidney disease and other comorbidities may be warranted to inform individual-level decisions and shared decision making. Available risk calculators may help estimate a given patient's risk of CKD progression and complications.
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Affiliation(s)
- Arnav Agarwal
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada, L8N 3Z5
- Department of Health Research Methods, Evidence and Impact, HSC 2C, Hamilton, Ontario, Canada, L8S 4L8
- MAGIC Evidence Ecosystem Foundation, Oslo, Norway, 0282
- . Both authors contributed equally (co-first authors)
| | - Xiaoxi Zeng
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China, 610041
- MAGIC Evidence Ecosystem Foundation, Oslo, Norway, 0282
- . Both authors contributed equally (co-first authors)
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China, 610041
- Chinese Evidence-Based Medicine Center, Cochrane China Center and MAGIC China Center, West China Hospital, Sichuan University, Chengdu, China, 610041
| | - Daniel Rayner
- Department of Health Research Methods, Evidence and Impact, HSC 2C, Hamilton, Ontario, Canada, L8S 4L8
| | - Farid Foroutan
- Department of Health Research Methods, Evidence and Impact, HSC 2C, Hamilton, Ontario, Canada, L8S 4L8
- MAGIC Evidence Ecosystem Foundation, Oslo, Norway, 0282
- Ted Rogers Center for Heart Research, Toronto, Ontario, Canada, M5G 1X8
| | - Bert Aertgeerts
- Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium, 3000
- CEBAM, Belgian Centre for Evidence-Based Medicine, Cochrane Belgium, Leuven, Belgium, 3000
| | | | - Pauline Darbellay Farhoumand
- Division of General Internal Medicine, Department of Medicine, Hôpitaux Universitaire de Genève and University of Geneva, Geneva, Switzerland, 1205
| | | | - Anja Fog Heen
- MAGIC Evidence Ecosystem Foundation, Oslo, Norway, 0282
- Department of Medicine, Lovisenberg Diaconal Hospital, Oslo, Norway, 0456
| | - Vivekanand Jha
- George Institute for Global Health, Elegance Tower, Jasola District Centre, New Delhi, India, 110025
- School of Public Health, Imperial College London, London, UK, SW7 2AZ
- Prasanna School of Public Health, Manipal Academy of Higher Education, Madhav Nagar, Eshwar Nagar, Manipal, Karnataka, India, 576104
| | | | - Evi Nagler
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium, 9000
| | - David J Tunnicliffe
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia, 2006
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia, 2145
| | - Gordon H Guyatt
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada, L8N 3Z5
- Department of Health Research Methods, Evidence and Impact, HSC 2C, Hamilton, Ontario, Canada, L8S 4L8
- MAGIC Evidence Ecosystem Foundation, Oslo, Norway, 0282
| | - Per Olav Vandvik
- MAGIC Evidence Ecosystem Foundation, Oslo, Norway, 0282
- Department of Medicine, Innlandet Hospital Trust, Gjøvik, Norway, 2819
| | - Belen Ponte
- Division of Nephrology and Hypertension, Department of Medicine, University of Geneva, University Hospitals of Geneva, Geneva, Switzerland, 1205
- . Both authors contributed equally (co-last authors)
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence and Impact, HSC 2C, Hamilton, Ontario, Canada, L8S 4L8
- MAGIC Evidence Ecosystem Foundation, Oslo, Norway, 0282
- Division of General Internal Medicine, Department of Medicine, Hôpitaux Universitaire de Genève and University of Geneva, Geneva, Switzerland, 1205
- . Both authors contributed equally (co-last authors)
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Barnini C, Oni L, Kronbichler A. Course of paediatric ANCA-associated glomerulonephritis: advocating for an age-inclusive approach. RMD Open 2024; 10:e004481. [PMID: 39004433 PMCID: PMC11253762 DOI: 10.1136/rmdopen-2024-004481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 07/03/2024] [Indexed: 07/16/2024] Open
Affiliation(s)
- Cecilia Barnini
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Tirol, Austria
| | - Louise Oni
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
| | - Andreas Kronbichler
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Tirol, Austria
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Rossing P, Hansen TW, Kümler T. Cardiovascular and non-renal complications of chronic kidney disease: Managing risk. Diabetes Obes Metab 2024. [PMID: 38982587 DOI: 10.1111/dom.15747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 06/11/2024] [Accepted: 06/13/2024] [Indexed: 07/11/2024]
Abstract
Chronic kidney disease (CKD) currently affects approximately 850 million people globally and is continuing to increase in prevalence as well as in importance as a cause of death. The excess mortality related to CKD is mostly caused by an increase in cardiovascular disease. This includes atherosclerotic cardiovascular disease as many promoters of atherosclerosis, such as blood pressure, lipid levels and hypercoagulation, are increased in people with CKD. Diabetes is a leading cause of CKD contributing to the risk of CVD, and obesity is also increasingly prevalent. Management of these risk factors is therefore very important in CKD, and to reduce risk of CKD progression. Heart failure is also more prevalent in CKD and, again, many risk factors are shared. The concept of foundational pillars in the management of heart failure has been adapted to the treatment of CKD, with many organ-protective interventions, such renin-angiotensin system blockade, sodium-glucose cotransporter-2 inhibition and mineralocorticoid receptor antagonism, reducing the risk for mortality in heart failure with reduced ejection fraction, but also for progression of CKD. Atrial fibrillation is also more common with CKD and affects the management of the former. In this review these non-renal complications of CKD are discussed, along with how the risk of these complications should be managed. Many new opportunities have demonstrated heart and kidney organ protection, but implementation is a challenge.
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Affiliation(s)
- Peter Rossing
- Clinical Translational Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Tine Willum Hansen
- Clinical Translational Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Kümler
- Clinical Translational Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
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Wong K, Pitcher D, Braddon F, Downward L, Steenkamp R, Masoud S, Annear N, Barratt J, Bingham C, Coward RJ, Chrysochou T, Game D, Griffin S, Hall M, Johnson S, Kanigicherla D, Karet Frankl F, Kavanagh D, Kerecuk L, Maher ER, Moochhala S, Pinney J, Sayer JA, Simms R, Sinha S, Srivastava S, Tam FW, Thomas K, Turner AN, Walsh SB, Waters A, Wilson P, Wong E, Sy KTL, Huang K, Ye J, Nitsch D, Saleem M, Bockenhauer D, Bramham K, Gale DP. Description and Cross-Sectional Analyses of 25,880 Adults and Children in the UK National Registry of Rare Kidney Diseases Cohort. Kidney Int Rep 2024; 9:2067-2083. [PMID: 39081723 PMCID: PMC11284373 DOI: 10.1016/j.ekir.2024.04.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 04/24/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction The National Registry of Rare Kidney Diseases (RaDaR) collects data from people living with rare kidney diseases across the UK, and is the world's largest, rare kidney disease registry. We present the clinical demographics and renal function of 25,880 prevalent patients and sought evidence of bias in recruitment to RaDaR. Methods RaDaR is linked with the UK Renal Registry (UKRR, with which all UK patients receiving kidney replacement therapy [KRT] are registered). We assessed ethnicity and socioeconomic status in the following: (i) prevalent RaDaR patients receiving KRT compared with patients with eligible rare disease diagnoses receiving KRT in the UKRR, (ii) patients recruited to RaDaR compared with all eligible unrecruited patients at 2 renal centers, and (iii) the age-stratified ethnicity distribution of RaDaR patients with autosomal dominant polycystic kidney disease (ADPKD) was compared to that of the English census. Results We found evidence of disparities in ethnicity and social deprivation in recruitment to RaDaR; however, these were not consistent across comparisons. Compared with either adults recruited to RaDaR or the English population, children recruited to RaDaR were more likely to be of Asian ethnicity (17.3% vs. 7.5%, P-value < 0.0001) and live in more socially deprived areas (30.3% vs. 17.3% in the most deprived Index of Multiple Deprivation (IMD) quintile, P-value < 0.0001). Conclusion We observed no evidence of systematic biases in recruitment of patients into RaDaR; however, the data provide empirical evidence of negative economic and social consequences (across all ethnicities) experienced by families with children affected by rare kidney diseases.
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Affiliation(s)
- Katie Wong
- National Registry of Rare Kidney Diseases, Bristol, UK
- Department of Renal Medicine, University College London, UK
| | - David Pitcher
- National Registry of Rare Kidney Diseases, Bristol, UK
- Department of Renal Medicine, University College London, UK
| | - Fiona Braddon
- National Registry of Rare Kidney Diseases, Bristol, UK
| | | | | | - Sherry Masoud
- National Registry of Rare Kidney Diseases, Bristol, UK
- Department of Renal Medicine, University College London, UK
| | | | | | | | | | | | - David Game
- Guy’s and St Thomas’ NHS Foundation Trust, UK
| | | | | | - Sally Johnson
- Great North Children’s Hospital, Newcastle Upon Tyne, UK
| | | | | | - David Kavanagh
- National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, UK
| | | | | | | | - Jenny Pinney
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - John A. Sayer
- Translational and Clinical Research Institute, Newcastle University, UK
| | - Roslyn Simms
- Department of Infection, Academic Unit of Nephrology, Immunity and Cardiovascular Disease, University of Sheffield, UK
| | - Smeeta Sinha
- University of Manchester, UK
- Northern Care Alliance NHS Foundation Trust, UK
| | | | - Frederick W.K. Tam
- Department of Immunology and Inflammation Centre for Inflammatory Disease, Imperial College London, UK
| | - Kay Thomas
- Guy’s and St Thomas’ NHS Foundation Trust, UK
| | | | | | - Aoife Waters
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Edwin Wong
- National Renal Complement Therapeutics Centre (NRCTC), Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | | | | | | | - Dorothea Nitsch
- UK Renal Registry, Bristol, UK
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Detlef Bockenhauer
- Department of Renal Medicine, University College London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Kate Bramham
- National Registry of Rare Kidney Diseases, Bristol, UK
- King’s College London and King’s Health Partners, London, UK
| | - Daniel P. Gale
- National Registry of Rare Kidney Diseases, Bristol, UK
- Department of Renal Medicine, University College London, UK
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Nester C, Decker DA, Meier M, Aslam S, Bomback AS, Caravaca-Fontán F, Cook TH, Feldman DL, Fremeaux-Bacchi V, Gale DP, Gooch A, Johnson S, Licht C, Mathur M, Pickering MC, Praga M, Remuzzi G, Selvarajah V, Smith RJ, Tabriziani H, van de Kar N, Wang Y, Wong E, Mistry K, Lim M, Portillo C, Balogun S, Trachtman H, Thompson A. Developing Therapies for C3 Glomerulopathy: Report of the Kidney Health Initiative C3 Glomerulopathy Trial Endpoints Work Group. Clin J Am Soc Nephrol 2024; 19:01277230-990000000-00395. [PMID: 38829708 PMCID: PMC11390019 DOI: 10.2215/cjn.0000000000000505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/28/2024] [Indexed: 06/05/2024]
Abstract
Randomized clinical trials are underway to evaluate the efficacy of novel agents targeting the alternative complement pathway in patients with C3 glomerulopathy (C3G), a rare glomerular disease. The Kidney Health Initiative convened a panel of experts in C3G to ( 1 ) assess the data supporting the use of the prespecified trial end points as measures of clinical benefit and ( 2 ) opine on efficacy findings they would consider compelling as treatment(s) of C3G in native kidneys. Two subpanels of the C3G Trial Endpoints Work Group reviewed the available evidence and uncertainties for the association between the three prespecified end points-( 1 ) proteinuria, ( 2 ) eGFR, and ( 3 ) histopathology-and anticipated outcomes. The full work group provided feedback on the summaries provided by the subpanels and on what potential treatment effects on the proposed end points they would consider compelling to support evidence of an investigational product's effectiveness for treating C3G. Members of the full work group agreed with the characterization of the data, evidence, and uncertainties, supporting the end points. Given the limitations of the available data, the work group was unable to define a minimum threshold for change in any of the end points that might be considered clinically meaningful. The work group concluded that a favorable treatment effect on all three end points would provide convincing evidence of efficacy in the setting of a therapy that targeted the complement pathway. A therapy might be considered effective in the absence of complete alignment in all three end points if there was meaningful lowering of proteinuria and stabilization or improvement in eGFR. The panel unanimously supported efforts to foster data sharing between academic and industry partners to address the gaps in the current knowledge identified by the review of the end points in the aforementioned trials.
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Affiliation(s)
- Carla Nester
- Department of Pediatrics, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Dima A Decker
- Apellis Pharmaceuticals Inc., Waltham, Massachusetts
| | | | - Shakil Aslam
- BioCryst Pharmaceuticals Inc., Durham, North Carolina
| | | | | | - Terence H Cook
- Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | | | | | - Daniel P Gale
- Department of Renal Medicine, University College of London, London, United Kingdom
- Rare Kidney Disease Registry (RaDaR), Bristol, United Kingdom
| | - Ann Gooch
- BioCryst Pharmaceuticals Inc., Durham, North Carolina
| | - Sally Johnson
- Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
| | | | | | - Matthew C Pickering
- Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Manuel Praga
- Department of Medicine, Nephrology Department, Complutense University, Madrid, Spain
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Viknesh Selvarajah
- Research and Early Development, Cardiovascular, Renal and Metabolism, Biopharmaceuticals R&D, AstraZeneca, Cambridge, United Kingdom
| | - Richard J Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | | | - Nicole van de Kar
- Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University, Nijmegen, The Netherlands
| | | | - Edwin Wong
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Kirtida Mistry
- Center for the Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Mark Lim
- Kidney Health Initiative, American Society of Nephrology, Washington, DC
| | - Cesia Portillo
- Kidney Health Initiative, American Society of Nephrology, Washington, DC
| | - Seyi Balogun
- Kidney Health Initiative, American Society of Nephrology, Washington, DC
| | - Howard Trachtman
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Aliza Thompson
- Center for the Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
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Allison SJ. Progression and outcomes of rare kidney diseases. Nat Rev Nephrol 2024; 20:353. [PMID: 38671191 DOI: 10.1038/s41581-024-00844-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
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Aiyegbusi OL, Fenton A. The impact of rare kidney diseases on kidney failure. Lancet 2024; 403:1211-1213. [PMID: 38492577 DOI: 10.1016/s0140-6736(24)00198-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/31/2024] [Indexed: 03/18/2024]
Affiliation(s)
- Olalekan Lee Aiyegbusi
- Centre for Patient Reported Outcomes Research, Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK; NIHR Birmingham Biomedical Research Centre, University of Birmingham, Birmingham, UK; NIHR Applied Research Collaboration West Midlands, Birmingham, UK.
| | - Anthony Fenton
- Department of Renal Medicine, Royal Stoke University Hospital, Stoke-on-Trent, UK
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