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Vernstrøm L, Gullaksen S, Sørensen SS, Ringgaard S, Laustsen C, Birn H, Funck KL, Laugesen E, Poulsen PL. Effects of semaglutide, empagliflozin and their combination on renal diffusion-weighted MRI and total kidney volume in patients with type 2 diabetes: a post hoc analysis from a 32 week randomised trial. Diabetologia 2024:10.1007/s00125-024-06228-y. [PMID: 39078489 DOI: 10.1007/s00125-024-06228-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 05/07/2024] [Indexed: 07/31/2024]
Abstract
AIMS/HYPOTHESIS The apparent diffusion coefficient (ADC) derived from diffusion-weighted MRI (DWI-MRI) has been proposed as a measure of changes in kidney microstructure, including kidney fibrosis. In advanced kidney disease, the kidneys often become atrophic; however, in the initial phase of type 2 diabetes, there is an increase in renal size. Glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors both provide protection against progression of kidney disease in diabetes. However, the mechanisms are incompletely understood. To explore this, we examined the effects of semaglutide, empagliflozin and their combination on renal ADC and total kidney volume (TKV). METHODS This was a substudy of a randomised clinical trial on the effects of semaglutide and empagliflozin alone or in combination. Eighty patients with type 2 diabetes and high risk of CVD were randomised into four groups (n=20 in each) receiving either tablet placebo, empagliflozin, a combination of semaglutide and tablet placebo (herein referred to as the 'semaglutide' group), or the combination of semaglutide and empagliflozin (referred to as the 'combination-therapy' group). The semaglutide and the combination-therapy group had semaglutide treatment for 16 weeks and then had either tablet placebo or empagliflozin added to the treatment, respectively, for a further 16 weeks; the placebo and empagliflozin groups were treated with the respective monotherapy for 32 weeks. We analysed the effects of treatment on changes in ADC (cortical, medullary and the cortico-medullary difference [ΔADC; medullary ADC subtracted from cortical ADC]), as well as TKV measured by MRI. RESULTS Both semaglutide and empagliflozin decreased cortical ADC significantly compared with placebo (semaglutide: -0.20×10-3 mm2/s [95% CI -0.30, -0.10], p<0.001; empagliflozin: -0.15×10-3 mm2/s [95% CI -0.26, -0.04], p=0.01). No significant change was observed in the combination-therapy group (-0.05×10-3 mm2/s [95%CI -0.15, 0.05]; p=0.29 vs placebo). The changes in cortical ADC were not associated with changes in GFR, albuminuria, TKV or markers of inflammation. Further, there were no changes in medullary ADC in any of the groups compared with placebo. Only treatment with semaglutide changed ΔADC significantly from placebo, showing a decrease of -0.13×10-3 mm2/s (95% CI -0.22, -0.04; p=0.01). Compared with placebo, TKV decreased by -3% (95% CI -5%, -0.3%; p=0.04), -3% (95% CI -5%, -0.4%; p=0.02) and -5% (95% CI -8%, -2%; p<0.001) in the semaglutide, empagliflozin and combination-therapy group, respectively. The changes in TKV were associated with changes in GFR, albuminuria and HbA1c. CONCLUSIONS/INTERPRETATION In a population with type 2 diabetes and high risk of CVD, semaglutide and empagliflozin significantly reduced cortical ADC compared with placebo, indicating microstructural changes in the kidneys. These changes were not associated with changes in GFR, albuminuria or inflammation. Further, we found a decrease in TKV in all active treatment groups, which was possibly mediated by a reduction in hyperfiltration. Our findings suggest that DWI-MRI may serve as a promising tool for investigating the underlying mechanisms of medical interventions in individuals with type 2 diabetes but may reflect effects not related to fibrosis. TRIAL REGISTRATION European Union Drug Regulating Authorities Clinical Trials Database (EudraCT) 2019-000781-38.
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Affiliation(s)
- Liv Vernstrøm
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark.
- Steno Diabetes Center, Aarhus University Hospital, Aarhus, Denmark.
| | - Søren Gullaksen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Regional Hospital Horsens, Horsens, Denmark
| | - Steffen S Sørensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Henrik Birn
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Kristian L Funck
- Steno Diabetes Center, Aarhus University Hospital, Aarhus, Denmark
| | - Esben Laugesen
- Steno Diabetes Center, Aarhus University Hospital, Aarhus, Denmark
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Per L Poulsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Steno Diabetes Center, Aarhus University Hospital, Aarhus, Denmark
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Reiss AB, Jacob B, Zubair A, Srivastava A, Johnson M, De Leon J. Fibrosis in Chronic Kidney Disease: Pathophysiology and Therapeutic Targets. J Clin Med 2024; 13:1881. [PMID: 38610646 PMCID: PMC11012936 DOI: 10.3390/jcm13071881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/14/2024] Open
Abstract
Chronic kidney disease (CKD) is a slowly progressive condition characterized by decreased kidney function, tubular injury, oxidative stress, and inflammation. CKD is a leading global health burden that is asymptomatic in early stages but can ultimately cause kidney failure. Its etiology is complex and involves dysregulated signaling pathways that lead to fibrosis. Transforming growth factor (TGF)-β is a central mediator in promoting transdifferentiation of polarized renal tubular epithelial cells into mesenchymal cells, resulting in irreversible kidney injury. While current therapies are limited, the search for more effective diagnostic and treatment modalities is intensive. Although biopsy with histology is the most accurate method of diagnosis and staging, imaging techniques such as diffusion-weighted magnetic resonance imaging and shear wave elastography ultrasound are less invasive ways to stage fibrosis. Current therapies such as renin-angiotensin blockers, mineralocorticoid receptor antagonists, and sodium/glucose cotransporter 2 inhibitors aim to delay progression. Newer antifibrotic agents that suppress the downstream inflammatory mediators involved in the fibrotic process are in clinical trials, and potential therapeutic targets that interfere with TGF-β signaling are being explored. Small interfering RNAs and stem cell-based therapeutics are also being evaluated. Further research and clinical studies are necessary in order to avoid dialysis and kidney transplantation.
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Affiliation(s)
- Allison B. Reiss
- Department of Medicine and Biomedical Research Institute, NYU Grossman Long Island School of Medicine, Mineola, NY 11501, USA; (B.J.); (A.Z.); (A.S.); (M.J.); (J.D.L.)
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Friedli I, Baid-Agrawal S, Unwin R, Morell A, Johansson L, Hockings PD. Magnetic Resonance Imaging in Clinical Trials of Diabetic Kidney Disease. J Clin Med 2023; 12:4625. [PMID: 37510740 PMCID: PMC10380287 DOI: 10.3390/jcm12144625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
Chronic kidney disease (CKD) associated with diabetes mellitus (DM) (known as diabetic kidney disease, DKD) is a serious and growing healthcare problem worldwide. In DM patients, DKD is generally diagnosed based on the presence of albuminuria and a reduced glomerular filtration rate. Diagnosis rarely includes an invasive kidney biopsy, although DKD has some characteristic histological features, and kidney fibrosis and nephron loss cause disease progression that eventually ends in kidney failure. Alternative sensitive and reliable non-invasive biomarkers are needed for DKD (and CKD in general) to improve timely diagnosis and aid disease monitoring without the need for a kidney biopsy. Such biomarkers may also serve as endpoints in clinical trials of new treatments. Non-invasive magnetic resonance imaging (MRI), particularly multiparametric MRI, may achieve these goals. In this article, we review emerging data on MRI techniques and their scientific, clinical, and economic value in DKD/CKD for diagnosis, assessment of disease pathogenesis and progression, and as potential biomarkers for clinical trial use that may also increase our understanding of the efficacy and mode(s) of action of potential DKD therapeutic interventions. We also consider how multi-site MRI studies are conducted and the challenges that should be addressed to increase wider application of MRI in DKD.
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Affiliation(s)
- Iris Friedli
- Antaros Medical, BioVenture Hub, 43183 Mölndal, Sweden
| | - Seema Baid-Agrawal
- Transplant Center, Sahlgrenska University Hospital, University of Gothenburg, 41345 Gothenburg, Sweden
| | - Robert Unwin
- AstraZeneca R&D BioPharmaceuticals, Translational Science and Experimental Medicine, Early Cardiovascular, Renal & Metabolic Diseases (CVRM), Granta Park, Cambridge CB21 6GH, UK
| | - Arvid Morell
- Antaros Medical, BioVenture Hub, 43183 Mölndal, Sweden
| | | | - Paul D Hockings
- Antaros Medical, BioVenture Hub, 43183 Mölndal, Sweden
- MedTech West, Chalmers University of Technology, 41345 Gothenburg, Sweden
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Emergent players in renovascular disease. Clin Sci (Lond) 2022; 136:239-256. [PMID: 35129198 DOI: 10.1042/cs20210509] [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: 11/02/2021] [Revised: 01/25/2022] [Accepted: 01/26/2022] [Indexed: 02/07/2023]
Abstract
Renovascular disease (RVD) remains a common etiology of secondary hypertension. Recent clinical trials revealed unsatisfactory therapeutic outcomes of renal revascularization, leading to extensive investigation to unravel key pathophysiological mechanisms underlying irreversible functional loss and structural damage in the chronically ischemic kidney. Research studies identified complex interactions among various players, including inflammation, fibrosis, mitochondrial injury, cellular senescence, and microvascular remodeling. This interplay resulted in a shift of our understanding of RVD from a mere hemodynamic disorder to a pro-inflammatory and pro-fibrotic pathology strongly influenced by systemic diseases like metabolic syndrome (MetS), hypertension, diabetes mellitus, and hyperlipidemia. Novel diagnostic approaches have been tested for early detection and follow-up of RVD progression, using new imaging techniques and biochemical markers of renal injury and dysfunction. Therapies targeting some of the pathological pathways governing the development of RVD have shown promising results in animal models, and a few have moved from bench to clinical research. This review summarizes evolving understanding in chronic ischemic kidney injury.
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Berchtold L, Crowe LA, Combescure C, Kassaï M, Aslam I, Legouis D, Moll S, Martin PY, de Seigneux S, Vallée JP. Diffusion-Magnetic Resonance Imaging predicts decline of kidney function in chronic kidney disease and in patients with a kidney allograft. Kidney Int 2022; 101:804-813. [PMID: 35031327 DOI: 10.1016/j.kint.2021.12.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 11/22/2021] [Accepted: 12/09/2021] [Indexed: 12/21/2022]
Abstract
Kidney cortical interstitial fibrosis is highly predictive of kidney prognosis and is currently assessed by evaluation of a biopsy. Diffusion-weighted magnetic resonance imaging is a promising non-invasive tool to evaluate kidney fibrosis. We recently adapted diffusion-weighted imaging sequence for discrimination between the kidney cortex and medulla and found that the cortico-medullary difference in apparent diffusion coefficient (ΔADC) correlated with histological interstitial fibrosis. Here, we assessed whether ΔADC as measured with diffusion-weighted magnetic resonance imaging is predictive of kidney function decline and dialysis initiation in chronic kidney disease (CKD) and patients with a kidney allograft in a prospective study encompassing 197 patients. We measured ΔADC in 43 patients with CKD (estimated GFR (eGFR) 55ml/min/1.73m2) and 154 patients with a kidney allograft (eGFR 53ml/min/1.73m2). Patients underwent a kidney biopsy and diffusion-weighted magnetic resonance imaging within one week of biopsy; median follow-up of 2.2 years with measured laboratory parameters. The primary outcome was a rapid decline of kidney function (eGFR decline over 30% or dialysis initiation) during follow up. Significantly, patients with a negative ΔADC had 5.4 times more risk of rapid decline of kidney function or dialysis (95% confidence interval: 2.29-12.58). After correction for kidney function at baseline and proteinuria, low ADC still predicted significant kidney function loss with a hazard ratio of 4.62 (95% confidence interval 1.56-13.67) independent of baseline age, sex, eGFR and proteinuria. Thus, low ΔADC can be a predictor of kidney function decline and dialysis initiation in patients with native kidney disease or kidney allograft, independent of baseline kidney function and proteinuria.
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Affiliation(s)
- Lena Berchtold
- Service and Laboratory of Nephrology, Department of Internal Medicine Specialties and of Physiology and Metabolism, University and University Hospital of Geneva, Geneva, Switzerland.
| | - Lindsey A Crowe
- Service of Radiology, Department of Radiology and Medical Informatics, University and University Hospital of Geneva, Geneva, Switzerland
| | - Christophe Combescure
- Division of Clinical-Epidemiology, Department of Health and Community Medicine, University of Geneva and University Hospitals of Geneva, Geneva, Switzerland
| | - Miklos Kassaï
- Service of Radiology, Department of Radiology and Medical Informatics, University and University Hospital of Geneva, Geneva, Switzerland
| | - Ibtisam Aslam
- Service of Radiology, Department of Radiology and Medical Informatics, University and University Hospital of Geneva, Geneva, Switzerland
| | - David Legouis
- Intensive Care Unit, Department of Anaesthesiology, Pharmacology and Intensive Care, University of Geneva, Geneva, Switzerland
| | - Solange Moll
- Institute of Clinical Pathology, Department of Clinical Pathology, University Hospital of Geneva, Geneva, Switzerland
| | - Pierre-Yves Martin
- Service and Laboratory of Nephrology, Department of Internal Medicine Specialties and of Physiology and Metabolism, University and University Hospital of Geneva, Geneva, Switzerland
| | - Sophie de Seigneux
- Service and Laboratory of Nephrology, Department of Internal Medicine Specialties and of Physiology and Metabolism, University and University Hospital of Geneva, Geneva, Switzerland
| | - Jean-Paul Vallée
- Service of Radiology, Department of Radiology and Medical Informatics, University and University Hospital of Geneva, Geneva, Switzerland
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Periquito JS, Gladytz T, Millward JM, Delgado PR, Cantow K, Grosenick D, Hummel L, Anger A, Zhao K, Seeliger E, Pohlmann A, Waiczies S, Niendorf T. Continuous diffusion spectrum computation for diffusion-weighted magnetic resonance imaging of the kidney tubule system. Quant Imaging Med Surg 2021; 11:3098-3119. [PMID: 34249638 DOI: 10.21037/qims-20-1360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/08/2021] [Indexed: 12/24/2022]
Abstract
Background The use of rigid multi-exponential models (with a priori predefined numbers of components) is common practice for diffusion-weighted MRI (DWI) analysis of the kidney. This approach may not accurately reflect renal microstructure, as the data are forced to conform to the a priori assumptions of simplified models. This work examines the feasibility of less constrained, data-driven non-negative least squares (NNLS) continuum modelling for DWI of the kidney tubule system in simulations that include emulations of pathophysiological conditions. Methods Non-linear least squares (LS) fitting was used as reference for the simulations. For performance assessment, a threshold of 5% or 10% for the mean absolute percentage error (MAPE) of NNLS and LS results was used. As ground truth, a tri-exponential model using defined volume fractions and diffusion coefficients for each renal compartment (tubule system: Dtubules , ftubules ; renal tissue: Dtissue , ftissue ; renal blood: Dblood , fblood ;) was applied. The impact of: (I) signal-to-noise ratio (SNR) =40-1,000, (II) number of b-values (n=10-50), (III) diffusion weighting (b-rangesmall =0-800 up to b-rangelarge =0-2,180 s/mm2), and (IV) fixation of the diffusion coefficients Dtissue and Dblood was examined. NNLS was evaluated for baseline and pathophysiological conditions, namely increased tubular volume fraction (ITV) and renal fibrosis (10%: grade I, mild) and 30% (grade II, moderate). Results NNLS showed the same high degree of reliability as the non-linear LS. MAPE of the tubular volume fraction (ftubules ) decreased with increasing SNR. Increasing the number of b-values was beneficial for ftubules precision. Using the b-rangelarge led to a decrease in MAPE ftubules compared to b-rangesmall. The use of a medium b-value range of b=0-1,380 s/mm2 improved ftubules precision, and further bmax increases beyond this range yielded diminishing improvements. Fixing Dblood and Dtissue significantly reduced MAPE ftubules and provided near perfect distinction between baseline and ITV conditions. Without constraining the number of renal compartments in advance, NNLS was able to detect the (fourth) fibrotic compartment, to differentiate it from the other three diffusion components, and to distinguish between 10% vs. 30% fibrosis. Conclusions This work demonstrates the feasibility of NNLS modelling for DWI of the kidney tubule system and shows its potential for examining diffusion compartments associated with renal pathophysiology including ITV fraction and different degrees of fibrosis.
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Affiliation(s)
- Joāo S Periquito
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany.,Institute of Physiology, Charité - Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany.,Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Thomas Gladytz
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Jason M Millward
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Paula Ramos Delgado
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany.,Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Kathleen Cantow
- Institute of Physiology, Charité - Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Dirk Grosenick
- Physikalisch-Technische Bundesanstalt (PTB), Berlin, Germany
| | - Luis Hummel
- Institute of Physiology, Charité - Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Ariane Anger
- Institute of Physiology, Charité - Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Kaixuan Zhao
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Erdmann Seeliger
- Institute of Physiology, Charité - Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Andreas Pohlmann
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Sonia Waiczies
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Thoralf Niendorf
- Berlin Ultrahigh Field Facility (B.U.F.F.), Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany.,Experimental and Clinical Research Center, a Joint Cooperation between the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
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Caroli A, Remuzzi A, Lerman LO. Basic principles and new advances in kidney imaging. Kidney Int 2021; 100:1001-1011. [PMID: 33984338 DOI: 10.1016/j.kint.2021.04.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 12/12/2022]
Abstract
Over the past few years, clinical renal imaging has seen great advances, allowing assessments of kidney structure and morphology, perfusion, function and metabolism, and oxygenation, as well as microstructure and the interstitium. Medical imaging is becoming increasingly important in the evaluation of kidney physiology and pathophysiology, showing promise in management of patients with renal disease, in particular with regard to diagnosis, classification, and prediction of disease development and progression, monitoring response to therapy, detection of drug toxicity, and patient selection for clinical trials. A variety of imaging modalities, ranging from routine to advanced tools, are currently available to probe the kidney both spatially and temporally, particularly ultrasonography, computed tomography, positron emission tomography, renal scintigraphy, and multiparametric magnetic resonance imaging. Given that the range is broad and varied, kidney imaging techniques should be chosen based on the clinical question and the specific underlying pathologic mechanism, taking into account contraindications and possible adverse effects. Integration of various modalities providing complementary information will likely provide the greatest insight into renal pathophysiology. This review aims to highlight major recent advances in key tools that are currently available or potentially relevant for clinical kidney imaging, with a focus on non-oncological applications. The review also outlines the context of use, limitations, and advantages of various techniques, and highlights gaps to be filled with future development and clinical adoption.
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Affiliation(s)
- Anna Caroli
- Bioengineering Department, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy.
| | - Andrea Remuzzi
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (Bergamo), Italy
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
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