Label-free whole blood cell differentiation based on multiple frequency AC impedance and light scattering analysis in a micro flow cytometer

Photothermal Enhancement of Ion Current for Red Blood Cell Flow Cytometry

Blood cell counting typically requires complex machinery. Flow cytometers used for this purpose involve precise optical alignment, costly detectors, and pretreatment with fluorescent labels. Coulter countertype devices, which monitor ion current, are simpler. However, conventional Coulter counters provide only information about size, making it impossible to distinguish similarly sized lymphocytes from red blood cells (RBCs). Inspired by the fact that RBCs have an exceptionally high propensity to absorb light and convert it to heat, i.e., photothermal effect, this study proposes integrating photothermal phenomena into a microfluidic Coulter counting chip. Photothermal heat selectively amplifies the ion current from RBCs over other components including lymphocytes. The combination of ion current monitoring and the photothermal effect for RBC counting suggests an evolution toward versatile flow cytometers.

Optimizing Microfluidic Impedance Cytometry by Bypass Electrode Layout Design

Microfluidic impedance cytometry (MIC) has emerged as a popular technique for single-cell analysis. Traditional MIC electrode designs consist of a pair of (or three) working electrodes, and their detection performance needs further improvements for microorganisms. In this study, we designed an 8-electrode MIC device in which the center pair was defined as the working electrode, and the connection status of bypass electrodes could be changed. This allowed us to compare the performance of layouts with no bypasses and those with floating or grounding electrodes by simulation and experiment. The results of detecting Φ 5 μm beads revealed that both the grounding and the floating electrode outperformed the no bypass electrode, and the grounding electrode demonstrated the best signal-to-noise ratio (SNR), coefficient of variation (CV), and detection sensitivity. Furthermore, the effects of different bypass grounding areas (numbers of grounding electrodes) were investigated. Finally, particles passing at high horizontal positions can be detected, and Φ 1 μm beads can be measured in a wide channel (150 μm) using a fully grounding electrode, with the sensitivity of bead volume detection reaching 0.00097%. This provides a general MIC electrode optimization technology for detecting smaller particles, even macromolecular proteins, viruses, and exosomes in the future.

PM2.5 induces a senescent state in mouse AT2 cells

PM2.5 is known to induce lung injury, but its toxic effects on lung regenerative machinery and the underlying mechanisms remain unknown. In this study, primary mouse alveolar type 2 (AT2) cells, considered stem cells in the gas-exchange barrier, were sorted using fluorescence-activated cell sorting. By developing microfluidic technology with constricted microchannels, we observed that both passage time and impedance opacities of mouse AT2 cells were reduced after PM2.5, indicating that PM2.5 induced a more deformable mechanical property and a higher membrane permeability. In vitro organoid cultures of primary mouse AT2 cells indicated that PM2.5 is able to impair the proliferative potential and self-renewal capacity of AT2 cells but does not affect AT1 differentiation. Furthermore, cell senescence biomarkers, p53 and γ-H2A.X at protein levels, P16ink4a and P21 at mRNA levels were increased in primary mouse AT2 cells after PM2.5 stimulations as shown by immunofluorescent staining and quantitative PCR analysis. Using several advanced single-cell technologies, this study sheds light on new mechanisms of the cytotoxic effects of atmospheric fine particulate matter on lung stem cell behavior.

Microfluidic impedance cytometry with flat-end cylindrical electrodes for accurate and fast analysis of marine microalgae

Marine microalgae play an increasingly significant role in addressing the issues of environmental monitoring and disease treatment, making the analysis of marine microalgae at the single-cell level an essential technique. For this, we put forward accurate and fast microfluidic impedance cytometry to analyze microalgal cells by assembling two cylindrical electrodes and microchannels to form a three-dimensional detection zone. Firstly, we established a mathematical model of microalgal cell detection based on Maxwell's mixture theory and numerically investigated the effects of the electrode gap, microalgal positions, and ion concentrations of the solution on detection to optimize detection conditions. Secondly, 80 μm stainless steel wires were used to construct flat-ended cylindrical electrodes and were then inserted into two collinear channels fabricated using standard photolithography techniques to form a spatially uniform electric field to promote the detection throughput and sensitivity. Thirdly, based on the validation of this method, we measured the impedance of living Euglena and Haematococcus pluvialis to study parametric influences, including ion concentration, cell density and electrode gap. The throughput of this method was also investigated, which reached 1800 cells per s in the detection of Haematococcus pluvialis. Fourthly, we analyzed live and dead Euglena to prove the ability of this method to detect the physiological status of cells and obtained impedances of 124.3 Ω and 31.0 Ω with proportions of 15.9% and 84.1%, respectively. Finally, this method was engineered for the analysis of marine microalgae, measuring living Euglena with an impedance of 159.61 Ω accounting for 3.9%, dead Euglena with an impedance of 36.43 Ω accounting for 10.1% and Oocystis sp. with an impedance of 55.00 Ω accounting for about 81.0%. This method could provide a reliable tool to analyze marine microalgae for monitoring the marine environment and treatment of diseases owing to its outstanding advantages of low cost, high throughput and high corrosion resistance.

A review on intelligent impedance cytometry systems: Development, applications and advances

Impedance cytometry is a well-established technique for counting and analyzing single cells, with several advantages, such as convenience, high throughput, and no labeling required. A typical experiment consists of the following steps: single-cell measurement, signal processing, data calibration, and particle subtype identification. At the beginning of this article, we compared commercial and self-developed options extensively and provided references for developing reliable detection systems, which are necessary for cell measurement. Then, a number of typical impedance metrics and their relationships to biophysical properties of cells were analyzed with respect to the impedance signal analysis. Given the rapid advances of intelligent impedance cytometry in the past decade, this article also discussed the development of representative machine learning-based approaches and systems, and their applications in data calibration and particle identification. Finally, the remaining challenges facing the field were summarized, and potential future directions for each step of impedance detection were discussed.

piRT-IFC: Physics-informed real-time impedance flow cytometry for the characterization of cellular intrinsic electrical properties

Real-time transformation was important for the practical implementation of impedance flow cytometry. The major obstacle was the time-consuming step of translating raw data to cellular intrinsic electrical properties (e.g., specific membrane capacitance Csm and cytoplasm conductivity σcyto). Although optimization strategies such as neural network-aided strategies were recently reported to provide an impressive boost to the translation process, simultaneously achieving high speed, accuracy, and generalization capability is still challenging. To this end, we proposed a fast parallel physical fitting solver that could characterize single cells' Csm and σcyto within 0.62 ms/cell without any data preacquisition or pretraining requirements. We achieved the 27000-fold acceleration without loss of accuracy compared with the traditional solver. Based on the solver, we implemented physics-informed real-time impedance flow cytometry (piRT-IFC), which was able to characterize up to 100,902 cells' Csm and σcyto within 50 min in a real-time manner. Compared to the fully connected neural network (FCNN) predictor, the proposed real-time solver showed comparable processing speed but higher accuracy. Furthermore, we used a neutrophil degranulation cell model to represent tasks to test unfamiliar samples without data for pretraining. After being treated with cytochalasin B and N-Formyl-Met-Leu-Phe, HL-60 cells underwent dynamic degranulation processes, and we characterized cell's Csm and σcyto using piRT-IFC. Compared to the results from our solver, accuracy loss was observed in the results predicted by the FCNN, revealing the advantages of high speed, accuracy, and generalizability of the proposed piRT-IFC.

Label-free microfluidic cell sorting and detection for rapid blood analysis

Blood tests are considered as standard clinical procedures to screen for markers of diseases and health conditions. However, the complex cellular background (>99.9% RBCs) and biomolecular composition often pose significant technical challenges for accurate blood analysis. An emerging approach for point-of-care blood diagnostics is utilizing "label-free" microfluidic technologies that rely on intrinsic cell properties for blood fractionation and disease detection without any antibody binding. A growing body of clinical evidence has also reported that cellular dysfunction and their biophysical phenotypes are complementary to standard hematoanalyzer analysis (complete blood count) and can provide a more comprehensive health profiling. In this review, we will summarize recent advances in microfluidic label-free separation of different blood cell components including circulating tumor cells, leukocytes, platelets and nanoscale extracellular vesicles. Label-free single cell analysis of intrinsic cell morphology, spectrochemical properties, dielectric parameters and biophysical characteristics as novel blood-based biomarkers will also be presented. Next, we will highlight research efforts that combine label-free microfluidics with machine learning approaches to enhance detection sensitivity and specificity in clinical studies, as well as innovative microfluidic solutions which are capable of fully integrated and label-free blood cell sorting and analysis. Lastly, we will envisage the current challenges and future outlook of label-free microfluidics platforms for high throughput multi-dimensional blood cell analysis to identify non-traditional circulating biomarkers for clinical diagnostics.

Advances in Microfluidics for Single Red Blood Cell Analysis

The utilizations of microfluidic chips for single RBC (red blood cell) studies have attracted great interests in recent years to filter, trap, analyze, and release single erythrocytes for various applications. Researchers in this field have highlighted the vast potential in developing micro devices for industrial and academia usages, including lab-on-a-chip and organ-on-a-chip systems. This article critically reviews the current state-of-the-art and recent advances of microfluidics for single RBC analyses, including integrated sensors and microfluidic platforms for microscopic/tomographic/spectroscopic single RBC analyses, trapping arrays (including bifurcating channels), dielectrophoretic and agglutination/aggregation studies, as well as clinical implications covering cancer, sepsis, prenatal, and Sickle Cell diseases. Microfluidics based RBC microarrays, sorting/counting and trapping techniques (including acoustic, dielectrophoretic, hydrodynamic, magnetic, and optical techniques) are also reviewed. Lastly, organs on chips, multi-organ chips, and drug discovery involving single RBC are described. The limitations and drawbacks of each technology are addressed and future prospects are discussed.

A Review on Microfluidics-Based Impedance Biosensors

Electrical impedance biosensors are powerful and continuously being developed for various biological sensing applications. In this line, the sensitivity of impedance biosensors embedded with microfluidic technologies, such as sheath flow focusing, dielectrophoretic focusing, and interdigitated electrode arrays, can still be greatly improved. In particular, reagent consumption reduction and analysis time-shortening features can highly increase the analytical capabilities of such biosensors. Moreover, the reliability and efficiency of analyses are benefited by microfluidics-enabled automation. Through the use of mature microfluidic technology, complicated biological processes can be shrunk and integrated into a single microfluidic system (e.g., lab-on-a-chip or micro-total analysis systems). By incorporating electrical impedance biosensors, hand-held and bench-top microfluidic systems can be easily developed and operated by personnel without professional training. Furthermore, the impedance spectrum provides broad information regarding cell size, membrane capacitance, cytoplasmic conductivity, and cytoplasmic permittivity without the need for fluorescent labeling, magnetic modifications, or other cellular treatments. In this review article, a comprehensive summary of microfluidics-based impedance biosensors is presented. The structure of this article is based on the different substrate material categorizations. Moreover, the development trend of microfluidics-based impedance biosensors is discussed, along with difficulties and challenges that may be encountered in the future.

Microfluidic flow cytometry for blood-based biomarker analysis

Flow cytometry has proven its capability for rapid and quantitative analysis of individual cells and the separation of targeted biological samples from others. The emerging microfluidics technology makes it possible to develop portable microfluidic diagnostic devices for point-of-care testing (POCT) applications. Microfluidic flow cytometry (MFCM), where flow cytometry and microfluidics are combined to achieve similar or even superior functionalities on microfluidic chips, provides a powerful single-cell characterisation and sorting tool for various biological samples. In recent years, researchers have made great progress in the development of the MFCM including focusing, detecting, and sorting subsystems, and its unique capabilities have been demonstrated in various biological applications. Moreover, liquid biopsy using blood can provide various physiological and pathological information. Thus, biomarkers from blood are regarded as meaningful circulating transporters of signal molecules or particles and have great potential to be used as non (or minimally)-invasive diagnostic tools. In this review, we summarise the recent progress of the key subsystems for MFCM and its achievements in blood-based biomarker analysis. Finally, foresight is offered to highlight the research challenges faced by MFCM in expanding into blood-based POCT applications, potentially yielding commercialisation opportunities.

Microfluidic Impedance-Deformability Cytometry for Label-Free Single Neutrophil Mechanophenotyping

The intrinsic biophysical states of neutrophils are associated with immune dysfunctions in diseases. While advanced image-based biophysical flow cytometers can probe cell deformability at high throughput, it is nontrivial to couple different sensing modalities (e.g., electrical) to measure other critical cell attributes including cell viability and membrane integrity. Herein, an "optics-free" impedance-deformability cytometer for multiparametric single cell mechanophenotyping is reported. The microfluidic platform integrates hydrodynamic cell pinching, and multifrequency impedance quantification of cell size, deformability, and membrane impedance (indicative of cell viability and activation). A newly-defined "electrical deformability index" is validated by numerical simulations, and shows strong correlations with the optical cell deformability index of HL-60 experimentally. Human neutrophils treated with various biochemical stimul are further profiled, and distinct differences in multimodal impedance signatures and UMAP analysis are observed. Overall, the integrated cytometer enables label-free cell profiling at throughput of >1000 cells min^-1 without any antibodies labeling to facilitate clinical diagnostics.

Systematic analysis of frequency dependent differential photoacoustic cross-section data for source size estimation

A frequency dependent differential photoacoustic cross-section (DPACS) over a large frequency band (100-1000 MHz) was computed, and subsequently, morphological parameters of a photoacoustic (PA) source were quantified. The Green's function approach was utilized for calculating the DPACS for spheroidal droplets with varying aspect ratios, Chebyshev particles with different waviness and deformation parameters, and normal red blood cells and cells affected by hereditary disorders (e.g., spherocytosis, elliptocytosis, and stomatocytosis). The theoretical framework considers that PA waves propagate through an acoustically dispersive and absorbing medium and are detected by a planar detector of finite size. The frequency dependent DPACS profile was fitted with tri-axial ellipsoid, finite cylinder, and toroid form factor models to obtain size and shape information of the PA source. The tri-axial ellipsoid form factor model was found to provide better estimates of the shape parameters compared to other models for a variety of sources. The inverse problem framework may motivate developing PA-based technology to assess single-cell morphology.

Nanocytometer for smart analysis of peripheral blood and acute myeloid leukemia: a pilot study

We realize an ultracompact nanocytometer for real-time impedimetric detection and classification of subpopulations of living cells. Nanoscopic nanowires in a microfluidic channel act as nanocapacitors and measure in real time the change of the amplitude and phase of the output voltage and, thus, the electrical properties of living cells. We perform the cell classification in the human peripheral blood (PBMC) and demonstrate for the first time the possibility to discriminate monocytes and subpopulations of lymphocytes in a label-free format. Further, we demonstrate that the PBMC of acute myeloid leukemia and healthy samples grant the label free identification of the disease. Using the algorithm based on machine learning, we generated specific data patterns to discriminate healthy donors and leukemia patients. Such a solution has the potential to improve the traditional diagnostics approaches with respect to the overall cost and time effort, in a label-free format, and restrictions of the complex data analysis.

Particle Self-Aligning, Focusing, and Electric Impedance Microcytometer Device for Label-Free Single Cell Morphology Discrimination and Yeast Budding Analysis

Microfluidic electric impedance flow cytometry (IFC) devices have been applied in single cell analysis, such as cell counting, volume discrimination, cell viability, etc. A cell's shape provides specific information about cellular physiological and pathological conditions, especially in microorganisms such as yeast. In this study, the particle orientation focusing was theoretically analyzed and realized by hydrodynamics. The pulse width (passing time for the particles) of the conductance signal was used to discriminate particle shapes. Spherical and rod-shaped particles with similar volumes/lengths were differentiated by the IFC device, using the impedance pulse parameters of the events. Then, typical late-budding, early budding, and unbudded yeast cells were distinguished by the width, amplitude, and ratio of width to amplitude (R) of the impedance pulse. The pulse amplitude and the R combination gate for identifying the late-budding yeast was estimated through the statistic results. Using the gate, the late-budding rates under different conditions were calculated. Late-budding rates obtained using our method showed a high correlation (R² = 0.83) with the manual cell counting result and represented the budding status of yeast cells under different conditions proficiently. Thus, the late-budding rate calculated using the above method can be used as a qualitative parameter to assess the reproductive performance of yeast and whether a yeast culturing environment is optimal. This IFC device and cell shape discrimination method is very simple and could be applied in the fermentation industry and other microorganisms' discrimination as a rapid analysis technique in the future.

Toward point-of-care assessment of patient response: a portable tool for rapidly assessing cancer drug efficacy using multifrequency impedance cytometry and supervised machine learning

We present a novel method to rapidly assess drug efficacy in targeted cancer therapy, where antineoplastic agents are conjugated to antibodies targeting surface markers on tumor cells. We have fabricated and characterized a device capable of rapidly assessing tumor cell sensitivity to drugs using multifrequency impedance spectroscopy in combination with supervised machine learning for enhanced classification accuracy. Currently commercially available devices for the automated analysis of cell viability are based on staining, which fundamentally limits the subsequent characterization of these cells as well as downstream molecular analysis. Our approach requires as little as 20 μL of volume and avoids staining allowing for further downstream molecular analysis. To the best of our knowledge, this manuscript presents the first comprehensive attempt to using high-dimensional data and supervised machine learning, particularly phase change spectra obtained from multi-frequency impedance cytometry as features for the support vector machine classifier, to assess viability of cells without staining or labelling.

Integrated inertial-impedance cytometry for rapid label-free leukocyte isolation and profiling of neutrophil extracellular traps (NETs)

Circulating leukocytes are indispensable components of the immune system, and rapid analysis of their native state or functionalities can help to unravel their pathophysiological roles and identify novel prognostic biomarkers in health and diseases. Herein we report a novel high throughput "sample-in-answer-out" integrated platform for continuous leukocyte sorting and single-cell electrical profiling in a label-free manner. The multi-staged platform enables isolation of neutrophils and monocytes from diluted or lysed blood samples directly within minutes based on Dean flow fractionation (DFF) (stage 1). Next DFF-purified leukocytes are inertially focused in serpentine channels into a single stream (stage 2) prior to impedance detection (stage 3). As a proof-of-concept for neutrophil functional characterization towards diabetes testing, we characterized the formation of neutrophil extracellular traps (NETosis) of healthy and glucose-treated neutrophils and observed significant changes in dielectric properties (size and opacity) between both groups. Interestingly, the NETosis profiles induced by calcium ionophore (CaI) and phorbol 12-myristate 13-acetate (PMA) were also electrically different, which could be attributed to the differential rates of cell enlargement and attenuated membrane permeability. Taken together, these results clearly demonstrated the potential of the developed platform for rapid (∼mins) and label-free leukocyte profiling and the use of impedance signatures as novel functional biomarkers for point-of-care testing in diabetes.

A Microfluidic Split-Flow Technology for Product Characterization in Continuous Low-Volume Nanoparticle Synthesis

A key aspect of microfluidic processes is their ability to perform chemical reactions in small volumes under continuous flow. However, a continuous process requires stable reagent flow over a prolonged period. This can be challenging in microfluidic systems, as bubbles or particles easily block or alter the flow. Online analysis of the product stream can alleviate this problem by providing a feedback signal. When this signal exceeds a pre-defined range, the process can be re-adjusted or interrupted to prevent contamination. Here we demonstrate the feasibility of this concept by implementing a microfluidic detector downstream of a segmented-flow system for the synthesis of lipid nanoparticles. To match the flow rate through the detector to the measurement bandwidth independent of the synthesis requirements, a small stream is sidelined from the original product stream and routed through a measuring channel with 2 × 2 µm cross-section. The small size of the measuring channel prevents the entry of air plugs, which are inherent to our segmented flow synthesis device. Nanoparticles passing through the small channel were detected and characterized by quantitative fluorescence measurements. With this setup, we were able to count single nanoparticles. This way, we were able to detect changes in the particle synthesis affecting the size, concentration, or velocity of the particles in suspension. We envision that the flow-splitting scheme demonstrated here can be transferred to detection methods other than fluorescence for continuous monitoring and feedback control of microfluidic nanoparticle synthesis.

A flow focusing microfluidic device with an integrated Coulter particle counter for production, counting and size characterization of monodisperse microbubbles

Flow focusing microfluidic devices (FFMDs) have been investigated for the production of monodisperse populations of microbubbles for chemical, biomedical and mechanical engineering applications. High-speed optical microscopy is commonly used to monitor FFMD microbubble production parameters, such as diameter and production rate, but this limits the scalability and portability of the approach. In this work, a novel FFMD design featuring integrated electronics for measuring microbubble diameters and production rates is presented. A micro Coulter particle counter (μCPC), using electrodes integrated within the expanding nozzle of an FFMD (FFMD-μCPC), was designed, fabricated and tested. Finite element analysis (FEA) of optimal electrode geometry was performed and validated with experimental data. Electrical data was collected for 8-20 μm diameter microbubbles at production rates up to 3.25 × 105 MB s-1 and compared to both high-speed microscopy data and FEA simulations. Within a valid operating regime, Coulter counts of microbubble production rates matched optical reference values. The Coulter method agreed with the optical reference method in evaluating the microbubble diameter to a coefficient of determination of R2 = 0.91.

Label-free leukocyte sorting and impedance-based profiling for diabetes testing

Circulating leukocytes comprise of approximately 1% of all blood cells and efficient enrichment of these cells from whole blood is critical for understanding cellular heterogeneity and biological significance in health and diseases. In this work, we report a novel microfluidic strategy for rapid (< 1 h) label-free leukocyte sorting and impedance-based profiling to determine cell activation in type 2 diabetes mellitus (T2DM) using whole blood. Leukocytes were first size-fractionated into different subtypes (neutrophils, monocytes, lymphocytes) using an inertial spiral sorter prior to single-cell impedance measurement in a microfluidic device with coplanar electrode design. Significant changes in membrane dielectric properties (size and opacity) were detected between healthy and activated leukocytes (TNF-α/LPS stimulated), during monocyte differentiation and among different monocyte subsets (classical, intermediate, non-classical). As proof-of-concept for diabetes testing, neutrophil/monocyte dielectric properties in T2DM subjects (n = 8) were quantified which were associated with cardiovascular risk factors including lipid levels, C-reactive protein (CRP) and vascular functions (LnRHI) (P < 0.05) were observed. Overall, these results clearly showed that T2DM subjects have pro-inflammatory leukocyte phenotypes and suggest leukocyte impedance signature as a novel surrogate biomarker for inflammation.

Electrical impedance microflow cytometry with oxygen control for detection of sickle cells

Polymerization of intracellular sickle hemoglobin induced by low oxygen tension has been recognized as a primary determinant of the pathophysiologic manifestations in sickle cell disease. Existing flow cytometry techniques for detection of sickle cells are typically based on fluorescence markers or cellular morphological analysis. Using microfluidics and electrical impedance spectroscopy, we develop a new, label-free flow cytometry for non-invasive measurement of single cells under controlled oxygen level. We demonstrate the capability of this new technique by determining the electrical impedance differential of normal red blood cells obtained from a healthy donor and sickle cells obtained from three sickle cell patients, under normoxic and hypoxic conditions and at three different electrical frequencies, 156 kHz, 500 kHz and 3 MHz. Under normoxia, normal cells and sickle cells can be separated completely using electrical impedance at 156 kHz and 500 kHz but not at 3 MHz. Sickle cells, intra-patient and inter-patient show significantly different electrical impedance between normoxia and hypoxia at all three frequencies. This study shows a proof of concept that electrical impedance signal can be used as an indicator of the disease state of a red blood cell as well as the cell sickling events in sickle cell disease. Electrical impedance-based microflow cytometry with oxygen control is a new method that can be potentially used for sickle cell disease diagnosis and monitoring.

Evaluation of Electrical Impedance Spectroscopy-on-a-Needle as a Novel Tool to Determine Optimal Surgical Margin in Partial Nephrectomy

A hypodermic needle has been introduced incorporating an electrical impedance spectroscopy (EIS) sensor, called micro-EIS-on-a-needle for depth profiling (μEoN-DP). The μEoN-DP can locate endophytic renal tumors as well as determine tumor margins by detecting the impedance difference between normal and cancer tissues. To evaluate the μEoN-DP as a novel tool to determine the optimal surgical margin during partial nephrectomy (PN), the electrical impedance differences between renal parenchymal tissues and renal cell carcinoma (RCC) tumors are investigated with regard to the distance from the tumors. Optimal frequencies at which the discrimination extent is maximized are suggested based on the discrimination index. The resistance and capacitance of normal and cancer tissues are extracted using electrical equivalent circuit by excluding the influences of other electrical components on the sensor output. The extracted resistance and capacitance of cancer tissues are 37.8% larger and 25.7% smaller than that of normal tissues, respectively. Additionally, high sensitivity and specificity are obtained by using extracted resistance and capacitance, thus implying that the μEoN-DP shows promise as a supplementary tool for PN margin evaluation and decreasing the prevalence of positive surgical margins while maximizing parenchymal preservation.