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Wang AYM, Tang TK, Yau YY, Lo WK. Impact of Parathyroidectomy Versus Oral Cinacalcet on Bone Mineral Density in Patients on Peritoneal Dialysis With Advanced Secondary Hyperparathyroidism: The PROCEED Pilot Randomized Trial. Am J Kidney Dis 2024; 83:456-466.e1. [PMID: 38040277 DOI: 10.1053/j.ajkd.2023.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 10/21/2023] [Accepted: 10/22/2023] [Indexed: 12/03/2023]
Abstract
RATIONALE & OBJECTIVE Parathyroidectomy and calcimimetics have been used to reduce fracture risk in patients with kidney failure and advanced secondary hyperparathyroidism (SHPT), but direct comparisons of these treatment approaches have not been implemented. This pilot study compared their effects on bone mineral density (BMD) in this patient population. STUDY DESIGN A prospective pilot open-label randomized trial. SETTING & PARTICIPANTS 65 patients receiving maintenance peritoneal dialysis with advanced SHPT recruited from 2 university-affiliated hospitals in Hong Kong. INTERVENTIONS Total parathyroidectomy with forearm autografting versus oral cinacalcet treatment for 12 months. OUTCOME Prespecified secondary end points including changes in BMD z and T scores of femoral neck, lumbar spine, and distal radius 12 months after treatment initiation and also categorized as osteopenia or osteoporosis according to the World Health Organization. RESULTS Both total parathyroidectomy and cinacalcet significantly improved BMD of the lumbar spine and femoral neck over 12 months, but the total parathyroidectomy group had a greater increase than the cinacalcet-treated group (P<0.001). The proportion of study participants classified as having osteopenia/osteoporosis by femoral neck T-score fell from 78.2% to 51.7% in the total parathyroidectomy group (P<0.001) and from 65.7% to 52.0% in cinacalcet-treated group after 12 months (P=0.7). The proportion of participants with a T-score at the lumbar spine classified as osteopenia/osteoporosis fell from 53.1% to 31.0% in the total parathyroidectomy group (P=0.01) and from 59.4% to 53.8% with cinacalcet (P=0.3). No significant change was observed in BMD T or z score of the distal radius over 12 months with either intervention. LIMITATIONS Bone histology was not assessed, and the study duration was 12 months. CONCLUSIONS A large proportion of peritoneal dialysis patients with advanced SHPT had low bone densities and osteopenia/osteoporosis. Total parathyroidectomy increased the BMD of the lumbar spine and femoral neck and reduced osteopenia/osteoporosis more than oral cinacalcet. FUNDING Grants from academic (The University of Hong Kong Research) and not-for-profit (Hong Kong Society of Nephrology) entities. REGISTRATION Registered at Clinicaltrials.gov with study number NCT01447368. PLAIN-LANGUAGE SUMMARY It is not known whether oral cinacalcet and surgical parathyroidectomy differ in their effects on bone parameters in patients with advanced secondary hyperparathyroidism (SHPT) receiving peritoneal dialysis. This pilot randomized trial evaluated the effect of medical versus surgical therapy on bone mineral densities (BMD) as prespecified secondary study end points. The findings showed that a large proportion of peritoneal dialysis patients with advanced SHPT had low bone densities and osteopenia/osteoporosis. Parathyroidectomy increased the BMD of the lumbar spine and femoral neck more than cinacalcet over 12 months. Parathyroidectomy reduced the proportion of patients with osteopenia/osteoporosis at the lumbar spine and femoral neck more than cinacalcet after 12 months. Neither intervention led to an increase in the BMD of the distal radius over 12 months.
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Affiliation(s)
- Angela Yee-Moon Wang
- University Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong.
| | - Tak-Ka Tang
- University Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | | | - Wai Kei Lo
- Department of Medicine, Tung Wah Hospital, Hong Kong
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Yan L, Xiong Q, Xu Q, Ren P, Li T, Cao H, Shao F. Study on the correlation between mineral bone metabolism and CRP in patients with SHPT during perioperative period. Immun Inflamm Dis 2023; 11:e828. [PMID: 37102663 PMCID: PMC10091369 DOI: 10.1002/iid3.828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 03/06/2023] [Accepted: 03/14/2023] [Indexed: 04/28/2023] Open
Abstract
OBJECTIVE This study mainly observes changes in perioperative mineral bone metabolism-related indicators and inflammatory factors in patients with secondary hyperparathyroidism (SHPT), and analyzed the correlation between mineral bone metabolism-related indicators and inflammatory factors. METHODS Clinical data were collected. The study detects mineral bone metabolism-related indicators and inflammatory factor of perioperative patients with SHPT before and 4 days after operation. The production of high-sensitivity c-reactive protein (hs-CRP) in human hepatocytes cells (LO2 cells) stimulated by different concentrations of parathyroid hormone-associated protein was detected by enzyme-linked immunosorbent assay, reverse-transcription polymerase chain reaction (RT-PCR), and western blot. RESULTS The levels of mineral bone metabolism-related indicators and hs-CRP in SHPT group were significantly higher than those of control group. After operation, serum calcium, serum phosphorus, iPTH, FGF-23 decreased, and the level of osteoblast active biomarkers increased, while the level of osteoclast active biomarkers decreased. The levels of hs-CRP decreased significantly after operation. With the increase of PTHrP concentration, hs-CRP level in supernatant of LO2 cells decreased first and then increased. RT-PCR and western blot shows the same trend. CONCLUSION Parathyroidectomy can significantly improve bone resorption and inflammation in SHPT patients. We speculate that there may be an optimal range of PTH concentrations to minimize inflammation in the body.
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Affiliation(s)
- Lei Yan
- Department of Nephrology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Key Laboratory of Kidney Disease and ImmunologyHenan Provincial Clinical Research Center for Kidney DiseaseZhengzhouChina
| | - Qiuyue Xiong
- Department of Nephrology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Key Laboratory of Kidney Disease and ImmunologyHenan Provincial Clinical Research Center for Kidney DiseaseZhengzhouChina
| | - Qin Xu
- Department of Nephrology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Key Laboratory of Kidney Disease and ImmunologyHenan Provincial Clinical Research Center for Kidney DiseaseZhengzhouChina
| | - Pengru Ren
- Department of Nephrology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Key Laboratory of Kidney Disease and ImmunologyHenan Provincial Clinical Research Center for Kidney DiseaseZhengzhouChina
| | - Tiantian Li
- Department of Nephrology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Key Laboratory of Kidney Disease and ImmunologyHenan Provincial Clinical Research Center for Kidney DiseaseZhengzhouChina
| | - Huixia Cao
- Department of Nephrology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Key Laboratory of Kidney Disease and ImmunologyHenan Provincial Clinical Research Center for Kidney DiseaseZhengzhouChina
| | - Fengmin Shao
- Department of Nephrology, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Key Laboratory of Kidney Disease and ImmunologyHenan Provincial Clinical Research Center for Kidney DiseaseZhengzhouChina
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Chen X, Yuan L, Zhang Y, Dai H, Fan Y, Chen X. Analyzing clinical characteristics of patients with different cumulative hemodialysis durations: a cross-sectional study. PeerJ 2021; 9:e10852. [PMID: 33732543 PMCID: PMC7953870 DOI: 10.7717/peerj.10852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 01/06/2021] [Indexed: 12/02/2022] Open
Abstract
Background The objective of this study was to examine the clinical characteristics of patients with different cumulative hemodialysis (HD) durations, so as to improve their survival rate. Methods In this cross-sectional study, we extracted background information and relevant clinical data from 145 patients who were undergoing maintenance HD three times a week at the Affiliated Hospital of Nantong University between January 1998 and January 2019. The study subjects were divided into four groups according to the duration of their HD: <5 years, 5–10 years, 10–15 years, and >15 years of HD. We collected the medical history and relevant clinical parameters for each subject, and measured the urea reduction ratio (URR), hemoglobin (Hb), serum calcium, phosphorus, parathyroid hormone (iPTH), and serum albumin (ALB) levels for each group. Results The average patient age was 52.06 ± 11.93 years old. The average patient age in the 10–15 years and >15 years groups was significantly lower than in the <5 years and 5–10 years groups (P = 0.002, P < 0.001, P = 0.012, and P = 0.0025, respectively). The most common cause of end-stage renal disease (ESRD) was chronic glomerulonephritis. We found no significant differences in URR, Hb, serum calcium, serum phosphorus, iPTH, and ALB levels. Conclusion A prolonged HD duration was related to a younger mean age at the start of HD treatment. The leading cause of ESRD was chronic glomerulonephritis. We predominantly found diabetic nephropathy in the group with a duration of <5 years cumulative HD. Most of the indexes related to hemodialysis almost satisfied the recommended values in these patients.
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Affiliation(s)
- Xu Chen
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong, China
| | - Li Yuan
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong, China
| | - Yuan Zhang
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong, China
| | - Houyong Dai
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong, China
| | - Yaping Fan
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong, China
| | - Xiaolan Chen
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong, China
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Wen P, Xu L, Zhao S, Gan W, Hou D, Zhang L, Cao J, Xiong M, Jiang L, Yang J. Risk Factors for Severe Hypocalcemia in Patients with Secondary Hyperparathyroidism after Total Parathyroidectomy. Int J Endocrinol 2021; 2021:6613659. [PMID: 33868402 PMCID: PMC8035008 DOI: 10.1155/2021/6613659] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 03/08/2021] [Accepted: 03/23/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Hypocalcemia is the most common complication of total parathyroidectomy in secondary hyperparathyroidism (SHPT) and is associated with adverse consequences such as spasms, epilepsy, and arrhythmia and even death if the serum calcium level decreases rapidly. Previous studies have identified several risk factors for postoperative severe hypocalcemia (SH) in patients with SHPT, but the sample sizes were small and thus the results may not be reliable. OBJECTIVES This study was performed to investigate the risk factors for SH after total parathyroidectomy without autotransplantation (tPTX) in a large sample of patients with uremic hyperparathyroidism. METHODS We retrospectively investigated the records of 1,095 patients with SHPT treated with tPTX between January 2008 and December 2018. Based on the postoperative serum calcium concentration, the patients were grouped into SH and non-SH groups. The clinical characteristics and biochemical results were analyzed, and binary logistic regression analysis was used to identify the risk factors for SH. RESULTS After surgery, 25.9% of the patients developed SH. Age, diastolic blood pressure (DBP), heart rate, frequency of bone pain, weight of resected glands, preoperative serum calcium, intact parathyroid hormone (iPTH), alkaline phosphatase (ALP), and hemoglobin levels differed between the two groups. Binary logistic regression analyses identified preoperative serum calcium, iPTH, and ALP levels as independent predictors of SH after surgery. CONCLUSIONS The preoperative serum calcium, iPTH, and ALP levels can be used to assess the risk of postoperative SH in patients with SHPT. Such patients should thus be monitored closely in order to initiate prompt interventions to avoid SH.
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Affiliation(s)
- Ping Wen
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lingling Xu
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Shasha Zhao
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wei Gan
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Dawei Hou
- Department of General Surgery, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Liang Zhang
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jinlong Cao
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mingxia Xiong
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lei Jiang
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Junwei Yang
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Rodríguez-Ortiz ME, Rodríguez M. Recent advances in understanding and managing secondary hyperparathyroidism in chronic kidney disease. F1000Res 2020; 9:F1000 Faculty Rev-1077. [PMID: 32913635 PMCID: PMC7463297 DOI: 10.12688/f1000research.22636.1] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2020] [Indexed: 12/31/2022] Open
Abstract
Secondary hyperparathyroidism is a complex pathology that develops as chronic kidney disease progresses. The retention of phosphorus and the reductions in calcium and vitamin D levels stimulate the synthesis and secretion of parathyroid hormone as well as the proliferation rate of parathyroid cells. Parathyroid growth is initially diffuse but it becomes nodular as the disease progresses, making the gland less susceptible to be inhibited. Although the mechanisms underlying the pathophysiology of secondary hyperparathyroidism are well known, new evidence has shed light on unknown aspects of the deregulation of parathyroid function. Secondary hyperparathyroidism is an important feature of chronic kidney disease-mineral and bone disorder and plays an important role in the development of bone disease and vascular calcification. Thus, part of the management of chronic kidney disease relies on maintaining acceptable levels of mineral metabolism parameters in an attempt to slow down or prevent the development of secondary hyperparathyroidism. Here, we will also review the latest evidence regarding several aspects of the clinical and surgical management of secondary hyperparathyroidism.
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Affiliation(s)
- María E. Rodríguez-Ortiz
- Maimónides Institute for Biomedical Research (IMIBIC), Avda. Menéndez Pidal, S/N. 14004 Córdoba, Spain
- University of Córdoba, Avda. Medina Azahara, 5. 14071 Córdoba, Spain
- University Hospital Reina Sofía, Avda. Menéndez Pidal, S/N. 14004 Córdoba, Spain
- Spanish Renal Research Network (REDinREN), Carlos III Health Institute, Madrid, Spain
| | - Mariano Rodríguez
- Maimónides Institute for Biomedical Research (IMIBIC), Avda. Menéndez Pidal, S/N. 14004 Córdoba, Spain
- University of Córdoba, Avda. Medina Azahara, 5. 14071 Córdoba, Spain
- Spanish Renal Research Network (REDinREN), Carlos III Health Institute, Madrid, Spain
- Nephrology Clinical Management Unit, University Hospital Reina Sofía, Avda. Menéndez Pidal, S/N. 14004 Córdoba, Spain
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Ko WC, Liu CL, Lee JJ, Liu TP, Wu CJ, Cheng SP. Osteocalcin is an Independent Predictor for Hungry Bone Syndrome After Parathyroidectomy. World J Surg 2019; 44:795-802. [DOI: 10.1007/s00268-019-05251-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Correlation of Fgf23 and Balp with Bone Mineral Density in Hemodialysis Patients. J Med Biochem 2019; 38:418-426. [PMID: 31496905 PMCID: PMC6708290 DOI: 10.2478/jomb-2019-0002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 01/04/2019] [Indexed: 02/05/2023] Open
Abstract
Background Chronic kidney disease (CKD) is associated with numerous complications such as bone mineral disorder. The aim of our study was to analyze the correlation of bone turnover markers with Bone Mineral Density (BMD) measurements in Tunisian end stage renal diseases (ESRD) patients. Methods This study included 100 ESRD Tunisian patients. Their estimated glomerular filtration rate (eGFR) was < 15 mL × min-1 × (1.73 m2)-1, which requires hemodialysis. Bone-specific alkaline phosphatase (BALP) serum concentration was determined with a chemiluminescence immunoassay. Fibroblast Growth Factor 23 (FGF23) serum was assessed by Enzyme-Linked Immunosorbent Assay method. The serum levels of 25-Hydroxyvitamin D (25(OH)D), intact parathyroid hormone (iPTH) and Beta cross-laps (CTX) was measured by Electrochemiluminescence Technology. DEXA (dual-energy x-ray absorptiometry) technique was used to evaluate BMD. Results We observed a statistically significant negative correlation between BALP levels and total body BMD (r = -0.268; P = 0.015) particularly in femoral neck (FN) (r = -0.219; P = 0.037). BALP concentrations were negatively associated with total BMD especially in FN for patients with BMI < 30, FGF23 concentrations were also negatively correlated with BMD in lumbar spine site (LS) (r = -0.209; P = 0.046). For osteopenic patients we found an inverse correlation between 25(OH)D concentrations and BMD in LS position (r = -0.336; P = 0.038). In men group, we have also found a negative correlation between iPTH and total BMD (r = -0.326; P = 0.015). However we found a positive correlation between calcium expression and BMD in LS site (r = 0.270; P = 0.031). Conclusions FGF23 and BALP can predict bone loss in ESRD through their strong correlation with BMD in LS and FN sites respectively.
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Kakani E, Sloan D, Sawaya BP, El-Husseini A, Malluche HH, Rao M. Long-term outcomes and management considerations after parathyroidectomy in the dialysis patient. Semin Dial 2019; 32:541-552. [PMID: 31313380 DOI: 10.1111/sdi.12833] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Parathyroidectomy (PTX) remains an important intervention for dialysis patients with poorly controlled secondary hyperparathyroidism (SHPT), though there are only retrospective and observational data that show a mortality benefit to this procedure. Potential consequences that we seek to avoid after PTX include persistent or recurrent hyperparathyroidism, and parathyroid insufficiency. There is considerable subjectivity in defining and diagnosing these conditions, given that we poorly understand the optimal PTH targets (particularly post PTX) needed to maintain bone and vascular health. While lowering PTH after PTX decreases bone turnover, long-term changes in bone activity have been poorly explored. High turnover bone disease, usually present at the time a PTX is considered, often swings to a state of low turnover in the setting of sufficiently low PTH levels. It remains unclear if all low bone turnover equate with disease. However, such changes in bone turnover appear to predispose to vascular calcification, with positive calcium balance after PTX being a potential contributor. We know little of how the post-PTX state resets calcium balance, how calcium and VDRA requirements change or what kind of adjustments are needed to avoid calcium loading. The current consensus cautions against excessive reduction of PTH although there is insufficient evidence-based guidance regarding the management of chronic kidney disease - mineral bone disease (CKD-MBD) parameters in the post-PTX state. This article aims to compile existing research, provide an overview of current practice with regard to PTX and post-PTX chronic management. It highlights gaps and controversies and aims to re-orient the focus to clinically relevant contemporary priorities in CKD-MBD management after PTX.
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Affiliation(s)
- Elijah Kakani
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - David Sloan
- Division of Endocrine Surgery, University of Kentucky, Lexington, KY, USA
| | - B Peter Sawaya
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - Amr El-Husseini
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - Hartmut H Malluche
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
| | - Madhumathi Rao
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington, KY, USA
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Silaghi CN, Ilyés T, Filip VP, Farcaș M, van Ballegooijen AJ, Crăciun AM. Vitamin K Dependent Proteins in Kidney Disease. Int J Mol Sci 2019; 20:ijms20071571. [PMID: 30934817 PMCID: PMC6479974 DOI: 10.3390/ijms20071571] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 03/24/2019] [Accepted: 03/27/2019] [Indexed: 12/12/2022] Open
Abstract
Patients with chronic kidney disease (CKD) have an increased risk of developing vascular calcifications, as well as bone dynamics impairment, leading to a poor quality of life and increased mortality. Certain vitamin K dependent proteins (VKDPs) act mainly as calcification inhibitors, but their involvement in the onset and progression of CKD are not completely elucidated. This review is an update of the current state of knowledge about the relationship between CKD and four extrahepatic VKDPs: matrix Gla protein, osteocalcin, growth-arrest specific protein 6 and Gla-rich protein. Based on published literature in the last ten years, the purpose of this review is to address fundamental aspects about the link between CKD and circulating VKDPs levels as well as to raise new topics about how the interplay between molecular weight and charge could influence the modifications of circulating VKDPs at the glomerular level, or whether distinct renal etiologies have effect on VKDPs. This review is the output of a systematic literature search and may open future research avenues in this niche domain.
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Affiliation(s)
- Ciprian N Silaghi
- Department of Molecular Sciences, University of Medicine and Pharmacy "Iuliu Hațieganu", 400012 Cluj-Napoca, Romania.
| | - Tamás Ilyés
- Department of Molecular Sciences, University of Medicine and Pharmacy "Iuliu Hațieganu", 400012 Cluj-Napoca, Romania.
| | - Vladimir P Filip
- Department of Molecular Sciences, University of Medicine and Pharmacy "Iuliu Hațieganu", 400012 Cluj-Napoca, Romania.
| | - Marius Farcaș
- Department of Molecular Sciences, University of Medicine and Pharmacy "Iuliu Hațieganu", 400012 Cluj-Napoca, Romania.
| | - Adriana J van Ballegooijen
- Department of Nephrology & Epidemiology and Biostatistics, Amsterdam University Medical Center, VUmc, 1117 HV Amsterdam, The Netherlands.
| | - Alexandra M Crăciun
- Department of Molecular Sciences, University of Medicine and Pharmacy "Iuliu Hațieganu", 400012 Cluj-Napoca, Romania.
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