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Aspromonte N, Fumarulo I, Petrucci L, Biferali B, Liguori A, Gasbarrini A, Massetti M, Miele L. The Liver in Heart Failure: From Biomarkers to Clinical Risk. Int J Mol Sci 2023; 24:15665. [PMID: 37958649 PMCID: PMC10649397 DOI: 10.3390/ijms242115665] [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: 09/20/2023] [Revised: 10/24/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
Heart failure (HF) is a clinical syndrome due to heart dysfunction, but in which other organs are also involved, resulting in a complex multisystemic disease, burdened with high mortality and morbidity. This article focuses on the mutual relationship between the heart and liver in HF patients. Any cause of right heart failure can cause hepatic congestion, with important prognostic significance. We have analyzed the pathophysiology underlying this double interaction. Moreover, we have explored several biomarkers and non-invasive tests (i.e., liver stiffness measurement, LSM) potentially able to provide important support in the management of this complex disease. Cardiac biomarkers have been studied extensively in cardiology as a non-invasive diagnostic and monitoring tool for HF. However, their usefulness in assessing liver congestion in HF patients is still being researched. On the other hand, several prognostic scores based on liver biomarkers in patients with HF have been proposed in recent years, recognizing the important burden that liver involvement has in HF. We also discuss the usefulness of a liver stiffness measurement (LSM), which has been recently proposed as a reliable and non-invasive method for assessing liver congestion in HF patients, with therapeutic and prognostic intentions. Lastly, the relationship between LSM and biomarkers of liver congestion is not clearly defined; more research is necessary to establish the clinical value of biomarkers in assessing liver congestion in HF patients and their relationship with LSM.
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Affiliation(s)
- Nadia Aspromonte
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (I.F.); (M.M.)
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Policlinic Foundation IRCCS, 00168 Rome, Italy
| | - Isabella Fumarulo
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (I.F.); (M.M.)
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Policlinic Foundation IRCCS, 00168 Rome, Italy
| | - Lucrezia Petrucci
- Department of Translational Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy; (L.P.); (B.B.); (A.L.); (A.G.); (L.M.)
- Department of Medical and Surgical Sciences, A. Gemelli University Policlinic Foundation IRCCS, 00168 Rome, Italy
| | - Bianca Biferali
- Department of Translational Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy; (L.P.); (B.B.); (A.L.); (A.G.); (L.M.)
- Department of Medical and Surgical Sciences, A. Gemelli University Policlinic Foundation IRCCS, 00168 Rome, Italy
| | - Antonio Liguori
- Department of Translational Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy; (L.P.); (B.B.); (A.L.); (A.G.); (L.M.)
- Department of Medical and Surgical Sciences, A. Gemelli University Policlinic Foundation IRCCS, 00168 Rome, Italy
| | - Antonio Gasbarrini
- Department of Translational Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy; (L.P.); (B.B.); (A.L.); (A.G.); (L.M.)
- Department of Medical and Surgical Sciences, A. Gemelli University Policlinic Foundation IRCCS, 00168 Rome, Italy
| | - Massimo Massetti
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy; (I.F.); (M.M.)
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Policlinic Foundation IRCCS, 00168 Rome, Italy
| | - Luca Miele
- Department of Translational Medicine and Surgery, Catholic University of the Sacred Heart, 00168 Rome, Italy; (L.P.); (B.B.); (A.L.); (A.G.); (L.M.)
- Department of Medical and Surgical Sciences, A. Gemelli University Policlinic Foundation IRCCS, 00168 Rome, Italy
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Manolis AA, Manolis TA, Manolis AS. Neurohumoral Activation in Heart Failure. Int J Mol Sci 2023; 24:15472. [PMID: 37895150 PMCID: PMC10607846 DOI: 10.3390/ijms242015472] [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: 08/28/2023] [Revised: 10/16/2023] [Accepted: 10/21/2023] [Indexed: 10/29/2023] Open
Abstract
In patients with heart failure (HF), the neuroendocrine systems of the sympathetic nervous system (SNS), the renin-angiotensin-aldosterone system (RAAS) and the arginine vasopressin (AVP) system, are activated to various degrees producing often-observed tachycardia and concomitant increased systemic vascular resistance. Furthermore, sustained neurohormonal activation plays a key role in the progression of HF and may be responsible for the pathogenetic mechanisms leading to the perpetuation of the pathophysiology and worsening of the HF signs and symptoms. There are biomarkers of activation of these neurohormonal pathways, such as the natriuretic peptides, catecholamine levels and neprilysin and various newer ones, which may be employed to better understand the mechanisms of HF drugs and also aid in defining the subgroups of patients who might benefit from specific therapies, irrespective of the degree of left ventricular dysfunction. These therapies are directed against these neurohumoral systems (neurohumoral antagonists) and classically comprise beta blockers, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers and vaptans. Recently, the RAAS blockade has been refined by the introduction of the angiotensin receptor-neprilysin inhibitor (ARNI) sacubitril/valsartan, which combines the RAAS inhibition and neprilysin blocking, enhancing the actions of natriuretic peptides. All these issues relating to the neurohumoral activation in HF are herein reviewed, and the underlying mechanisms are pictorially illustrated.
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Affiliation(s)
- Antonis A Manolis
- First Department of Cardiology, Evagelismos Hospital, 106 76 Athens, Greece
| | - Theodora A Manolis
- Department of Psychiatry, Aiginiteio University Hospital, 115 28 Athens, Greece
| | - Antonis S Manolis
- First Department of Cardiology, Ippokrateio University Hospital, 115 27 Athens, Greece
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Alcidi G, Goffredo G, Correale M, Brunetti ND, Iacoviello M. Brain Natriuretic Peptide Biomarkers in Current Clinical and Therapeutic Scenarios of Heart Failure. J Clin Med 2022; 11:jcm11113192. [PMID: 35683578 PMCID: PMC9181765 DOI: 10.3390/jcm11113192] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/23/2022] [Accepted: 06/01/2022] [Indexed: 01/25/2023] Open
Abstract
Brain natriuretic peptide (BNP) and its inactive N-terminal fragment, NT-proBNP, are serum biomarkers with key roles in the management of heart failure (HF). An increase in the serum levels of these peptides is closely associated with the pathophysiological mechanisms underlying HF such as the presence of structural and functional cardiac abnormalities, myocardial stretch associated with a high filling pressure and neuro-hormonal activation. As BNP and NT-proBNP measurements are possible, several studies have investigated their clinical utility in the diagnosis, prognostic stratification, monitoring and guiding therapy of patients with HF. BNP and NT-proBNP have also been used as criteria for enrollment in randomized trials evaluating the efficacy of new therapeutic strategies for HF. Nevertheless, the use of natriuretic peptides is still limited in clinical practice due to the controversial aspect of their use in different clinical settings. The purpose of this review is to discuss the main issues associated with using BNP and NT-proBNP serum levels in the management of patients with HF under current clinical and therapeutic scenarios.
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Affiliation(s)
- Gianmarco Alcidi
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy; (G.A.); (M.C.); (N.D.B.)
- Cardiology Unit, Polyclinic University Hospital Riuniti of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy
| | - Giovanni Goffredo
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy; (G.A.); (M.C.); (N.D.B.)
- Cardiology Unit, Polyclinic University Hospital Riuniti of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy
- Correspondence: (G.G.); (M.I.)
| | - Michele Correale
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy; (G.A.); (M.C.); (N.D.B.)
- Cardiology Unit, Polyclinic University Hospital Riuniti of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy
| | - Natale Daniele Brunetti
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy; (G.A.); (M.C.); (N.D.B.)
- Cardiology Unit, Polyclinic University Hospital Riuniti of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy
| | - Massimo Iacoviello
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy; (G.A.); (M.C.); (N.D.B.)
- Cardiology Unit, Polyclinic University Hospital Riuniti of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy
- Correspondence: (G.G.); (M.I.)
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Novel Biomarkers in Heart Failure: New Insight in Pathophysiology and Clinical Perspective. J Clin Med 2021; 10:jcm10132771. [PMID: 34202603 PMCID: PMC8268524 DOI: 10.3390/jcm10132771] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/17/2021] [Accepted: 06/20/2021] [Indexed: 12/18/2022] Open
Abstract
Heart failure (HF) is a complex clinical syndrome with a huge social burden in terms of cost, morbidity, and mortality. Brain natriuretic peptide (BNP) appears to be the gold standard in supporting the daily clinical management of patients with HF. Novel biomarkers may supplement BNP to improve the understanding of this complex disease process and, possibly, to personalize care for the different phenotypes, in order to ameliorate prognosis. In this review, we will examine some of the most promising novel biomarkers in HF. Inflammation plays a pivotal role in the genesis and progression of HF and, therefore, several candidate molecules have been investigated in recent years for diagnosis, prognosis, and therapy monitoring. Noncoding RNAs are attractive as biomarkers and their potential clinical applications may be feasible in the era of personalized medicine. Given the complex pathophysiology of HF, it is reasonable to expect that the future of biomarkers lies in the application of precision medicine, through wider testing panels and “omics” technologies, to further improve HF care delivery.
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Giglio RV, Stoian AP, Haluzik M, Pafili K, Patti AM, Rizvi AA, Ciaccio M, Papanas N, Rizzo M. Novel molecular markers of cardiovascular disease risk in type 2 diabetes mellitus. Biochim Biophys Acta Mol Basis Dis 2021; 1867:166148. [PMID: 33892081 DOI: 10.1016/j.bbadis.2021.166148] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 03/15/2021] [Accepted: 04/13/2021] [Indexed: 02/07/2023]
Abstract
Diabetes represents the leading risk factor for the development of cardiovascular disease (CVD). Chronic hyperglycemia and/or acute post-prandial changes in blood glucose determine an increase in reactive oxygen species (ROS), which play a fundamental role in endothelial dysfunction and in the nuclear transport of pro-atherogenic transcription factors that activate the "inflammasome". In addition, the glycemic alteration favors the formation and stabilization of atherosclerotic plaque through the mechanism of non-enzymatic glycation of different molecules, with the establishment of the so-called "advanced glycosylation end products" (AGE). Laboratory information provided by the level of biomarkers could make a quantitative and qualitative contribution to the clinical process of screening, prediction, prevention, diagnosis, prognosis and monitoring of cardiovascular (CV) risk linked to diabetes. This review describes the importance of specific biomarkers, with particular focus on novel ones, for stratifying and management of diabetes CV risk.
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Affiliation(s)
- Rosaria Vincenza Giglio
- Department of Biomedicine, Neuroscience, and Advanced Diagnostics, Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Laboratory Medicine, University of Palermo, Palermo, Italy
| | - Anca Pantea Stoian
- Faculty of General Medicine, Diabetes, Nutrition and Metabolic Diseases Department, Carol Davila University, Bucharest, Romania
| | - Martin Haluzik
- Centre for Experimental Medicine and Department of Diabetes, Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Institute of Medical Biochemistry and Laboratory Diagnostics, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Kalliopi Pafili
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Greece
| | - Angelo Maria Patti
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy.
| | - Ali Abbas Rizvi
- Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, Emory University, Atlanta, Georgia, USA; Division of Endocrinology, Diabetes and Metabolism, University of South Carolina School of Medicine Columbia, South Carolina, USA
| | - Marcello Ciaccio
- Department of Biomedicine, Neuroscience, and Advanced Diagnostics, Institute of Clinical Biochemistry, Clinical Molecular Medicine, and Laboratory Medicine, University of Palermo, Palermo, Italy; Department of Laboratory Medicine, University-Hospital, Palermo, Italy
| | - Nikolaos Papanas
- Diabetes Centre, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Greece
| | - Manfredi Rizzo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy; Division of Endocrinology, Diabetes and Metabolism, University of South Carolina School of Medicine Columbia, South Carolina, USA
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Blanda V, Bracale UM, Di Taranto MD, Fortunato G. Galectin-3 in Cardiovascular Diseases. Int J Mol Sci 2020; 21:ijms21239232. [PMID: 33287402 PMCID: PMC7731136 DOI: 10.3390/ijms21239232] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 11/28/2020] [Accepted: 12/01/2020] [Indexed: 12/11/2022] Open
Abstract
Galectin-3 (Gal-3) is a β-galactoside-binding protein belonging to the lectin family with pleiotropic regulatory activities and several physiological cellular functions, such as cellular growth, proliferation, apoptosis, differentiation, cellular adhesion, and tissue repair. Inflammation, tissue fibrosis and angiogenesis are the main processes in which Gal-3 is involved. It is implicated in the pathogenesis of several diseases, including organ fibrosis, chronic inflammation, cancer, atherosclerosis and other cardiovascular diseases (CVDs). This review aims to explore the connections of Gal-3 with cardiovascular diseases since they represent a major cause of morbidity and mortality. We herein discuss the evidence on the pro-inflammatory role of Gal-3 in the atherogenic process as well as the association with plaque features linked to lesion stability. We report the biological role and molecular mechanisms of Gal-3 in other CVDs, highlighting its involvement in the development of cardiac fibrosis and impaired myocardium remodelling, resulting in heart failure and atrial fibrillation. The role of Gal-3 as a prognostic marker of heart failure is described together with possible diagnostic applications to other CVDs. Finally, we report the tentative use of Gal-3 inhibition as a therapeutic approach to prevent cardiac inflammation and fibrosis.
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Affiliation(s)
- Valeria Blanda
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, 80131 Naples, Italy; (V.B.); (G.F.)
- Istituto Zooprofilattico Sperimentale della Sicilia, via Gino Marinuzzi 3, 90129 Palermo, Italy
| | - Umberto Marcello Bracale
- Dipartimento di Sanità Pubblica, Università degli Studi di Napoli Federico II, 80131 Naples, Italy;
| | - Maria Donata Di Taranto
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, 80131 Naples, Italy; (V.B.); (G.F.)
- CEINGE S.C.a r.l. Biotecnologie Avanzate, 80131 Naples, Italy
- Correspondence: ; Tel.: +39-081-7463530
| | - Giuliana Fortunato
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, 80131 Naples, Italy; (V.B.); (G.F.)
- CEINGE S.C.a r.l. Biotecnologie Avanzate, 80131 Naples, Italy
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Perrone MA, Zaninotto M, Masotti S, Musetti V, Padoan A, Prontera C, Plebani M, Passino C, Romeo F, Bernardini S, Clerico A. The combined measurement of high-sensitivity cardiac troponins and natriuretic peptides: a useful tool for clinicians? J Cardiovasc Med (Hagerstown) 2020; 21:953-963. [DOI: 10.2459/jcm.0000000000001022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Xiao N, Zhang J, Chen C, Wan Y, Wang N, Yang J. miR-129-5p improves cardiac function in rats with chronic heart failure through targeting HMGB1. Mamm Genome 2019; 30:276-288. [PMID: 31646380 DOI: 10.1007/s00335-019-09817-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 10/09/2019] [Indexed: 12/14/2022]
Abstract
Increasing evidence shows that miRNAs play pivotal roles in cardiovascular diseases, including heart failure (HF). The aim of this study was to investigate the role of miR-129-5p in chronic heart failure and the underlying mechanisms. The levels of miR-129-5p and HMGB1 in chronic heart failure patients (CHF) and normal controls were examined by RT-qPCR and ELISA. Cardiac function, hemodynamics parameters, oxidative stress, and inflammation factors were analyzed in CHF rat model after transfection of miR-129-5p or HMGB1. Dual-luciferase activity reporter assay was conducted to validate the interaction between miR-129-5p and HMGB1. Downregulation of miR-129-5p and upregulation of HMGB1 were observed in the serum of CHF patients, respectively. Transfection of miR-129-5p improved heart function and hemodynamic parameters, as well as attenuated oxidative stress and inflammation factors in CHF rats. We further confirmed that HMGB1 is a direct target of miR-129-5p. Transfection of miR-129-5p also decreased the mRNA and protein levels of HMGB1 in myocardial tissues of CHF rats. Overexpression of HMGB1 diminished the effects of miR-129-5p on ameliorating oxidative stress and inflammatory response in rats with CHF. Our findings suggest that miR-129-5p protects the heart by targeting HMGB1.
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Affiliation(s)
- Na Xiao
- Department Cardiovascular V, Cangzhou Central Hospital, No. 16 Xinhua West Road, Cangzhou, 061000, Hebei, China.
| | - Jun Zhang
- Department Cardiovascular V, Cangzhou Central Hospital, No. 16 Xinhua West Road, Cangzhou, 061000, Hebei, China
| | - Chao Chen
- Department Cardiovascular V, Cangzhou Central Hospital, No. 16 Xinhua West Road, Cangzhou, 061000, Hebei, China
| | - Yanfang Wan
- Department Cardiovascular V, Cangzhou Central Hospital, No. 16 Xinhua West Road, Cangzhou, 061000, Hebei, China
| | - Ning Wang
- Department Cardiovascular V, Cangzhou Central Hospital, No. 16 Xinhua West Road, Cangzhou, 061000, Hebei, China
| | - Jing Yang
- Department Cardiovascular V, Cangzhou Central Hospital, No. 16 Xinhua West Road, Cangzhou, 061000, Hebei, China
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Abstract
PURPOSE OF REVIEW Cardiac biomarkers play important roles in routine evaluation of cardiac patients. But while these biomarkers can be extremely valuable, none of them should ever be used by themselves-without adding the clinical context. This paper explores the non-cardiac pathologies that can be seen with the cardiac biomarkers most commonly used. RECENT FINDINGS High-sensitivity troponin assay gained FDA approval for use in the USA, and studies demonstrated its diagnostic utility can be extended to patients with renal impairment. Gender-specific cut points may be utilized for high-sensitivity troponin assays. In the realm of the natriuretic peptides, studies demonstrated states of natriuretic peptide deficiency in obesity and in subjects of African-American race. Regardless, BNP and NT-proBNP both retained prognostic utilities across a variety of comorbid conditions. We are rapidly gaining clinical evidence with use of soluble ST2 and procalcitonin levels in management of cardiac disease states. In order to get the most utility from their measurement, one must be aware of non-cardiac pathologies that may affect the levels of biomarkers as although many of these are actually true values, they may not represent the disease we are trying to delineate. A few take-home points are as follows: 1. A biomarker value should never be used without clinical context 2. Serial sampling of biomarkers is often helpful 3. Panels of biomarkers may be valuable.
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Clerico A, Zaninotto M, Passino C, Plebani M. Obese phenotype and natriuretic peptides in patients with heart failure with preserved ejection fraction. Clin Chem Lab Med 2019; 56:1015-1025. [PMID: 29381470 DOI: 10.1515/cclm-2017-0840] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 01/02/2018] [Indexed: 02/06/2023]
Abstract
The results of several recent experimental studies using animal models and clinical trials suggested that obesity is not merely an epiphenomenon or a prominent comorbidity in patients with heart failure (HF). Indeed, recent studies suggest that obesity is intimately involved in the pathogenesis of HF with preserved ejection fraction (HFpEF). The most recent studies indicate that approximately 50% of HF patients have HFpEF. As standard pharmacological treatment usually shows only a weak or even neutral effect on primary outcomes in patients with HFpEF, treatment strategies targeted to specific groups of HFpEF patients, such as those with obesity, may increase the likelihood of reaching substantial clinical benefit. Considering the well-known inverse relationship between body mass index (BMI) values and B-type natriuretic peptide (BNP) levels, it is theoretically conceivable that the measurement of natriuretic peptides, using cutoff values adjusted for age and BMI, should increase diagnostic and prognostic accuracy in HFpEF patients. However, further experimental studies and clinical trials are needed to differentiate and better understand specific mechanisms of the various HFpEF phenotypes, including obese HFpEF.
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Affiliation(s)
- Aldo Clerico
- Fondazione CNR Regione Toscana G. Monasterio and Scuola Superiore Sant'Anna, Pisa, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University-Hospital, Padova, Italy
| | - Claudio Passino
- Fondazione CNR Regione Toscana G. Monasterio and Scuola Superiore Sant'Anna, Pisa, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University-Hospital, Padova, Italy
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