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Kamiya K, Hatayama N, Tawada M, Asai A, Yamauchi M, Kinashi H, Kunoki S, Yamaguchi M, Mizuno M, Suzuki Y, Banshodani M, Ishimoto T, Naito M, Kawanishi H, Ito Y. Role of endothelial hyaluronan in peritoneal membrane transport and disease conditions during peritoneal dialysis. Sci Rep 2024; 14:7412. [PMID: 38548914 PMCID: PMC10978880 DOI: 10.1038/s41598-024-58148-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 03/26/2024] [Indexed: 04/01/2024] Open
Abstract
Peritoneal membrane dysfunction in peritoneal dialysis (PD) is primarily attributed to angiogenesis; however, the integrity of vascular endothelial cells can affect peritoneal permeability. Hyaluronan, a component of the endothelial glycocalyx, is reportedly involved in preventing proteinuria in the normal glomerulus. One hypothesis suggests that development of encapsulating peritoneal sclerosis (EPS) is triggered by protein leakage due to vascular endothelial injury. We therefore investigated the effect of hyaluronan in the glycocalyx on peritoneal permeability and disease conditions. After hyaluronidase-mediated degradation of hyaluronan on the endothelial cells of mice, macromolecules, including albumin and β2 microglobulin, leaked into the dialysate. However, peritoneal transport of small solute molecules was not affected. Pathologically, hyaluronan expression was diminished; however, expression of vascular endothelial cadherin and heparan sulfate, a core protein of the glycocalyx, was preserved. Hyaluronan expression on endothelial cells was studied using 254 human peritoneal membrane samples. Hyaluronan expression decreased in patients undergoing long-term PD treatment and EPS patients treated with conventional solutions. Furthermore, the extent of hyaluronan loss correlated with the severity of vasculopathy. Hyaluronan on endothelial cells is involved in the peritoneal transport of macromolecules. Treatment strategies that preserve hyaluronan in the glycocalyx could prevent the leakage of macromolecules and subsequent related complications.
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Affiliation(s)
- Keisuke Kamiya
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute City, Aichi, 480-1195, Japan
| | - Naoyuki Hatayama
- Department of Anatomy, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| | - Mitsuhiro Tawada
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Akimasa Asai
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute City, Aichi, 480-1195, Japan
| | - Mai Yamauchi
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute City, Aichi, 480-1195, Japan
| | - Hiroshi Kinashi
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute City, Aichi, 480-1195, Japan
| | - Shunnosuke Kunoki
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute City, Aichi, 480-1195, Japan
- Department of Nephrology, Nippon Medical School, Tokyo, Japan
| | - Makoto Yamaguchi
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute City, Aichi, 480-1195, Japan
| | - Masashi Mizuno
- Department of Surgery and Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, Hiroshima, Japan
| | - Yasuhiro Suzuki
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masataka Banshodani
- Department of Surgery and Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, Hiroshima, Japan
| | - Takuji Ishimoto
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute City, Aichi, 480-1195, Japan
| | - Munekazu Naito
- Department of Anatomy, Aichi Medical University School of Medicine, Nagakute, Aichi, Japan
| | - Hideki Kawanishi
- Department of Surgery and Artificial Organs, Akane-Foundation, Tsuchiya General Hospital, Hiroshima, Japan
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, 1-1 Karimata, Yazako, Nagakute City, Aichi, 480-1195, Japan.
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2
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Chaichayanon S, Banjongjit A, Kanjanabuch T, Perl J. Chylous ascites: A warning sign of life-threatening encapsulated peritoneal sclerosis in patient recently transferred to haemodialysis. Perit Dial Int 2024; 44:149-151. [PMID: 37691434 DOI: 10.1177/08968608231193930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Affiliation(s)
| | - Athiphat Banjongjit
- Nephrology unit, Department of Medicine, Vichaiyut Hospital, Bangkok, Thailand
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Peritoneal Dialysis Excellent Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Jeffrey Perl
- Division of Nephrology and Keenan Research Center, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
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3
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Harada W, Banshodani M, Shimamoto F, Shintaku S, Moriishi M, Masaki T, Kawanishi H. Encapsulating Peritoneal Sclerosis 43 Years after Distal Gastrectomy for Early Gastric Cancer. Intern Med 2024; 63:659-663. [PMID: 37468244 PMCID: PMC10982008 DOI: 10.2169/internalmedicine.2037-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/11/2023] [Indexed: 07/21/2023] Open
Abstract
We herein report a case of encapsulating peritoneal sclerosis (EPS) in a patient without chronic kidney disease after gastrectomy. A 69-year-old man underwent distal gastrectomy for early gastric cancer at 25 years old. After 43 years, he developed bowel obstruction and underwent enterolysis of the encapsulated small intestine. A pathological examination of the capsular membranes revealed inflammation, foam, and giant cells that destroyed foreign substances. The patient was discharged 1.5 months later. Foreign body reactions to surgical instruments used in gastrectomy are considered a cause of EPS. EPS due to foreign body reactions to surgical instruments should also be considered in such cases.
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Affiliation(s)
- Wataru Harada
- Department of Kidney Disease and Blood Purification Therapy, Akane-Foundation, Tsuchiya General Hospital, Japan
- Department of Nephrology, Hiroshima University Hospital, Japan
| | - Masataka Banshodani
- Department of Kidney Disease and Blood Purification Therapy, Akane-Foundation, Tsuchiya General Hospital, Japan
| | - Fumio Shimamoto
- Diagnostic Pathology, Pathology Clinic, Japan
- Department of Nursing, Faculty of Health Sciences Dean, Hiroshima Cosmopolitan University, Japan
| | - Sadanori Shintaku
- Department of Kidney Disease and Blood Purification Therapy, Akane-Foundation, Tsuchiya General Hospital, Japan
| | - Misaki Moriishi
- Department of Kidney Disease and Blood Purification Therapy, Akane-Foundation, Tsuchiya General Hospital, Japan
| | - Takao Masaki
- Department of Nephrology, Hiroshima University Hospital, Japan
| | - Hideki Kawanishi
- Department of Kidney Disease and Blood Purification Therapy, Akane-Foundation, Tsuchiya General Hospital, Japan
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4
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Kadoya H, Hirano A, Umeno R, Kajimoto E, Iwakura T, Kondo M, Wada Y, Kidokoro K, Kishi S, Nagasu H, Sasaki T, Taniguchi S, Takahashi M, Kashihara N. Activation of the inflammasome drives peritoneal deterioration in a mouse model of peritoneal fibrosis. FASEB J 2023; 37:e23129. [PMID: 37606578 DOI: 10.1096/fj.202201777rrr] [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: 11/04/2022] [Revised: 07/10/2023] [Accepted: 07/25/2023] [Indexed: 08/23/2023]
Abstract
During peritoneal dialysis (PD), the peritoneum is exposed to a bioincompatible dialysate, deteriorating the tissue and limiting the long-term effectiveness of PD. Peritoneal fibrosis is triggered by chronic inflammation induced by a variety of stimuli, including peritonitis. Exposure to PD fluid alters peritoneal macrophages phenotype. Inflammasome activation triggers chronic inflammation. First, it was determined whether inflammasome activation causes peritoneal deterioration. In the in vivo experiments, the increased expression of the inflammasome components, caspase-1 activity, and concomitant overproduction of IL-1β and IL-18 were observed in a mouse model of peritoneal fibrosis. ASC-positive and F4/80-positive cells colocalized in the subperitoneal mesothelial cell layer. These macrophages expressed high CD44 levels indicating that the CD44-positive macrophages contribute to developing peritoneal deterioration. Furthermore, intravital imaging of the peritoneal microvasculature demonstrated that the circulating CD44-positive leukocytes may contribute to peritoneal fibrosis. Bone marrow transplantation in ASC-deficient mice suppressed inflammasome activation, thereby attenuating peritoneal fibrosis in a high glucose-based PD solution-injected mouse model. Our results suggest inflammasome activation in CD44-positive macrophages may be involved in developing peritoneal fibrosis. The inflammasome-derived pro-inflammatory cytokines might therefore serve as new biomarkers for developing encapsulating peritoneal sclerosis.
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Affiliation(s)
- Hiroyuki Kadoya
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Akira Hirano
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Reina Umeno
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Eriko Kajimoto
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Tsukasa Iwakura
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Megumi Kondo
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Yoshihisa Wada
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Kengo Kidokoro
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Seiji Kishi
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Hajime Nagasu
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Tamaki Sasaki
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Shun'ichiro Taniguchi
- Advanced Cancer Medicine for Gynecologic Cancer, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Masafumi Takahashi
- Division of Inflammation Research, Center for Molecular Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
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Fukui S, Mizuno M, Tawada M, Suzuki Y, Kojima H, Matsukawa Y, Imai M, Kim H, Kinashi H, Mizutani M, Minoshima K, Maruyama S, Ito Y. Peritoneal Expression of Membrane Complement Regulators Is Decreased in Peritoneal Dialysis Patients with Infected Peritonitis. Int J Mol Sci 2023; 24:ijms24119146. [PMID: 37298097 DOI: 10.3390/ijms24119146] [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: 04/24/2023] [Revised: 05/11/2023] [Accepted: 05/15/2023] [Indexed: 06/12/2023] Open
Abstract
In peritoneal dialysis (PD) patients, fungi and Pseudomonas aeruginosa are considered important causative microorganisms for peritonitis with poor prognosis. Our objective was to explore expressions of membrane complement (C) regulators (CRegs) and tissue injuries in the peritoneum of patients with PD-related peritonitis, including fungal and Pseudomonas aeruginosa peritonitis. In peritoneal biopsy tissues obtained at PD catheter removal, we investigated the severity of peritonitis-associated peritoneal injuries and the expression of CRegs, CD46, CD55, and CD59 against peritoneal tissues without any episode of peritonitis. In addition, we evaluated peritoneal injuries among fungal and Pseudomonas aeruginosa-peritonitis (P1) and Gram-positive bacterial peritonitis (P2). We also observed deposition of C activation products such as activated C and C5b-9 and measured sC5b-9 in the PD fluid of patients. As a result, the severity of peritoneal injuries correlated inversely with the expression of peritoneal CRegs. Peritoneal CReg expression in peritonitis was significantly reduced compared to no peritonitis. Peritoneal injuries were more severe in P1 than in P2. CReg expression was further decreased and C5b-9 further increased in P1 than in P2. In conclusion, severe peritoneal injuries due to fungal and Pseudomonas aeruginosa-peritonitis decreased CReg expression and increased deposition of activated C3 and C5b-9 in the peritoneum, suggesting that peritonitis, particularly fungal and Pseudomonas aeruginosa-peritonitis, might induce susceptibility to further peritoneal injuries due to excessive C activation.
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Affiliation(s)
- Sosuke Fukui
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
- Department of Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Masashi Mizuno
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
- Department of Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Mitsuhiro Tawada
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Yasuhiro Suzuki
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
- Department of Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Hiroshi Kojima
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
- Department of Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Yoshihisa Matsukawa
- Department of Urology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Masaki Imai
- Department of Immunology, Nagoya City University, Nagoya 467-8601, Japan
| | - Hangsoo Kim
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
- Department of Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Hiroshi Kinashi
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute 480-1195, Japan
| | | | | | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute 480-1195, Japan
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Kobayashi K, Ozeki T, Kim H, Imai M, Kojima H, Iguchi D, Fukui S, Suzuki M, Suzuki Y, Maruyama S, Ito Y, Mizuno M. Long-term peritoneal dialysate exposure modulates expression of membrane complement regulators in human peritoneal mesothelial cells. Front Med (Lausanne) 2022; 9:972592. [PMID: 36619632 PMCID: PMC9815709 DOI: 10.3389/fmed.2022.972592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
The membrane complement regulators (CRegs) CD46, CD55, and CD59 are highly expressed on human peritoneal mesothelial cells. However, how mesothelial CRegs change according to the peritoneal dialysis (PD) history of patients has remained unclear. We therefore examined longitudinal changes in CRegs in primary cultured mesothelial cells from PD patients (human peritoneal mesothelial cells; HPMCs) and examined which components of PD fluid (PDF) affect CRegs in vitro. We measured levels of soluble C5b-9 in overnight-dwelling PDF in PD patients and also evaluated changes in CRegs expression on HPMCs collected from PDF using flow cytometry and polymerase chain reaction at a 1-year interval of PD therapy. We also evaluated changes in CReg expressions with stimulation by each component of PDF (glucose, lactic acid and pH) using the Met5A human mesothelial cell line. Levels of sC5b-9 in PDF decreased significantly during 1 year, while expressions of CD46 and CD59 proteins and mRNAs increased significantly in HPMCs during 1 year. Analyzing Met-5A cells, we observed that expressions of the three CRegs were increased by glucose and lactic acid in a concentration-dependent manner, but conversely that expressions of CRegs were decreased by lower pH stimulation. History of PD might influence expression of CRegs by HPMCs through properties of PDF such as glucose, lactic acid, and pH. These results suggest that mesothelial cells may alter expression of CRegs for the purpose of protecting the peritoneum and the presence of PDF might affect peritoneal homeostasis associated with the complement system.
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Affiliation(s)
- Kazuma Kobayashi
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toshikazu Ozeki
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hangsoo Kim
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan,Department of Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masaki Imai
- Department of Immunology, Nagoya City University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Kojima
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan,Department of Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daiki Iguchi
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Sosuke Fukui
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan,Department of Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masafumi Suzuki
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiro Suzuki
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan,Department of Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Masashi Mizuno
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan,Department of Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya, Japan,*Correspondence: Masashi Mizuno, ,
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7
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Ozeki T, Mizuno M, Iguchi D, Kojima H, Kim H, Suzuki Y, Kinashi H, Ishimoto T, Maruyama S, Ito Y. C1 inhibitor mitigates peritoneal injury in zymosan-induced peritonitis. Am J Physiol Renal Physiol 2021; 320:F1123-F1132. [PMID: 33818127 DOI: 10.1152/ajprenal.00600.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Peritonitis, due to a fungal or bacterial infection, leads to injury of the peritoneal lining and thereby forms a hazard for the long-term success of peritoneal dialysis (PD) and remains a lethal complication in patients with PD. This study investigated whether C1 inhibitor (C1-INH) could protect against the progression of peritoneal injuries with five daily administrations of zymosan after mechanical scraping of the rat peritoneum to mimic fungal peritonitis. Severe peritoneal injuries were seen in this model, accompanied by fibrinogen/fibrin exudation and peritoneal deposition of complement activation products such as activated C3 and C5b-9. However, intraperitoneal injection of C1-INH decreased peritoneal depositions of activated C3 and C5b-9, ameliorated peritoneal thickening, reduced the influx of inflammatory cells, and prevented the production of peritoneal fibrous layers with both one and two doses of C1-INH each day. Our results suggest that C1-INH might be useful to protect against peritoneal injuries after causes of peritonitis such as fungal infection. This clinically available agent may thus help extend the duration of PD.NEW & NOTEWORTHY Peritoneal injuries associated with peritonitis comprise an important issue to prevent long-term peritoneal dialysis (PD) therapy. Here, we showed that C1 inhibitor (C1-INH), as an anticomplement agent, protected against peritoneal injuries in a peritonitis animal model related to fungal infection. Therefore, C1-INH might be useful to protect against peritoneal injuries after peritonitis due to fungal infection. This clinically available agent may thus help extend the duration of PD.
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Affiliation(s)
- Toshikazu Ozeki
- Division of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masashi Mizuno
- Division of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Daiki Iguchi
- Division of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Kojima
- Division of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hangsoo Kim
- Division of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiro Suzuki
- Division of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Kinashi
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
| | - Takuji Ishimoto
- Division of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shoichi Maruyama
- Division of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuhiko Ito
- Department of Nephrology and Rheumatology, Aichi Medical University, Nagakute, Japan
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