1
|
Alharbi FHM, Almutairi FAS, Aljutayli ZAA, Albuhayji SAS, Alharbi HDD, Almutairi AAS. Severe Renal Impairment in a Patient with Recent Rheumatoid Arthritis Diagnosis following Methotrexate Initiation: A Case Report. JOURNAL OF PHARMACY AND BIOALLIED SCIENCES 2024; 16:S1878-S1882. [PMID: 38882813 PMCID: PMC11174238 DOI: 10.4103/jpbs.jpbs_1284_23] [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: 12/24/2023] [Revised: 01/14/2024] [Accepted: 01/17/2024] [Indexed: 06/18/2024] Open
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disease frequently treated with immunosuppressive agents such as methotrexate (MTX). Although MTX is generally well-tolerated, it can lead to adverse effects, including renal impairment. We present a case of a patient with newly diagnosed RA who developed severe renal impairment shortly after initiating MTX therapy. A 50-year-old male with recently diagnosed RA presented with vomiting, skin itching, mouth ulcers, and a pruritic rash, all occurring shortly after starting MTX treatment. These symptoms led to acute kidney injury (AKI), necessitating hemodialysis. The patient's symptoms and laboratory findings were indicative of ANCA-associated small-vessel vasculitis with a picture of rapidly progressive glomerulonephritis (RPGN). Treatment included discontinuation of MTX, hemodialysis, immunosuppressive therapy with corticosteroids and cyclophosphamide, and patient education. This case emphasizes the need for close monitoring of RA patients initiated on MTX therapy and prompt evaluation of renal function. Clinicians should be vigilant for signs of renal impairment and be prepared to initiate appropriate interventions, including discontinuation of MTX and consideration of immunosuppressive therapy, to optimize patient outcomes. Further research is warranted to understand better the mechanisms underlying renal complications in RA patients receiving MTX treatment.
Collapse
|
2
|
Kronbichler A, Bajema IM, Bruchfeld A, Mastroianni Kirsztajn G, Stone JH. Diagnosis and management of ANCA-associated vasculitis. Lancet 2024; 403:683-698. [PMID: 38368016 DOI: 10.1016/s0140-6736(23)01736-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/05/2023] [Accepted: 08/17/2023] [Indexed: 02/19/2024]
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis consists of two main diseases, granulomatosis with polyangiitis and microscopic polyangiitis, and remains among the most devastating and potentially lethal forms of autoimmune inflammatory disease. Granulomatosis with polyangiitis and microscopic polyangiitis are characterised by a necrotising vasculitis that can involve almost any organ, and have generally been studied together. The diseases commonly affect the kidneys, lungs, upper respiratory tract, skin, eyes, and peripheral nerves. Granulomatous inflammation and multinucleated giant cells are key pathological hallmarks of granulomatosis with polyangiitis, but are absent in microscopic polyangiitis. Many immune system events are essential to disease aetiopathogenesis, such as activation of the alternative complement pathway, neutrophil activation via complement receptors, and the influx of inflammatory cells, including monocytes and macrophages. These cells perpetuate inflammation and lead to organ damage. During the 21st century, the management of ANCA-associated vasculitis has moved away from reliance on cytotoxic medications and towards targeted biological medications for both the induction and maintenance of disease remission. Earlier diagnosis, partly the result of more reliable ANCA testing, has led to improved patient outcomes and better survival. Reductions in acute disease-related mortality have now shifted focus to long-term morbidities related to ANCA-associated vasculitis and their treatments, such as chronic kidney disease and cardiovascular disease. Therapeutic approaches in both clinical trials and clinical practice still remain too reliant on glucocorticoids, and continued efforts to reduce toxicity from glucocorticoids remain a priority in the development of new treatment strategies.
Collapse
Affiliation(s)
- Andreas Kronbichler
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria; Department of Medicine, University of Cambridge, Cambridge, UK.
| | - Ingeborg M Bajema
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, Netherlands
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Department of Renal Medicine, Karolinska University Hospital and CLINTEC Karolinska Institutet, Stockholm, Sweden
| | | | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
3
|
Boud'hors C, Riou J, Fage N, Samoreau C, Desouche A, Gatault P, Bridoux F, Martin C, Wacrenier S, Vinatier E, Djema A, Henry N, Croué A, Piccoli GB, Copin MC, Augusto JF, Brilland B. Adding 6-month parameters for the prediction of kidney prognosis in ANCA-associated glomerulonephritis. Clin Kidney J 2023; 16:2530-2541. [PMID: 38046032 PMCID: PMC10689158 DOI: 10.1093/ckj/sfad157] [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: 02/21/2023] [Indexed: 12/05/2023] Open
Abstract
Background Antineutrophil-cytoplasmic antibody (ANCA)-associated vasculitis (AAV) with kidney involvement (AAV-GN) frequently evolves to end-stage kidney disease (ESKD) despite aggressive immunosuppressive treatment. Several risk scores have been used to assess renal prognosis. We aimed to determine whether kidney function and markers of AAV-GN activity after 6 months could improve the prediction of ESKD. Methods This retrospective and observational study included adult patients with AAV-GN recruited from six French nephrology centers (including from the Maine-Anjou AAV registry). The primary outcome was kidney survival. Analyses were conducted in the whole population and in a sub-population that did not develop ESKD early in the course of the disease. Results When considering the 102 patients with all data available at diagnosis, Berden classification and Renal Risk Score (RRS) were not found to be better than kidney function [estimated glomerular filtration rate (eGFR)] alone at predicting ESKD (C-index = 0.70, 0.79, 0.82, respectively). Multivariables models did not indicate an improved prognostic value when compared with eGFR alone.When considering the 93 patients with all data available at 6 months, eGFR outperformed Berden classification and RRS (C-index = 0.88, 0.62, 0.69, respectively) to predict ESKD. RRS performed better when it was updated with the eGFR at 6 months instead of the baseline eGFR. While 6-month proteinuria was associated with ESKD and improved ESKD prediction, hematuria and serological remission did not. Conclusion This work suggests the benefit of the reassessment of the kidney prognosis 6 months after AAV-GN diagnosis. Kidney function at this time remains the most reliable for predicting kidney outcome. Of the markers tested, persistent proteinuria at 6 months was the only one to slightly improve the prediction of ESKD.
Collapse
Affiliation(s)
- Charlotte Boud'hors
- Service de Néphrologie-Dialyse-Transplantation, CHU d'Angers, Angers, France
| | - Jérémie Riou
- Département de Méthodologie et Biostatistiques, Délégation pour la Recherche Clinique et l'Innovation, CHU d'Angers, Angers, France
| | - Nicolas Fage
- Service de Néphrologie-Dialyse-Transplantation, CHU d'Angers, Angers, France
| | - Clément Samoreau
- Service de Néphrologie-Dialyse-Transplantation, CHU d'Angers, Angers, France
| | - Alice Desouche
- Service de Néphrologie-Dialyse-Transplantation, CHU d'Angers, Angers, France
| | - Philippe Gatault
- Service de Néphrologie-Dialyse-Transplantation, CHU de Tours, Tours, France
| | - Frank Bridoux
- Service de Néphrologie-Dialyse-Transplantation, CHU de Poitiers, Poitiers, France
| | - Cécile Martin
- Service de Néphrologie-Dialyse-Transplantation, CHU de Poitiers, Poitiers, France
| | - Samuel Wacrenier
- Service de Néphrologie-Dialyse, Centre Hospitalier du Mans, Le Mans, France
| | - Emeline Vinatier
- Laboratoire d'Immunologie et Allergologie, CHU Angers, Angers, France
- Université d'Angers, Inserm, CNRS, Nantes Université, CRCI2NA, Angers, France
| | - Assia Djema
- Service de Néphrologie-Dialyse, Centre Hospitalier de Cholet, Cholet, France
| | - Nicolas Henry
- Service de Néphrologie-Dialyse, Centre Hospitalier de Laval, Laval, France
| | - Anne Croué
- Département de pathologie cellulaire et tissulaire, CHU d'Angers, Angers, France
| | | | - Marie-Christine Copin
- Université d'Angers, Inserm, CNRS, Nantes Université, CRCI2NA, Angers, France
- Département de pathologie cellulaire et tissulaire, CHU d'Angers, Angers, France
| | - Jean-François Augusto
- Service de Néphrologie-Dialyse-Transplantation, CHU d'Angers, Angers, France
- Université d'Angers, Inserm, CNRS, Nantes Université, CRCI2NA, Angers, France
| | - Benoît Brilland
- Service de Néphrologie-Dialyse-Transplantation, CHU d'Angers, Angers, France
- Université d'Angers, Inserm, CNRS, Nantes Université, CRCI2NA, Angers, France
| |
Collapse
|
4
|
Aqeel F, Xu L, Geetha D. Repeat Kidney Biopsies in Anti-Neutrophil Cytoplasmic Autoantibody-Associated Vasculitis: Clinical and Histologic Progression. Kidney Int Rep 2023; 8:2146-2149. [PMID: 37850018 PMCID: PMC10577318 DOI: 10.1016/j.ekir.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 10/19/2023] Open
Affiliation(s)
- Faten Aqeel
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lillian Xu
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Duvuru Geetha
- Department of Internal Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
5
|
Odler B, Bruchfeld A, Scott J, Geetha D, Little MA, Jayne DRW, Kronbichler A. Challenges of defining renal response in ANCA-associated vasculitis: call to action? Clin Kidney J 2023; 16:965-975. [PMID: 37261001 PMCID: PMC10229283 DOI: 10.1093/ckj/sfad009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Indexed: 12/06/2023] Open
Abstract
Avoiding end-stage kidney disease in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) has a high therapeutic priority. Although renal response is a crucial measure to capture clinically relevant changes, clinal trials have used various definitions and no well-studied key surrogate markers to predict renal outcome in AAV exist. Differences in clinical features and histopathologic and therapeutic approaches will influence the course of kidney function. Its assessment through traditional surrogates (i.e. serum creatinine, glomerular filtration rate, proteinuria, hematuria and disease activity scores) has limitations. Refinement of these markers and the incorporation of novel approaches such as the assessment of histopathological changes using cutting-edge molecular and machine learning mechanisms or new biomarkers could significantly improve prognostication. The timing is favourable since large datasets of trials conducted in AAV are available and provide a valuable resource to establish renal surrogate markers and, likely, aim to investigate optimized and tailored treatment approaches according to a renal response score. In this review we discuss important points missed in the assessment of kidney function in patients with AAV and point towards the importance of defining renal response and clinically important short- and long-term predictors of renal outcome.
Collapse
Affiliation(s)
- Balazs Odler
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Annette Bruchfeld
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine Karolinska Institutet, Stockholm, Sweden
- Department of Health, Medicine and Caring Sciences, Linköpings Universitet, Linköping, Sweden
| | - Jennifer Scott
- Trinity Health Kidney Center, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Mark A Little
- Trinity Health Kidney Center, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | | |
Collapse
|
6
|
Benichou N, Charles P, Terrier B, Jones RB, Hiemstra T, Mouthon L, Bajema I, Berden A, Thervet E, Guillevin L, Jayne D, Karras A. PROTEINURIA AND HEMATURIA AFTER REMISSION INDUCTION ARE ASSOCIATED WITH OUTCOME IN ANCA-ASSOCIATED VASCULITIS. Kidney Int 2023; 103:1144-1155. [PMID: 36940799 DOI: 10.1016/j.kint.2023.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 02/07/2023] [Accepted: 02/16/2023] [Indexed: 03/22/2023]
Abstract
In anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), hematuria and proteinuria are biomarkers reflecting kidney involvement at diagnosis. Yet, the prognostic value of their persistence after immunosuppressive induction therapy, reflecting kidney damage or persistent disease, remains uncertain. To study this, our post-hoc analysis included participants of five European randomized clinical trials on AAV (MAINRITSAN, MAINRITSAN2, RITUXVAS, MYCYC, IMPROVE). Urine protein-creatinine ratio (UPCR) and hematuria of spot urine samples collected at the end of induction therapy (four-six months after treatment initiation) were correlated with the occurrence of a combined endpoint of death and/or kidney failure, or relapses during follow-up. Among 571 patients (59% men, median age 60), 60% had anti-proteinase 3-ANCA and 35% had anti-myeloperoxidase-ANCA, while 77% had kidney involvement. After induction therapy, 157/526 (29.8%) had persistent hematuria and 165/481 (34.3%) had UPCR of 0.05 g/mmol or more. After a median follow-up of 28 months (inter quartile range 18-42), and adjustment for age, ANCA type, maintenance therapy, serum creatinine and persistent hematuria after induction, a UPCR of 0.05 g/mmol or more after induction was associated with significant risk of death/kidney failure (adjusted Hazard Ratio (HR) 3.06, 95% confidence interval (1.09-8.59) and kidney relapse (adjusted subdistribution HR 2.22, 1.16-4.24). Persistent hematuria was associated with significant kidney relapse (adjusted subdistribution HR 2.16, (1.13-4.11) but not with relapse affecting any organ nor with death/kidney failure. Thus, in this large cohort of patients with AAV, persistent proteinuria after induction therapy was associated with death/kidney failure and kidney relapse, whereas persistent hematuria was an independent predictor of kidney relapse. Hence, these parameters must be considered to assess long-term kidney prognosis of patients with AAV.
Collapse
Affiliation(s)
- Nicolas Benichou
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France.
| | - Pierre Charles
- Department of Internal Medicine, Institut Mutualiste Montsouris, Paris, France
| | - Benjamin Terrier
- Université de Paris, Paris, France; Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Rachel B Jones
- Lupus and Vasculitis Clinic, Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK; Department of Medicine, University of Cambridge, Cambridge, UK
| | - Thomas Hiemstra
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Luc Mouthon
- Université de Paris, Paris, France; Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands; Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Annelies Berden
- Department of Rheumatology and Clinical immunology, Maasstad Hospital, Rotterdam, The Netherlands
| | - Eric Thervet
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France
| | - Loïc Guillevin
- Université de Paris, Paris, France; Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Hôpital Cochin, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - David Jayne
- Lupus and Vasculitis Clinic, Department of Renal Medicine, Addenbrooke's Hospital, Cambridge, UK; Department of Medicine, University of Cambridge, Cambridge, UK
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France; Université de Paris, Paris, France
| | -
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, Paris, France
| |
Collapse
|
7
|
Kronbichler A, Bajema I, Geetha D, Säemann M. Novel aspects in the pathophysiology and diagnosis of glomerular diseases. Ann Rheum Dis 2022; 82:585-593. [PMID: 36535746 DOI: 10.1136/ard-2022-222495] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Immune deposits/complexes are detected in a multitude of tissues in autoimmune disorders, but no organ has attracted as much attention as the kidney. Several kidney diseases are characterised by the presence of specific configurations of such deposits, and many of them are under a 'shared care' between rheumatologists and nephrologists. This review focuses on five different diseases commonly encountered in rheumatological and nephrological practice, namely IgA vasculitis, lupus nephritis, cryoglobulinaemia, anti-glomerular basement membrane disease and anti-neutrophil cytoplasm-antibody glomerulonephritis. They differ in disease aetiopathogenesis, but also the potential speed of kidney function decline, the responsiveness to immunosuppression/immunomodulation and the deposition of immune deposits/complexes. To date, it remains unclear if deposits are causing a specific disease or aim to abrogate inflammatory cascades responsible for tissue damage, such as neutrophil extracellular traps or the complement system. In principle, immunosuppressive therapies have not been developed to tackle immune deposits/complexes, and repeated kidney biopsy studies found persistence of deposits despite reduction of active inflammation, again highlighting the uncertainty about their involvement in tissue damage. In these studies, a progression of active lesions to chronic changes such as glomerulosclerosis was frequently reported. Novel therapeutic approaches aim to mitigate these changes more efficiently and rapidly. Several new agents, such as avacopan, an oral C5aR1 inhibitor, or imlifidase, that dissolves IgG within minutes, are more specifically reducing inflammatory cascades in the kidney and repeat tissue sampling might help to understand their impact on immune cell deposition and finally kidney function recovery and potential impact of immune complexes/deposits.
Collapse
Affiliation(s)
- Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, UK .,Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden and Department of Pathology and Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Duvuru Geetha
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marcus Säemann
- 6th Medical Department, Nephrology and Dialysis, Clinic Ottakring, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
| |
Collapse
|
8
|
What to Know About Biopsy Sampling and Pathology in Vasculitis? Curr Rheumatol Rep 2022; 24:279-291. [PMID: 35895226 DOI: 10.1007/s11926-022-01082-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To summarize the histologic findings of vasculitis, and to give some practical considerations on biopsy samples. RECENT FINDINGS The larger use of imaging and the discoveries of serological markers in the diagnosis of vasculitis have increased the clinical recognition of these entities. Nevertheless, biopsy remains the gold standard for diagnosis in most cases. So far, biopsies are also useful to obtain information about prognosis and to guide a more specific treatment. In recent years, less invasive diagnostic approaches have become available, lowering the risks related to the procedure and permitting a definite diagnosis in most cases. Histological examination permits a definite diagnosis of vasculitis. However, the findings may be nonspecific if not evaluated in the proper clinical setting. The interaction between clinicians and pathologists is crucial to obtain a definite diagnosis.
Collapse
|
9
|
Molnár A, Studinger P, Ledó N. Diagnostic and Therapeutic Approach in ANCA-Associated Glomerulonephritis: A Review on Management Strategies. Front Med (Lausanne) 2022; 9:884188. [PMID: 35721093 PMCID: PMC9205443 DOI: 10.3389/fmed.2022.884188] [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: 02/25/2022] [Accepted: 05/18/2022] [Indexed: 11/24/2022] Open
Abstract
Anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis is a destructive small vessel vasculitis affecting multiple organs. Renal involvement often leads to end-stage renal disease and increases mortality. Prompt diagnosis and initiation of adequate immunosuppressive therapy are critical for the best patient and kidney outcomes. However, considerable heterogeneity in symptoms and severity across the patients frequently hinder the diagnosis and management. The objective of this review is to emphasize the heterogeneity of the ANCA-associated vasculitis, facilitate the recognition and give guidance to the therapeutical possibilities. We present epidemiologic and risk factors, pathogenesis, and provide comprehensive clinical features of the disease. This article also focuses on the currently available therapeutic options and emerging cellular and molecular targets for the management of systemic and especially renal disease. We conducted extensive literature research published on PubMed and Google Scholar. We systematically reviewed, analyzed, and assembled databases, covering a broad spectrum of aspects of the disease. We compared and summarized the recommendations of two recent guidelines on ANCA-associated vasculitis. The incidence of ANCA-associated vasculitis, hence glomerulonephritis shows a steady increase. Familiarity with the presenting symptoms and laboratory abnormalities are necessary for rapid diagnosis. Early initiation of treatment is the key aspect for favorable patient and renal outcomes. A better understanding of the pathogenesis constantly leads to more targeted and therefore more efficient and less toxic treatment.
Collapse
Affiliation(s)
| | | | - Nóra Ledó
- Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
| |
Collapse
|