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Ran X, Niu GC, Shao YH, Fan FF, Yang M, Lin LT, Chen LZ, Zou YH. Contrast-enhanced ultrasound evaluation of renal perfusion before angioplasty and its predictive value for hypertension. Technol Health Care 2024; 32:963-976. [PMID: 37522235 DOI: 10.3233/thc-230357] [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] [Indexed: 08/01/2023]
Abstract
BACKGROUND Atherosclerotic renal artery stenosis (ARAS) is a common disease in the elderly population. OBJECTIVE The aim was to develop a contrast-enhanced ultrasound (CEUS)-based model for predicting post-angioplasty improvement in hypertension in patients with severe ARAS. METHODS Thirty-five patients with severe ARAS (⩾ 70%) were included in this study, and 42 renal arteries received percutaneous transluminal renal arterial stenting. An optimal integral formula was developed from pre-interventional color-coded duplex sonography (CCDS) and CEUS parameters using least absolute shrinkage and selection operator (LASSO) regression and receiver operating characteristic (ROC) curve analysis. A model for predicting short-term hypertension improvement was established using the integral formula and clinical risk factors. Bootstrapping was used for internal validation. RESULTS Two integral formulas, LASSO.CCDS and LASSO.CEUS, were established. ROC curves of the two integral formulas showed that LASSO.CEUS was the better formula for predicting hypertension improvement (AUC 0.816, specificity 78.6%). Univariate and multivariate regression analyses showed that duration of hypertension (OR 0.841, P= 0.027), diabetes (OR = 0.019, P= 0.010), and LASSO.CEUS (OR 7.641, P= 0.052) were predictors of short-term hypertension improvement after interventional therapy. Using LASSO.CEUS combined with clinical risk factors, the following prediction model was established: logit (short-term improvement in hypertension) = 1.879-0.173 × hypertension duration - 3.961 × diabetes + 2.034 × LASSO.CEUS (AUC 0.939). CONCLUSIONS The model established using CEUS parameters and clinical risk factors could predict hypertension improvement after interventional therapy, but further research and verification are needed.
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Affiliation(s)
- Xu Ran
- Department of Ultrasound Medicine, Peking University First Hospital, Beijing, China
- Department of Ultrasound Medicine, Peking University First Hospital, Beijing, China
| | - Guo-Chen Niu
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
- Department of Ultrasound Medicine, Peking University First Hospital, Beijing, China
| | - Yu-Hong Shao
- Department of Ultrasound Medicine, Peking University First Hospital, Beijing, China
| | - Fang-Fang Fan
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Min Yang
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
| | - Le-Tao Lin
- Minimally Invasive Interventional Division, Department of Medical Imaging and Interventional Radiology, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China
| | - Lu-Zeng Chen
- Department of Ultrasound Medicine, Peking University First Hospital, Beijing, China
| | - Ying-Hua Zou
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, China
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Skov-Jeppesen SM, Petersen NA, Yderstraede KB, Jensen BL, Bistrup C, Lund L. Low-Intensity Extracorporeal Shockwave Therapy (LI-ESWT) in Renal Diseases: A Review of Animal and Human Studies. Int J Nephrol Renovasc Dis 2023; 16:31-42. [PMID: 36778197 PMCID: PMC9912820 DOI: 10.2147/ijnrd.s389219] [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: 09/08/2022] [Accepted: 01/25/2023] [Indexed: 02/09/2023] Open
Abstract
Background Low-intensity extracorporeal shockwave therapy (LI-ESWT) has been suggested as a treatment for vascular diseases such as ischemic heart disease, diabetic foot ulcers, and erectile dysfunction. Primarily, LI-ESWT is known for its ability to stimulate angiogenesis and activation of stem cells in target tissues. Application of LI-ESWT in chronic progressive renal diseases is a novel area. The aim of the present review was to summarize available data on the effects of LI-ESWT used in the setting of renal diseases. Methods We systematically searched PubMed, Medline, and Embase databases for relevant studies. Our review included the results from preclinical animal experiments and clinical research. Results Eleven animal studies and one clinical study were included in the review. In the animal studies, LI-ESWT was used for the treatment of hypertensive nephropathy (n=1), diabetic nephropathy (n=1), or various types of ischemic renal injury (ie, artery occlusion, reperfusion injury) (n=9). The clinical study was conducted in a single-arm cohort as a Phase 1 study with patients having diabetic nephropathy. In animal studies, the application of LI-ESWT was associated with several effects: LI-ESWT led to increased VEGF and endothelial cell proliferation and improved vascularity and perfusion of the kidney tissue. LI-ESWT reduced renal inflammation and fibrosis. LI-ESWT caused only mild side effects in the clinical study, and, similarly, there were no signs of kidney injury after LI-ESWT in the animal studies. Conclusion LI-ESWT, as a non-invasive treatment, reduces the pathological manifestations (inflammation, capillary rarefaction, fibrosis, decreased perfusion) associated with certain types of renal disease. The efficacy of renal LI-ESWT needs to be confirmed in randomized clinical trials.
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Affiliation(s)
- Sune Moeller Skov-Jeppesen
- Department of Urology, Odense University Hospital, Odense, Denmark,Clinical Institute, University of Southern Denmark, Odense, Denmark,Correspondence: Sune Moeller Skov-Jeppesen, Department of Urology, Odense University Hospital, Sdr. Boulevard 29, Odense, 5000, Denmark, Tel +45 51210911, Fax +45 65411726, Email
| | | | - Knud Bonnet Yderstraede
- Clinical Institute, University of Southern Denmark, Odense, Denmark,Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Boye L Jensen
- Department of Cardiovascular and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Claus Bistrup
- Clinical Institute, University of Southern Denmark, Odense, Denmark,Department of Nephrology, Odense University Hospital, Odense, Denmark
| | - Lars Lund
- Department of Urology, Odense University Hospital, Odense, Denmark,Clinical Institute, University of Southern Denmark, Odense, Denmark
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Emergent players in renovascular disease. Clin Sci (Lond) 2022; 136:239-256. [PMID: 35129198 DOI: 10.1042/cs20210509] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/25/2022] [Accepted: 01/26/2022] [Indexed: 02/07/2023]
Abstract
Renovascular disease (RVD) remains a common etiology of secondary hypertension. Recent clinical trials revealed unsatisfactory therapeutic outcomes of renal revascularization, leading to extensive investigation to unravel key pathophysiological mechanisms underlying irreversible functional loss and structural damage in the chronically ischemic kidney. Research studies identified complex interactions among various players, including inflammation, fibrosis, mitochondrial injury, cellular senescence, and microvascular remodeling. This interplay resulted in a shift of our understanding of RVD from a mere hemodynamic disorder to a pro-inflammatory and pro-fibrotic pathology strongly influenced by systemic diseases like metabolic syndrome (MetS), hypertension, diabetes mellitus, and hyperlipidemia. Novel diagnostic approaches have been tested for early detection and follow-up of RVD progression, using new imaging techniques and biochemical markers of renal injury and dysfunction. Therapies targeting some of the pathological pathways governing the development of RVD have shown promising results in animal models, and a few have moved from bench to clinical research. This review summarizes evolving understanding in chronic ischemic kidney injury.
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4
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Lerman LO. Cell-based regenerative medicine for renovascular disease. Trends Mol Med 2021; 27:882-894. [PMID: 34183258 PMCID: PMC8403163 DOI: 10.1016/j.molmed.2021.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/22/2021] [Accepted: 06/03/2021] [Indexed: 12/25/2022]
Abstract
Renal artery stenosis (RAS) elicits the development of hypertension and post-stenotic kidney damage, which may become irresponsive to restoration of arterial patency. Rather than mere losses of blood flow or oxygen supply, irreversible intrarenal microvascular rarefaction, tubular injury, and interstitial fibrosis are now attributed to intrinsic pathways activated within the kidney, focusing attention on the kidney parenchyma as a therapeutic target. Several regenerative approaches involving the delivery of reparative cells or products have achieved kidney repair in experimental models of RAS and the delivery of mesenchymal stem/stromal cells (MSCs) has already been translated to human subjects with RAS with promising results. The ongoing development of innovative approaches in kidney disease awaits application, validation, and acceptance as routine clinical treatment to avert kidney damage in RAS.
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Affiliation(s)
- Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.
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5
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Skov-Jeppesen SM, Yderstraede KB, Jensen BL, Bistrup C, Hanna M, Lund L. Low-Intensity Shockwave Therapy (LI-ESWT) in Diabetic Kidney Disease: Results from an Open-Label Interventional Clinical Trial. Int J Nephrol Renovasc Dis 2021; 14:255-266. [PMID: 34285548 PMCID: PMC8286109 DOI: 10.2147/ijnrd.s315143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/04/2021] [Indexed: 01/07/2023] Open
Abstract
Purpose Treatment with low-intensity shockwave therapy (LI-ESWT) is associated with angiogenesis and is suggested as a treatment for different types of vascular diseases. It was hypothesized that LI-ESWT improves the renal filtration barrier and halts the progression of GFR decline in diabetic kidney disease (DKD) potentially through VEGF and NO formation. We present the first data on LI-ESWT in human DKD. Methods The study was designed as an interventional, prospective, one-arm, Phase 1 study. We investigated change in GFR and albuminuria in 28 patients with DKD treated with six sessions of LI-ESWT over three weeks. The patients were followed for six months. Urine excretion of kidney injury markers, vascular endothelial growth factor (VEGF) and nitric oxide metabolites (NOx) was studied after LI-ESWT. Results There were no significant changes in GFR and albuminuria up to six months after LI-ESWT compared to baseline. Urine VEGF was transiently reduced one month after LI-ESWT, but there were no other significant changes in urine VEGF or NOx after LI-ESWT. Secondary analysis showed that NOx increased after LI-ESWT in patients who had low levels of NOx at baseline. Kidney injury marker trefoil factor 3 (TFF3) increased acutely after the first session of LI-ESWT indicating transient endothelial repair. Other markers of kidney injury were stable in relation to LI-ESWT. Conclusion LI-ESWT treatment did not significantly improve kidney function and albumin excretion. It is concluded that LI-ESWT is not harmful. A randomized blinded study should be performed to clarify whether adjunctive treatment with LI-ESWT is superior to standard treatment of DKD.
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Affiliation(s)
- Sune Moeller Skov-Jeppesen
- Department of Urology, Odense University Hospital, Odense, Denmark.,OPEN, Odense Patient data Explorative Network, Odense University Hospital, Odense, Denmark.,Clinical Institute, University of Southern Denmark, Odense, Denmark
| | - Knud Bonnet Yderstraede
- Clinical Institute, University of Southern Denmark, Odense, Denmark.,Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Boye L Jensen
- Department of Cardiovascular and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark
| | - Claus Bistrup
- Clinical Institute, University of Southern Denmark, Odense, Denmark.,Department of Nephrology, Odense University Hospital, Odense, Denmark
| | - Milad Hanna
- Department of Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Lars Lund
- Department of Urology, Odense University Hospital, Odense, Denmark.,Clinical Institute, University of Southern Denmark, Odense, Denmark
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Chen XJ, Kim SR, Jiang K, Ferguson CM, Tang H, Zhu XY, Lerman A, Eirin A, Lerman LO. Renovascular Disease Induces Senescence in Renal Scattered Tubular-Like Cells and Impairs Their Reparative Potency. Hypertension 2021; 77:507-518. [PMID: 33390051 DOI: 10.1161/hypertensionaha.120.16218] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Scattered tubular-like cells (STCs), dedifferentiated renal tubular epithelial cells, contribute to renal self-healing, but severe injury might blunt their effectiveness. We hypothesized that ischemic renovascular disease (RVD) induces senescence in STC and impairs their reparative potency. CD24+/CD133+ STCs were isolated from swine kidneys after 16 weeks of RVD or healthy controls. To test their reparative capabilities in injured kidneys, control or RVD-STC (5×105) were prelabeled and injected into the aorta of 2 kidneys, 1-clip (2k,1c) mice 2 weeks after surgery. Murine renal function and oxygenation were studied in vivo 2 weeks after injection using micro-magnetic resonance imaging, and fibrosis, tubulointerstitial injury, capillary density, and expression of profibrotic and inflammatory genes ex vivo. STC isolated from swine RVD kidneys showed increased gene expression of senescence and senescence-associated secretory phenotype markers and positive SA-β-gal staining. Delivery of normal pig STCs in 2k,1c mice improved murine renal perfusion, blood flow, and glomerular filtration rate, and downregulated profibrotic and inflammatory gene expression. These renoprotective effects were blunted using STC harvested from RVD kidneys, which also failed to attenuate hypoxia, fibrosis, tubular injury, and capillary loss in injured mouse 2k,1c kidneys. Hence, RVD may induce senescence in endogenous STC and impair their reparative capacity. These observations implicate cellular senescence in the pathophysiology of ischemic kidney disease and support senolytic therapy to permit self-healing of senescent kidneys.
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Affiliation(s)
- Xiao-Jun Chen
- From the Division of Nephrology and Hypertension (X.-J.C., S.R.K., K.J., C.M.F., H.T., X.-Y.Z., A.E., L.O.L.), Mayo Clinic, Rochester, MN.,Department of Nephrology, The Second Xiangya Hospital of Central-South University, Changsha, Hunan, China (X.-J.C.)
| | - Seo Rin Kim
- From the Division of Nephrology and Hypertension (X.-J.C., S.R.K., K.J., C.M.F., H.T., X.-Y.Z., A.E., L.O.L.), Mayo Clinic, Rochester, MN.,Division of Nephrology, Pusan National University Yangsan Hospital, Korea (S.R.K.)
| | - Kai Jiang
- From the Division of Nephrology and Hypertension (X.-J.C., S.R.K., K.J., C.M.F., H.T., X.-Y.Z., A.E., L.O.L.), Mayo Clinic, Rochester, MN
| | - Christopher M Ferguson
- From the Division of Nephrology and Hypertension (X.-J.C., S.R.K., K.J., C.M.F., H.T., X.-Y.Z., A.E., L.O.L.), Mayo Clinic, Rochester, MN
| | - Hui Tang
- From the Division of Nephrology and Hypertension (X.-J.C., S.R.K., K.J., C.M.F., H.T., X.-Y.Z., A.E., L.O.L.), Mayo Clinic, Rochester, MN
| | - Xiang-Yang Zhu
- From the Division of Nephrology and Hypertension (X.-J.C., S.R.K., K.J., C.M.F., H.T., X.-Y.Z., A.E., L.O.L.), Mayo Clinic, Rochester, MN
| | - Amir Lerman
- Department of Cardiovascular Diseases (A.L.), Mayo Clinic, Rochester, MN
| | - Alfonso Eirin
- From the Division of Nephrology and Hypertension (X.-J.C., S.R.K., K.J., C.M.F., H.T., X.-Y.Z., A.E., L.O.L.), Mayo Clinic, Rochester, MN
| | - Lilach O Lerman
- From the Division of Nephrology and Hypertension (X.-J.C., S.R.K., K.J., C.M.F., H.T., X.-Y.Z., A.E., L.O.L.), Mayo Clinic, Rochester, MN
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Abstract
Chronic kidney disease is a global health care burden, yet clinically-proven treatments are limited. Low-intensity shockwave, which utilizes ≈10% of the energy levels used in clinically indicated shockwave lithotripsy, is a promising technique to ameliorate ischemia and regenerate tissues. It has been demonstrated to improve healing in tissues such as bone, muscle, myocardium, and kidney via several mechanisms, particularly through promoting neovascularization. Low-intensity shockwave stimulates mechanoreceptors located primarily in endothelial and proximal tubular cells and subsequently upregulates vascular endothelial growth factors. This, in turn, promotes angiogenesis and ameliorates renal hypoxia, inflammation, and fibrosis, and ultimately preserves renal function. Furthermore, low-intensity shockwave can stimulate release of homing factors to attract endothelial progenitor or stem cells into injured kidneys for tissue repair. These effects may be beneficial in several kidney disease models, including renal artery stenosis, diabetic kidney disease, and various chronic kidney diseases, although most studies reported to date have been performed in animal models. Because of its low energy intensity, the procedure is relatively tolerable and safe, yet, more clinical studies are needed to establish its efficacy beyond currently existing strategies. Therefore, low-intensity shockwave therapy emerges as an alternative therapeutic approach that may offer a promising noninvasive intervention for treating renal diseases. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT02515461; NCT03602807; and NCT03445247.
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Affiliation(s)
- Nattawat Klomjit
- From the Division of Nephrology and Hypertension (N.K., L.O.L.), Mayo Clinic, Rochester, MN
| | - Amir Lerman
- Department of Cardiovascular Disease (A.L.), Mayo Clinic, Rochester, MN
| | - Lilach O Lerman
- From the Division of Nephrology and Hypertension (N.K., L.O.L.), Mayo Clinic, Rochester, MN
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Chen XJ, Zhang X, Jiang K, Krier JD, Zhu X, Conley S, Lerman A, Lerman LO. Adjunctive mesenchymal stem/stromal cells augment microvascular function in poststenotic kidneys treated with low-energy shockwave therapy. J Cell Physiol 2020; 235:9806-9818. [PMID: 32430932 DOI: 10.1002/jcp.29794] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/05/2020] [Accepted: 05/05/2020] [Indexed: 12/21/2022]
Abstract
Effective therapeutic strategies are needed to preserve renal function in patients with atherosclerotic renal artery stenosis (ARAS). Low-energy shockwave therapy (SW) and adipose tissue-derived mesenchymal stem/stromal cells (MSCs) both stimulate angiogenesis repair of stenotic kidney injury. This study tested the hypothesis that intrarenal delivery of adipose tissue-derived MSCs would enhance the capability of SW to preserve stenotic kidney function and structure. Twenty-two pigs were studied after 16 weeks of ARAS, ARAS treated with a SW regimen (bi-weekly for 3 weeks) with or without subsequent intrarenal delivery of adipose tissue-derived MSCs and controls. Four weeks after treatment, single-kidney renal blood flow (RBF) before and after infusion of acetylcholine, glomerular filtration rate (GFR), and oxygenation were assessed in vivo and the renal microcirculation, fibrosis, and oxidative stress ex vivo. Mean arterial pressure remained higher in ARAS, ARAS + SW, and ARAS + SW + MSC compared with normal. Both SW and SW + MSC similarly elevated the decreased stenotic kidney GFR and RBF observed in ARAS to normal levels. Yet, SW + MSC significantly improved RBF response to acetylcholine in ARAS, and attenuated capillary loss and oxidative stress more than SW alone. Density of larger microvessels was similarly increased by both interventions. Therefore, although significant changes in functional outcomes were not observed in a short period of time, adjunct MSCs enhanced pro-angiogenic effect of SW to improve renal microvascular outcomes, suggesting this as an effective stratege for long-term management of renovascular disease.
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Affiliation(s)
- Xiao-Jun Chen
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota.,Department of Nephrology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Xin Zhang
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Kai Jiang
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - James D Krier
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Xiangyang Zhu
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Sabena Conley
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Amir Lerman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Lilach O Lerman
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota.,Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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Improving intrarenal microcirculation prior to balloon angioplasty: new chances for the treatment of atherosclerotic renal artery stenosis? J Hypertens 2020; 37:1963-1965. [PMID: 31464862 DOI: 10.1097/hjh.0000000000002167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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10
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Reply. J Hypertens 2019; 37:2302-2303. [PMID: 31567761 DOI: 10.1097/hjh.0000000000002242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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