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Seipone ID, Mendham AE, Storbeck KH, Oestlund I, Kufe CN, Chikowore T, Masemola M, Crowther NJ, Kengne AP, Norris S, Olsson T, Brown T, Micklesfield LK, Goedecke JH. SHBG, Free Testosterone, and Type 2 Diabetes Risk in Middle-aged African Men: A Longitudinal Study. J Endocr Soc 2024; 8:bvae129. [PMID: 39055720 PMCID: PMC11272087 DOI: 10.1210/jendso/bvae129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Indexed: 07/27/2024] Open
Abstract
Objectives To investigate longitudinal changes in SHBG and free testosterone (free T) levels among Black middle-aged African men, with and without coexistent HIV, and explore associations with incident dysglycaemia and measures of glucose metabolism. Design This longitudinal study enrolled 407 Black South African middle-aged men, comprising primarily 322 men living without HIV (MLWOH) and 85 men living with HIV (MLWH), with normal fasting glucose at enrollment. Follow-up assessments were conducted after 3.1 ± 1.5 years. Methods At baseline and follow-up, SHBG, albumin, and total testosterone were measured and free T was calculated. An oral glucose tolerance test at follow-up determined dysglycaemia (impaired fasting glucose, impaired glucose tolerance, type 2 diabetes) and glucose metabolism parameters including insulin sensitivity (Matsuda index), insulin resistance (homeostasis model assessment of insulin resistance), and beta(β)-cell function (disposition index). The primary analysis focussed on MLWOH, with a subanalysis on MLWH to explore whether associations in MLWOH differed from MLWH. Results The prevalence of dysglycaemia at follow-up was 17% (n = 55) in MLWOH. Higher baseline SHBG was associated with a lower risk of incident dysglycaemia (odds ratio 0.966; 95% confidence interval 0.945-0.987) and positively associated with insulin sensitivity (β = 0.124, P < .001) and β-cell function (β = 0.194, P = .001) at follow-up. Free T did not predict dysglycaemia. In MLWH, dysglycaemia prevalence at follow-up was 12% (n = 10). Neither baseline SHBG nor free T were associated with incident dysglycaemia and glucose metabolism parameters in MLWH. Conclusion SHBG levels predict the development of dysglycaemia in middle-aged African men but do not exhibit the same predictive value in MLWH.
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Affiliation(s)
- Ikanyeng D Seipone
- Biomedical Research Innovation Platform, South African Medical Research Council, Cape Town 7505, South Africa
| | - Amy E Mendham
- Riverland Academy of Clinical Excellence, Riverland Mallee Coorong Local Health Network, South Australia Health, Berri, SA 5343, Australiacountry
- South African Medical Research Council/WITS Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
- Health through Physical Activity, Lifestyle and Sport Research Centre, FIMS International Collaborating Centre of Sports Medicine, Division of Physiological Sciences, Department of Human Biology, Faculty of Health Sciences, University of Cape Town, Cape Town 7701, South Africa
| | - Karl-Heinz Storbeck
- Department of Biochemistry, Stellenbosch University, Stellenbosch 7602, South Africa
| | - Imken Oestlund
- Department of Biochemistry, Stellenbosch University, Stellenbosch 7602, South Africa
| | - Clement N Kufe
- South African Medical Research Council/WITS Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
| | - Tinashe Chikowore
- South African Medical Research Council/WITS Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
| | - Maphoko Masemola
- South African Medical Research Council/WITS Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
| | - Nigel J Crowther
- Department of Chemical Pathology, National Health Laboratory Service and University of the Witwatersrand Faculty of Health Sciences, Johannesburg 2000, South Africa
| | - Andre Pascal Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town 7505, South Africa
| | - Shane Norris
- South African Medical Research Council/WITS Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
| | - Tommy Olsson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå 90187, Sweden
| | - Todd Brown
- Division of Endocrinology and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD 21218, USA
| | - Lisa K Micklesfield
- South African Medical Research Council/WITS Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
| | - Julia H Goedecke
- Biomedical Research Innovation Platform, South African Medical Research Council, Cape Town 7505, South Africa
- South African Medical Research Council/WITS Developmental Pathways for Health Research Unit, Department of Paediatrics, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
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2
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De Vincentis S, Rochira V. Update on acquired hypogonadism in men living with HIV: pathogenesis, clinic, and treatment. Front Endocrinol (Lausanne) 2023; 14:1201696. [PMID: 37455928 PMCID: PMC10338827 DOI: 10.3389/fendo.2023.1201696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/08/2023] [Indexed: 07/18/2023] Open
Abstract
Hypogonadism is a frequent finding among men living with HIV (MLWH) and it seems to occur earlier in comparison with the general male population. Although the prevalence of hypogonadism in MLWH has significantly lowered thanks to advancements in medical management, it remains high if compared with age-matched HIV-uninfected men, ranging from 13% to 40% in the age group of 20-60 years. Signs and symptoms of low serum testosterone (T) in MLWH are cause of concern since they are non-specific, of mild-to-moderate degree, and often overlapping with those of infection per se. For these reasons, hypogonadism can be underestimated in the absence of targeted laboratory blood examinations. With regard to the etiological factors involved in the T decrease, emerging evidence has suggested the functional nature of hypogonadism in MLWH, pointing out the mutual relationship between sex steroids, health status, comorbidities, and HIV-related factors. In agreement with this hypothesis, a therapeutic approach aiming at improving or reversing concomitant diseases through lifestyle changes (e.g. physical activity) rather than pharmacological T treatment should be theoretically considered. However, considering both patient's barriers to lifestyle changes to be maintained overtime and the lack of evidence-based data on the efficacy of lifestyle changes in normalizing serum T in MLWH, T therapy remains an option when other non-pharmacological interventions are ineffective as well as for all other functional forms of hypogonadism. From this perspective, the traditional therapeutic management of male hypogonadism in MLWH, especially the role of T supplementation, should be revised in the light of the probable functional nature of hypogonadism by considering a good balance between benefits and harmful. This narrative review presents an overview of current knowledge on hypogonadism in MLWH, deepening the factors driving and taking part in T decrease, providing advice for the clinical approach, and underlining the importance of individualized treatment aiming at optimizing non-gonadal comorbidities and thus avoiding over-, or even unnecessary, treatment with T.
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Affiliation(s)
- Sara De Vincentis
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Vincenzo Rochira
- Unit of Endocrinology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
- Unit of Endocrinology, Department of Medical Specialties, Azienda Ospedaliero-Universitaria of Modena, Modena, Italy
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3
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Narinx N, David K, Walravens J, Vermeersch P, Claessens F, Fiers T, Lapauw B, Antonio L, Vanderschueren D. Role of sex hormone-binding globulin in the free hormone hypothesis and the relevance of free testosterone in androgen physiology. Cell Mol Life Sci 2022; 79:543. [PMID: 36205798 DOI: 10.1007/s00018-022-04562-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 08/12/2022] [Accepted: 09/17/2022] [Indexed: 11/03/2022]
Abstract
According to the free hormone hypothesis, biological activity of a certain hormone is best reflected by free rather than total hormone concentrations. A crucial element in this theory is the presence of binding proteins, which function as gatekeepers for steroid action. For testosterone, tissue exposure is governed by a delicate equilibrium between free and total testosterone which is determined through interaction with the binding proteins sex hormone-binding globulin and albumin. Ageing, genetics and various pathological conditions influence this equilibrium, hereby possibly modulating hormonal exposure to the target tissues. Despite ongoing controversy on the subject, strong evidence from recent in vitro, in vivo and human experiments emphasizes the relevance of free testosterone. Currently, however, clinical possibilities for free hormone diagnostics are limited. Direct immunoassays are inaccurate, while gold standard liquid chromatography with tandem mass spectrometry (LC-MS/MS) coupled equilibrium dialysis is not available for clinical routine. Calculation models for free testosterone, despite intrinsic limitations, provide a suitable alternative, of which the Vermeulen calculator is currently the preferred method. Calculated free testosterone is indeed associated with bone health, frailty and other clinical endpoints. Moreover, the added value of free testosterone in the clinical diagnosis of male hypogonadism is clearly evident. In suspected hypogonadal men in whom borderline low total testosterone and/or altered sex hormone-binding globulin levels are detected, the determination of free testosterone avoids under- and overdiagnosis, facilitating adequate prescription of hormonal replacement therapy. As such, free testosterone should be integrated as a standard biochemical parameter, on top of total testosterone, in the diagnostic workflow of male hypogonadism.
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Affiliation(s)
- N Narinx
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000, Leuven, Belgium.,Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - K David
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000, Leuven, Belgium.,Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - J Walravens
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - P Vermeersch
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - F Claessens
- Laboratory of Molecular Endocrinology, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - T Fiers
- Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - B Lapauw
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium.,Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - L Antonio
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000, Leuven, Belgium.,Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - D Vanderschueren
- Laboratory of Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Herestraat 49, ON1bis box 902, 3000, Leuven, Belgium. .,Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium.
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Huhtaniemi IT, Wu FCW. Ageing male (part I): Pathophysiology and diagnosis of functional hypogonadism. Best Pract Res Clin Endocrinol Metab 2022; 36:101622. [PMID: 35210191 DOI: 10.1016/j.beem.2022.101622] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This narrative review summarizes key points of the pathogenesis and diagnosis of the ageing-related decline of testosterone (T) in men. The condition is commonly termed late-onset hypogonadism (LOH), but because it is more often caused by other factors than chronological ageing (obesity and other comorbidities), a more appropriate term is functional hypogonadism (FH). Unlike the classical organic hypogonadism, no anatomical or genetic aberrations are found in FH, and the suppression of T is milder. Moreover, FH can be reversible if the underlying cause (e.g. obesity, chronic disease) is removed/treated. Low serum total T in connection with more specific hypogonadism-associated symptoms (primarily sexual) form the basis of the diagnosis of FH. When T concentrations are borderline, the accuracy of diagnosis can be improved by assessment of free or calculated free T, especially when suppressed SHBG levels (usually related to obesity) are likely. Current data indicate that FH (low T and sexual symptoms) is not a common condition, and it is detectable in about 2% of community-dwelling men aged 40-80 years.
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Affiliation(s)
- Ilpo T Huhtaniemi
- Department of Digestion, Metabolism and Reproduction, Institute of Reproductive and Developmental Biology, Hammersmith Campus, Imperial College London, London W12 0NN, UK.
| | - Frederick C W Wu
- Division of Endocrinology, Diabetes & Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9WL, UK
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5
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Dias JP, Piggott DA, Sun J, Wehbeh L, Garza J, Abraham A, Astemborski J, Moseley KF, Basaria S, Varadhan R, Brown TT. SHBG, Bone Mineral Density, and Physical Function Among Injection Drug Users With and Without HIV and HCV. J Clin Endocrinol Metab 2022; 107:e2971-e2981. [PMID: 35293996 PMCID: PMC9202730 DOI: 10.1210/clinem/dgac144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Sex hormone-binding globulin (SHBG) is a glycoprotein that regulates the bioavailability of sex hormones and is higher in people with HIV (PWH) and hepatitis C virus (HCV). SHBG is associated with aging-related diseases, including osteoporosis and frailty in the general population. However, the relationship between SHBG concentration and bone mineral density (BMD) and physical function among PWH and HCV is unclear. OBJECTIVE This study aimed to evaluate the association between chronic infection with HIV and HCV and SHBG, and to assess the relationship of circulating SHBG concentrations with low BMD, physical function impairment, and frailty. METHODS A cross-sectional study was conducted of 278 HCV-exposed (HCV antibody positive) adults enrolled with and without HIV and HCV from the AIDS Linked to the IntraVenous Experience cohort study into 4 groups: HCV-/HIV-, HCV-/HIV+, HCV+/HIV-, and HCV+/HIV+. We evaluated the association between SHBG concentrations and grip strength, gait speed, Short Physical Performance Battery score, frailty (Fried Frailty Phenotype), and BMD (lumbar spine, total hip, and femoral neck T-score) by using adjusted multivariable regression stratified by sex. RESULTS SHBG concentrations were higher in women, in those with HIV RNA greater than 400 copies/mL (P = .02) and HCV RNA greater than 15 IU/mL (P < .001). In adjusted models, higher SHBG concentrations among women were statistically significantly associated with lower grip strength (-0.43 [95% CI, -0.77 to -0.081] kg/10 nmol/L, P < .05), higher odds of frailty (odds ratio, 1.49 [95% CI, 1.07 to 2.08], P < .05), and lower T-scores at the lumbar spine (-0.070 [95% CI, -0.15 to -0.001] SD/10 nmol/L T-score BMD, P < .05). Similar associations were not observed among men. CONCLUSION Higher SHBG concentrations are associated with the presence of HIV and HCV viremia. Among women, but not men, higher SHBG concentrations were associated with lower grip strength, higher odds of frailty, and lower lumbar spine BMD. The underlying mechanisms of these associations require further investigation.
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Affiliation(s)
- Jenny Pena Dias
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Damani A Piggott
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jing Sun
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Leen Wehbeh
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Joshua Garza
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Alison Abraham
- Department of Epidemiology Johns Hopkins Bloomberg School of Public Health; Department of Epidemiology, School of Public Health and Department of Ophthalmology, School of Medicine, University of Colorado Anschutz Medical Campus, Colorado, USA
| | - Jacquie Astemborski
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Kendall F Moseley
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Shehzad Basaria
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ravi Varadhan
- Department of Oncology; Biostatistics and Bioinformatics, Johns Hopkins University, Baltimore, Maryland, USA
| | - Todd T Brown
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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6
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Wu S, Hilton O, Pereira B, Girometti N, Milinkovic A, Ollandini G, Boffito M. Correlation between different equations to calculate free testosterone for improved detection of hypogonadism in people living with HIV. Int J STD AIDS 2022; 33:613-617. [PMID: 35379047 DOI: 10.1177/09564624221083760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The diagnosis of hypogonadism in people living with HIV (PLWH) remains challenging by the lack of a standardised diagnostic algorithm. Since sexual hormone-binding globulin levels are commonly increased in PLWH, guidelines recommend assessing free testosterone (FT) along with total testosterone levels. We compared different online equations available to estimate FT levels and found a good correlation amongst all algorithms. Estimating FT levels increased diagnostic accuracy of hypogonadism and therefore should be encouraged in clinical practice in PLWH with clinical symptoms of hypogonadism, even when total testosterone levels are normal.
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Affiliation(s)
- Shuang Wu
- 4615Department of Infectious Diseases, Imperial College London, London, UK
| | - Orla Hilton
- 4615Department of Infectious Diseases, Imperial College London, London, UK
| | - Branca Pereira
- 4615Department of Infectious Diseases, Imperial College London, London, UK.,HIV/GUM Directorate, 9762Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Nicolo Girometti
- HIV/GUM Directorate, 9762Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Ana Milinkovic
- HIV/GUM Directorate, 9762Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Giangiacomo Ollandini
- Urology Department, 156774Milton Keynes University Hospital, Milton Keynes, UK.,Department of HIV and Sexual Health, 577312King's College Hospital, London, UK
| | - Marta Boffito
- 4615Department of Infectious Diseases, Imperial College London, London, UK.,HIV/GUM Directorate, 9762Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
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Anderson LJ, Migula D, Abay R, Crabtree S, Graf SA, Matsumoto AM, Chauncey TR, Garcia JM. Androgens and estrogens predict sexual function after autologous hematopoietic stem cell transplant in men. Andrology 2022; 10:291-302. [PMID: 34624176 PMCID: PMC8760151 DOI: 10.1111/andr.13117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/07/2021] [Accepted: 09/29/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Autologous hematopoietic stem cell transplantation (AHSCT) is associated with sexual dysfunction and hypogonadism. Androgens are associated with sexual function in healthy men, but the role of estrogens is less well-known, and the association of these sex steroids with sexual function during AHSCT has not been characterized. OBJECTIVES The purpose of this study was to determine the predictive value of sex hormones before and acutely after AHSCT on sexual function recovery. MATERIALS AND METHODS We examined sex hormones and self-reported sexual function before (PRE) and 1-month post-AHSCT (MONTH1; n = 19), and sexual function again 1-year post-AHSCT in men (YEAR1; n = 15). RESULTS Sexual function decreased from PRE to MONTH1 (p ≤ 0.05) with no differences between PRE and YEAR1. Erectile dysfunction was prevalent at PRE (68.4%) and increased at MONTH1 (100%; p ≤ 0.05) but was not different between PRE and YEAR1 (60.0%). From PRE to MONTH1, total testosterone (TT), dihydrotestosterone (DHT), follicle-stimulating hormone, and sex-hormone-binding globulin (SHBG) increased (p ≤ 0.02) while estradiol (p ≤ 0.026) and estrone decreased (p ≤ 0.001). MONTH1 TT and DHT were associated with sexual function at MONTH1, while PRE SHBG, MONTH1 estradiol, and change in estrone predicted sexual function at YEAR1. DISCUSSION Sexual dysfunction is very prevalent prior to AHSCT and is transiently and severely worsened acutely after. AHSCT induces acute decreases in total and free estrogens, with SHBG increases leading to increases in total androgens, without changes in free androgens. CONCLUSION Androgens and estrogens are both adversely affected by AHSCT but may predict sexual dysfunction in this population. This supports the premise that estrogen impacts sexual function independent from androgens and that steroid hormones are associated with acute changes in sexual function in this setting. Larger, controlled trials with long-term sex hormone assessment will need to confirm the association between early changes in estrogens and long-term sexual function recovery.
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Affiliation(s)
- Lindsey J. Anderson
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, 98195, WA, USA
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, 98108, WA, USA
| | - Dorota Migula
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, 98108, WA, USA
| | - Rebecca Abay
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, 98108, WA, USA
| | - Stephanie Crabtree
- Bone Marrow Transplant Unit, Veterans Affairs Puget Sound Health Care System, Seattle, 98108, WA, USA
| | - Solomon A. Graf
- Bone Marrow Transplant Unit, Veterans Affairs Puget Sound Health Care System, Seattle, 98108, WA, USA
- Oncology, University of Washington Department of Medicine, Seattle, 98195, WA, USA
- Fred Hutchinson Cancer Research Center, Seattle, 98109, WA, USA
| | - Alvin M. Matsumoto
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, 98195, WA, USA
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, 98108, WA, USA
| | - Thomas R. Chauncey
- Bone Marrow Transplant Unit, Veterans Affairs Puget Sound Health Care System, Seattle, 98108, WA, USA
- Oncology, University of Washington Department of Medicine, Seattle, 98195, WA, USA
- Fred Hutchinson Cancer Research Center, Seattle, 98109, WA, USA
| | - Jose M. Garcia
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, 98195, WA, USA
- Geriatric Research, Education and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, 98108, WA, USA
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