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Meinderts JR, Metselaar HJ, van Hoek B, den Hoed CM, Rijntjes D, Groenewout M, van Vilsteren FGI, Groen H, Berger SP, Prins JR, de Jong MFC. Long-term maternal outcomes of pregnancy after orthotopic liver transplantation in the Netherlands: A retrospective multicenter cohort study. Liver Transpl 2024:01445473-990000000-00459. [PMID: 39250125 DOI: 10.1097/lvt.0000000000000477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Accepted: 08/26/2024] [Indexed: 09/10/2024]
Abstract
Pregnancy after orthotopic liver transplantation (OLT) puts the mother, child, and transplanted organ at risk. Little is known about long-term outcomes. We performed a nationwide retrospective cohort study to evaluate short-term and long-term outcomes of post-OLT pregnancies. The secondary aim was to assess predictors for adverse pregnancy outcomes. A composite outcome of preeclampsia, preterm birth, low birth weight, and neonatal intensive care unit admission was made. Survival of women who received a transplant at <50 years of age with and without pregnancy after OLT were compared (Dutch Organ Transplantation Registry data). Descriptive statistics, regression analysis, Kaplan-Meier and log-rank analysis, and generalized estimating equation analysis were used. Among the included 70 women with 113 pregnancies >20 weeks of gestation, hypertension occurred in 20% and preeclampsia in 12%. The live birth rate was 87%; 33% were preterm, and 23% had low birth weight. Long-term follow-up (median 10 y [IQR: = 4-14]) showed small changes in serum creatinine and bilirubin ( p < 0.001). Sixteen mothers (23%) died during follow-up (median 8 y [IQR: = 4-12]), with all their children aged <18 years. No difference in survival was found when comparing women with and without pregnancy after OLT. The composite outcome occurred in 43/98 of pregnancies. Higher body mass index (BMI) and maternal age at conception increased the composite outcome risk (OR: 1.24, p < 0.01, and OR: 1.25, p = 0.01, respectively). To conclude, pregnancy after OLT does not seem to influence long-term outcomes of graft, kidney function, or patient survival in most cases. However, although pregnancy does not seem to impact survival after OLT, we do show that a substantial number of children will lose their mothers early in life. We believe this is important for pregnancy couseling of patients with an OLT and their partners.
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Affiliation(s)
- Jildau R Meinderts
- Department of Nephrology, Groningen Institute for Organ Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Herold J Metselaar
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bart van Hoek
- Department of Gastroenterology and Hepatology, LUMC Transplantation Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Caroline M den Hoed
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Douwe Rijntjes
- Department of Gastroenterology and Hepatology, LUMC Transplantation Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Mariette Groenewout
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frederike G I van Vilsteren
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Henk Groen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Stefan P Berger
- Department of Nephrology, Groningen Institute for Organ Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jelmer R Prins
- Department of Gastroenterology and Hepatology, Groningen Institute for Organ Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margriet F C de Jong
- Department of Nephrology, Groningen Institute for Organ Transplantation, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Gupta M, Yadav A. Reproductive Health in Kidney Transplant Recipients. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:466-475. [PMID: 39232617 DOI: 10.1053/j.akdh.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/15/2024] [Accepted: 04/24/2024] [Indexed: 09/06/2024]
Abstract
Increasing number of women with kidney transplants are of reproductive age and desire successful pregnancies. Successful outcomes of pregnancy can be achieved with preconception counseling, education about contraception use, the timing of pregnancy (delaying by first year post-transplant), and the choice of immunosuppression medication. Ensuring stable renal function including optimized creatinine, proteinuria, and blood pressure increases successful outcomes. Pregnancy with kidney transplant has an increased risk of preeclampsia, gestational diabetes militeus, cesarean section, and preterm delivery. Multidisciplinary cooperation with high-risk obstetrics and transplant nephrologists is vital.
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Affiliation(s)
- Maitreyee Gupta
- Division of Nephrology and Transplantation, Sidney Kimmel Medical School with Thomas Jefferson University, Philadelphia, PA.
| | - Anju Yadav
- Division of Nephrology and Transplantation, Sidney Kimmel Medical School with Thomas Jefferson University, Philadelphia, PA
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Gosselink ME, Snoek R, Cerkauskaite-Kerpauskiene A, van Bakel SPJ, Vollenberg R, Groen H, Cerkauskiene R, Miglinas M, Attini R, Tory K, Claes KJ, van Calsteren K, Servais A, de Jong MFC, Gillion V, Vogt L, Mastrangelo A, Furlano M, Torra R, Bramham K, Wiles K, Ralston ER, Hall M, Liu L, Hladunewich MA, Lely AT, van Eerde AM. Reassuring pregnancy outcomes in women with mild COL4A3-5-related disease (Alport syndrome) and genetic type of disease can aid personalized counseling. Kidney Int 2024; 105:1088-1099. [PMID: 38382843 DOI: 10.1016/j.kint.2024.01.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 12/22/2023] [Accepted: 01/08/2024] [Indexed: 02/23/2024]
Abstract
Individualized pre-pregnancy counseling and antenatal care for women with chronic kidney disease (CKD) require disease-specific data. Here, we investigated pregnancy outcomes and long-term kidney function in women with COL4A3-5 related disease (Alport Syndrome, (AS)) in a large multicenter cohort. The ALPART-network (mAternaL and fetal PregnAncy outcomes of women with AlpoRT syndrome), an international collaboration of 17 centers, retrospectively investigated COL4A3-5 related disease pregnancies after the 20th week. Outcomes were stratified per inheritance pattern (X-Linked AS (XLAS)), Autosomal Dominant AS (ADAS), or Autosomal Recessive AS (ARAS)). The influence of pregnancy on estimated glomerular filtration rate (eGFR)-slope was assessed in 192 pregnancies encompassing 116 women (121 with XLAS, 47 with ADAS, and 12 with ARAS). Median eGFR pre-pregnancy was over 90ml/min/1.73m2. Neonatal outcomes were favorable: 100% live births, median gestational age 39.0 weeks and mean birth weight 3135 grams. Gestational hypertension occurred during 23% of pregnancies (reference: 'general' CKD G1-G2 pregnancies incidence is 4-20%) and preeclampsia in 20%. The mean eGFR declined after pregnancy but remained within normal range (over 90ml/min/1.73m2). Pregnancy did not significantly affect eGFR-slope (pre-pregnancy β=-1.030, post-pregnancy β=-1.349). ARAS-pregnancies demonstrated less favorable outcomes (early preterm birth incidence 3/11 (27%)). ARAS was a significant independent predictor for lower birth weight and shorter duration of pregnancy, next to the classic predictors (pre-pregnancy kidney function, proteinuria, and chronic hypertension) though missing proteinuria values and the small ARAS-sample hindered analysis. This is the largest study to date on AS and pregnancy with reassuring results for mild AS, though inheritance patterns could be considered in counseling next to classic risk factors. Thus, our findings support personalized reproductive care and highlight the importance of investigating kidney disease-specific pregnancy outcomes.
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Affiliation(s)
- Margriet E Gosselink
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Obstetrics, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Rozemarijn Snoek
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Obstetrics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Agne Cerkauskaite-Kerpauskiene
- Clinic of Gastroenterology, Nephro-Urology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Sophie P J van Bakel
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Obstetrics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Renee Vollenberg
- Department of Genetics, University Medical Center Utrecht, Utrecht, the Netherlands; Department of Obstetrics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Henk Groen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Rimante Cerkauskiene
- Clinic of Children's Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Marius Miglinas
- Clinic of Gastroenterology, Nephro-Urology and Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Rossella Attini
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza, Sant'Anna Hospital, Turin, Italy
| | - Kálmán Tory
- MTA-SE Lendulet Nephrogenetic Laboratory, Pediatric Center, Semmelweis University, Budapest, Hungary
| | - Kathleen J Claes
- Department of Nephrology, University Hospital Leuven, Leuven, Belgium
| | - Kristel van Calsteren
- Department of Obstetrics and Gynaecology, University Hospital Leuven, Leuven, Belgium
| | - Aude Servais
- Department of Nephrology and Transplantation, Necker Enfants Maladies University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Margriet F C de Jong
- Division of Nephrology, Department of Internal Medicine, University Medical Center Groningen, Groningen, the Netherlands
| | - Valentine Gillion
- Department of Nephrology, Cliniques Universitaires Saint-Luc (Université Catholique de Louvain), Brussels, Belgium
| | - Liffert Vogt
- Section Nephrology, Department of Internal Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Antonio Mastrangelo
- Pediatric Nephrology, Dialysis, and Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Monica Furlano
- Department of Nephrology, Inherited Kidney Diseases, Fundació Puigvert, Institut d'Investigacions Biomèdiques Sant Pau Universitat Autònoma de Barcelona, RICORS2040 (Kidney Disease), Barcelona, Spain
| | - Roser Torra
- Department of Nephrology, Inherited Kidney Diseases, Fundació Puigvert, Institut d'Investigacions Biomèdiques Sant Pau Universitat Autònoma de Barcelona, RICORS2040 (Kidney Disease), Barcelona, Spain
| | - Kate Bramham
- Department of Women and Children's Health, King's College London, London, UK
| | - Kate Wiles
- Department of Women and Children, Barts National Health Service Trust and Queen Mary University of London, London, UK
| | - Elizabeth R Ralston
- Department of Women and Children's Health, King's College London, London, UK
| | - Matthew Hall
- Department of Nephrology, Nottingham University Hospitals, Nottingham, UK
| | - Lisa Liu
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Michelle A Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - A Titia Lely
- Department of Obstetrics, University Medical Center Utrecht, Utrecht, the Netherlands
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Schagen MR, Ulu AN, Francke MI, van de Wetering J, van Buren MC, Schoenmakers S, Matic M, van Schaik RHN, Hesselink DA, de Winter BCM. Modelling changes in the pharmacokinetics of tacrolimus during pregnancy after kidney transplantation: A retrospective cohort study. Br J Clin Pharmacol 2024; 90:176-188. [PMID: 37596793 DOI: 10.1111/bcp.15886] [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: 05/17/2023] [Revised: 07/19/2023] [Accepted: 08/05/2023] [Indexed: 08/20/2023] Open
Abstract
AIMS Pregnancy after kidney transplantation is realistic but immunosuppressants should be continued to prevent rejection. Tacrolimus is safe during pregnancy and is routinely dosed based on whole-blood predose concentrations. However, maintaining these concentrations is complicated as physiological changes during pregnancy affect tacrolimus pharmacokinetics. The aim of this study was to describe tacrolimus pharmacokinetics throughout pregnancy and explain the changes by investigating covariates in a population pharmacokinetic model. METHODS Data of pregnant women using a twice-daily tacrolimus formulation following kidney transplantation were retrospectively collected from 6 months before conception, throughout gestation and up to 6 months postpartum. Pharmacokinetic analysis was performed using nonlinear mixed effects modelling. Demographic, clinical and genetic parameters were evaluated as covariates. The final model was evaluated using goodness-of-fit plots, visual predictive checks and a bootstrap analysis. RESULTS A total of 260 whole-blood tacrolimus predose concentrations from 14 pregnant kidney transplant recipients were included. Clearance increased during pregnancy from 34.5 to 41.7 L/h, by 15, 19 and 21% in the first, second and third trimester, respectively, compared to prior to pregnancy. This indicates a required increase in the tacrolimus dose by the same percentage to maintain the prepregnancy concentration. Haematocrit and gestational age were negatively correlated with tacrolimus clearance (P ≤ 0.01), explaining 18% of interindividual and 85% of interoccasion variability in oral clearance. CONCLUSIONS Tacrolimus clearance increases during pregnancy, resulting in decreased exposure to tacrolimus, which is explained by gestational age and haematocrit. To maintain prepregnancy target whole-blood tacrolimus predose concentrations during pregnancy, increasing the dose is required.
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Affiliation(s)
- Maaike R Schagen
- Erasmus MC Transplant Institute, Department of Internal Medicine, Division of Nephrology and Transplantation, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
| | - Asiye Nur Ulu
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marith I Francke
- Erasmus MC Transplant Institute, Department of Internal Medicine, Division of Nephrology and Transplantation, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
| | - Jacqueline van de Wetering
- Erasmus MC Transplant Institute, Department of Internal Medicine, Division of Nephrology and Transplantation, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marleen C van Buren
- Erasmus MC Transplant Institute, Department of Internal Medicine, Division of Nephrology and Transplantation, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sam Schoenmakers
- Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Maja Matic
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ron H N van Schaik
- Department of Clinical Chemistry, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dennis A Hesselink
- Erasmus MC Transplant Institute, Department of Internal Medicine, Division of Nephrology and Transplantation, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Brenda C M de Winter
- Erasmus MC Transplant Institute, Department of Internal Medicine, Division of Nephrology and Transplantation, University Medical Center Rotterdam, Rotterdam, the Netherlands
- Rotterdam Clinical Pharmacometrics Group, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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van Buren MC, Gosselink M, Massey EK, van de Wetering J, Lely AT. Counselling on Conceiving: Attitudes and Factors Influencing Advice of Professionals in Transplantation. Transpl Int 2023; 36:11052. [PMID: 37234219 PMCID: PMC10205991 DOI: 10.3389/ti.2023.11052] [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: 11/14/2022] [Accepted: 04/25/2023] [Indexed: 05/27/2023]
Abstract
Pregnancy after kidney transplantation (KT) conveys risks of adverse pregnancy outcomes (APO). Little is known about performance of pre-pregnancy counselling after KT. This study investigated perceptions of risk, attitudes towards pregnancy and factors influencing advice given at pre-pregnancy counselling after KT. A web-based vignette survey was conducted among nephrologists and gynaecologists between March 2020 and March 2021, consisting of five vignettes containing known risk factors for APO and general questions on pre-pregnancy counselling after KT. Per vignette, attitudes towards pregnancy and estimation of outcomes were examined. In total 52 nephrologists and 25 gynaecologists participated, 56% from university hospitals. One third had no experience with pregnancy after KT. All gave positive pregnancy advice in the vignette with ideal circumstances (V1), versus 83% in V2 (proteinuria), 81% in V3 (hypertension), 71% in V4 (eGFR 40 ml/min/1.73 m2). Only 2% was positive in V5 (worst-case scenario). Chance of preeclampsia was underestimated by 89% in V1. 63% and 98% overestimated risk for graft loss in V4 and V5. Professionals often incorrectly estimated risk of APO after KT. As experience with pregnancy after KT was limited among professionals, patients should be referred to specialised centres for multidisciplinary pre-pregnancy counselling to build experience and increase consistency in given advice.
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Affiliation(s)
- Marleen C. van Buren
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Margriet Gosselink
- Department of Obstetrics and Gynaecology, Wilhelmina Children’s Hospital Birth Centre, University Medical Center Utrecht, Utrecht, Netherlands
| | - Emma K. Massey
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jacqueline van de Wetering
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - A. Titia Lely
- Department of Obstetrics and Gynaecology, Wilhelmina Children’s Hospital Birth Centre, University Medical Center Utrecht, Utrecht, Netherlands
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Gosselink ME, van Buren MC, Kooiman J, Groen H, Ganzevoort W, van Hamersvelt HW, van der Heijden OWH, van de Wetering J, Lely AT. A nationwide Dutch cohort study shows relatively good pregnancy outcomes after kidney transplantation and finds risk factors for adverse outcomes. Kidney Int 2022; 102:866-875. [PMID: 35777440 DOI: 10.1016/j.kint.2022.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/04/2022] [Accepted: 06/03/2022] [Indexed: 12/14/2022]
Abstract
Although numbers of pregnancy after kidney transplantation (KT) are rising, high risks of adverse pregnancy outcomes (APO) remain. Though important for pre-conception counselling and pregnancy monitoring, analyses of pregnancy outcomes after KT per pre-pregnancy estimated glomerular filtration rate-chronic kidney disease (eGFR-CKD)-categories have not been performed on a large scale before. To do this, we conducted a Dutch nationwide cohort study of consecutive singleton pregnancies over 20 weeks of gestation after KT. Outcomes were analyzed per pre-pregnancy eGFR-CKD category and a composite APO (cAPO) was established including birth weight under 2500 gram, preterm birth under 37 weeks, third trimester severe hypertension (systolic blood pressure over 160 and/or diastolic blood pressure over 110 mm Hg) and/or over 15% increase in serum creatinine during pregnancy. Risk factors for cAPO were analyzed in a multilevel model after multiple imputation of missing predictor values. In total, 288 pregnancies in 192 women were included. Total live birth was 93%, mean gestational age 35.6 weeks and mean birth weight 2383 gram. Independent risk factors for cAPO were pre-pregnancy eGFR, midterm percentage serum creatinine dip and midterm mean arterial pressure dip; odds ratio 0.98 (95% confidence interval 0.96-0.99), 0.95 (0.93-0.98) and 0.94 (0.90-0.98), respectively. The cAPO was a risk indicator for graft loss (hazard ratio 2.55, 1.09-5.96) but no significant risk factor on its own when considering pre-pregnancy eGFR (2.18, 0.92-5.13). This was the largest and most comprehensive study of pregnancy outcomes after KT, including pregnancies in women with poor kidney function, to facilitate individualized pre-pregnancy counselling based on pre-pregnancy graft function. Overall obstetric outcomes are good. The risk of adverse outcomes is mainly dependent on pre-pregnancy graft function and hemodynamic adaptation to pregnancy.
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Affiliation(s)
- Margriet E Gosselink
- Department of Obstetrics and Gynaecology, Wilhelmina Children's Hospital Birth Centre, University Medical Centre Utrecht, Utrecht, the Netherlands.
| | - Marleen C van Buren
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Judith Kooiman
- Department of Obstetrics and Gynaecology, Wilhelmina Children's Hospital Birth Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Henk Groen
- Department of Epidemiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, the Netherlands
| | - Henk W van Hamersvelt
- Department of Nephrology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - Jacqueline van de Wetering
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - A Titia Lely
- Department of Obstetrics and Gynaecology, Wilhelmina Children's Hospital Birth Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
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Pregnancy After Kidney Transplantation and Its Impact on Graft Function: Some Answers but Several Questions Still Remain. Transplantation 2021; 106:1109-1110. [PMID: 34456264 DOI: 10.1097/tp.0000000000003933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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