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Liu Q, Qin L, Liang Y, Xu M, Zhang J, Mo X, Tang X, Lu Y, Wang X, Cao J, Huang C, Rong J, Teng K, Zhao L, Wu S, Luo L, Guan Q, Zhang T, Jin W, Qin J, Cai J, Zhang Z. Correlations between growth differentiation factor 15 (GDF-15) serum levels and gene polymorphism with type 2 diabetes mellitus. Heliyon 2024; 10:e33044. [PMID: 38988547 PMCID: PMC11234026 DOI: 10.1016/j.heliyon.2024.e33044] [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: 03/20/2024] [Revised: 06/11/2024] [Accepted: 06/13/2024] [Indexed: 07/12/2024] Open
Abstract
Purpose To date, the relationship between Growth Differentiation Factor 15 (GDF-15) gene polymorphism and the risk of type 2 diabetes mellitus (T2DM) has not been clarified. Our study aims to explore the association between serum GDF-15 levels and related gene polymorphism with the risk of T2DM in a Chinese rural Yao population. Methods This was a 1:1 case-control study with 179 T2DM patients and 179 age- and sex-matched control participants. Serum GDF-15 levels were measured by enzyme-linked immunosorbent assay, and polymorphisms (rs1059519, rs1059369, rs1804826 and rs1054564) were genotyped by MassArray mass spectrometry. Results Serum GDF-15 (sGDF-15) levels were higher in patients with T2DM and glycosylated hemoglobin (HbA1c) ≥ 6.5 % compared to that in controls (p < 0.001). The area under the curve (AUC) corresponding to sGDF-15 levels was 0.626. Serum GDF-15 was positively correlated with fasting plasma glucose (FPG) (rs = 0.150, p < 0.001) and HbA1c (rs = 0.160, p < 0.001). The frequency of GDF-15 gene rs1054564 GC + CC genotype was significantly associated with increased risk of T2DM compared to GG genotype (OR = 1.724, 95CI: 1.046-2.841, p = 0.033). Frequencies of rs1804826 T allele (β additive = 113.318, p = 0.026) and rs1054564 C allele (β additive = 247.282, p = 0.001, β dominant = 286.109, p = 0.001) was significantly correlated with higher sGDF-15. The rs1059519 C allele was negatively correlated with FPG (β recessive = -0.607, p = 0.047) and HbA1c (β recessive = -0.456, p = 0.020). Conclusion Serum GDF-15 levels were positively correlated with FPG and HbA1c. The GDF-15 rs1054564 GC + CC genotype was associated with a significantly higher T2DM risk. The rs1059519 C allele was negatively correlated with FPG and HbA1c.
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Affiliation(s)
- Qiumei Liu
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Lidong Qin
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Yujian Liang
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Min Xu
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Junling Zhang
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Xiaoting Mo
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Xu Tang
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Yufu Lu
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Xuexiu Wang
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Jiejing Cao
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Chuwu Huang
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Jiahui Rong
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Kaisheng Teng
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Linhai Zhao
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Songju Wu
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Lei Luo
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Qinyi Guan
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - TianTian Zhang
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Wenjia Jin
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
| | - Jian Qin
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
- Guangxi Colleges and Universities Key Laboratory of Prevention and Control of Highly Prevalent Diseases, Guangxi Medical University, Nanning, China
- Guangxi Key Laboratory of Environment and Health Research, Guangxi Medical University, Nanning, China
- Key Laboratory of Longevity and Aging-related Diseases of Chinese Ministry of Education, Guangxi Medical University, Nanning, China
| | - Jiansheng Cai
- Key Laboratory of Tumor Immunology and Microenvironmental Regulation, Guilin Medical University, Guilin, China
| | - Zhiyong Zhang
- Department of Occupational and Environmental Health, School of Public Health, Guangxi Medical University, Nanning, China
- Department of Environmental Health and Occupational Medicine, School of Public Health, Guilin Medical University, Guilin, China
- Guangxi Health Commission Key Laboratory of Entire Lifecycle Health and Care, Guilin Medical University, Guilin, China
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Kučerka O, Blahutová M, Kosek V, Mináriková P, Horáček JM, Urbánek P, Malý M. Exploring the Role of GDF-15 in Inflammatory Bowel Disease: A Case-Controlled Study Comparing Crohn's Disease and Ulcerative Colitis with Non-Inflammatory Controls. Metabolites 2024; 14:185. [PMID: 38668313 PMCID: PMC11051727 DOI: 10.3390/metabo14040185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/08/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
Inflammatory bowel disease, encompassing Crohn's disease and ulcerative colitis, is a persistent immune-mediated inflammatory gastrointestinal disease. This study investigates the role of growth differentiation factor 15 in severe IBD cases, aiming to identify a reliable parameter to assess disease severity and monitor activity. We analyzed plasma samples from 100 patients undergoing biologic therapy for severe IBD and 50 control subjects. Our analysis included evaluations of GDF-15 levels, inflammatory markers, and clinical features. We employed statistical methods such as the Mann-Whitney U test, ANOVA, and Spearman's correlation for an in-depth analysis. Our results demonstrated consistently higher GDF-15 levels in patients with both Crohn's disease and ulcerative colitis compared to the control group, irrespective of the biologic treatment received. The correlation analysis indicated significant relationships between GDF-15 levels, patient age, fibrinogen, and IL-6 levels. This study positions GDF-15 as a promising biomarker for severe IBD, with notable correlations with age and inflammatory markers. These findings underscore GDF-15's potential in enhancing disease monitoring and management strategies in an IBD context and encourage further research to clarify GDF-15's role in the IBD pathophysiology.
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Affiliation(s)
- Ondřej Kučerka
- Department of Medicine, First Faculty of Medicine, Charles University and Military University Hospital Prague, 169 02 Prague, Czech Republic
- Department of Military Internal Medicine and Military Hygiene, Military Faculty of Medicine, University of Defence, 500 02 Hradec Kralove, Czech Republic
| | - Marie Blahutová
- Department of Clinical Biochemistry, Military University Hospital, 169 02 Prague, Czech Republic
| | - Vít Kosek
- Department of Food Chemistry and Analysis, University of Chemistry and Technology, 160 00 Prague, Czech Republic
| | - Petra Mináriková
- Department of Medicine, First Faculty of Medicine, Charles University and Military University Hospital Prague, 169 02 Prague, Czech Republic
| | - Jan M Horáček
- Department of Military Internal Medicine and Military Hygiene, Military Faculty of Medicine, University of Defence, 500 02 Hradec Kralove, Czech Republic
| | - Petr Urbánek
- Department of Medicine, First Faculty of Medicine, Charles University and Military University Hospital Prague, 169 02 Prague, Czech Republic
| | - Martin Malý
- Department of Medicine, First Faculty of Medicine, Charles University and Military University Hospital Prague, 169 02 Prague, Czech Republic
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Wang Q, Li Q, Wang R, Li Y, Wang J, Guo Z, Li F, Chen B, Xiang H, Wang T, Wu X. Identification of CD8 + T cell-related biomarkers and immune infiltration characteristic of rheumatoid arthritis. Aging (Albany NY) 2024; 16:1399-1413. [PMID: 38231477 PMCID: PMC10866417 DOI: 10.18632/aging.205435] [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: 08/29/2023] [Accepted: 12/04/2023] [Indexed: 01/18/2024]
Abstract
Rheumatoid arthritis (RA) is an autoimmune rheumatic disease, which do not respond well to current treatment partially. Therefore, further in-depth elucidation of the molecular mechanism and pathogenesis of RA is urgently needed for the diagnosis, personalized therapy and drug development. Herein, we collected 111 RA samples from Gene Expression Omnibus (GEO) database, and conducted differentially expressed genes and GESA analysis. Abnormal activation and imbalance of immune cells in RA were observed. WGCNA was utilized to explore the gene modules and CD8+ T cell-related genes (CRGs) were chosen for KEGG and GO analysis. Besides, to explore biomarkers of RA in depth, machine learning algorithms and bioinformatics analysis were used, and we identified GDF15, IGLC1, and IGHM as diagnostic markers of RA, which was confirmed by clinical samples. Next, ssGSEA algorithms were adopted to investigate the differences in immune infiltration of 23 immune cell subsets between RA and healthy control group. Finally, optimal classification analysis based on consensus clustering combined with ssGSEA algorithms were conducted. GDF15 was revealed that to be positively correlated with mast cells and type 2 T helper cells, but negatively correlated with most other immune cells. On the other hand, IGHM and IGLC1 were negatively correlated with CD56dim natural killer cells, while positively associated with other immune cells. Finally, RA samples in subtype A exhibited a higher immune infiltration status. This study could provide guidance for individualized treatment of RA patients and provide new targets for drug design.
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Affiliation(s)
- Qizun Wang
- Department of Orthopedics, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Qianqian Li
- Department of Ultrasound, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Ronghuan Wang
- Department of Orthopedics, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Yanning Li
- Laboratory, The First Affiliated Hospital of Shanghai Jiao Tong University, Shanghai 200080, China
| | - Jie Wang
- Department of Orthopedics, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Zhu Guo
- Department of Orthopedics, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Feng Li
- Department of Orthopedics, Weifang People’s Hospital, Weifang, Shandong 261000, China
| | - Bohua Chen
- Department of Orthopedics, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Hongfei Xiang
- Department of Orthopedics, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Tianrui Wang
- Department of Orthopedics, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
| | - Xiaolin Wu
- Department of Orthopedics, The Affiliated Hospital of Qingdao University, Qingdao 266000, China
- Cancer Institute, The Affiliated Hospital of Qingdao University, Qingdao University, Qingdao Cancer Institute, Qingdao 266071, China
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Lorenz G, Ribeiro A, von Rauchhaupt E, Würf V, Schmaderer C, Cohen CD, Vohra T, Anders HJ, Lindenmeyer M, Lech M. GDF15 Suppresses Lymphoproliferation and Humoral Autoimmunity in a Murine Model of Systemic Lupus Erythematosus. J Innate Immun 2022; 14:673-689. [PMID: 35443244 PMCID: PMC9801254 DOI: 10.1159/000523991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/21/2022] [Indexed: 01/02/2023] Open
Abstract
Growth and differentiation factor 15 (GDF15), a divergent member of the transforming growth factor-β superfamily, has been associated with acute and chronic inflammatory conditions including autoimmune disease, i.e., type I diabetes and rheumatoid arthritis. Still, its role in systemic autoimmune disease remains elusive. Thus, we studied GDF15-deficient animals in Fas-receptor intact (C57BL/6) or deficient (C57BL/6lpr/lpr) backgrounds. Further, lupus nephritis (LN) microdissected kidney biopsy specimens were analyzed to assess the involvement of GDF15 in human disease. GDF15-deficiency in lupus-prone mice promoted lymphoproliferation, T-, B- and plasma cell-expansion, a type I interferon signature, and increased serum levels of anti-DNA autoantibodies. Accelerated systemic inflammation was found in association with a relatively mild renal phenotype. Splenocytes of phenotypically overall-normal Gdf15-/- C57BL/6 and lupus-prone C57BL/6lpr/lpr mice displayed increased in vitro lymphoproliferative responses or interferon-dependent transcription factor induction in response to the toll-like-receptor (TLR)-9 ligand CpG, or the TLR-7 ligand Imiquimod, respectively. In human LN, GDF15 expression was downregulated whereas type I interferon expression was upregulated in glomerular- and tubular-compartments versus living donor controls. These findings demonstrate that GDF15 regulates lupus-like autoimmunity by suppressing lymphocyte-proliferation and -activation. Further, the data indicate a negative regulatory role for GDF15 on TLR-7 and -9 driven type I interferon signaling in effector cells of the innate immune system.
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Affiliation(s)
- Georg Lorenz
- LMU Klinikum, Medizinische Klinik und Poliklinik IV, Department of Nephrology, Ludwig-Maximilians-Universität München, Munich, Germany,Klinikum rechts der Isar, Department of Nephrology, Section of Rheumatology, Technical University Munich, Munich, Germany
| | - Andrea Ribeiro
- LMU Klinikum, Medizinische Klinik und Poliklinik IV, Department of Nephrology, Ludwig-Maximilians-Universität München, Munich, Germany,Klinikum rechts der Isar, Department of Nephrology, Technical University Munich, Munich, Germany
| | - Ekatharina von Rauchhaupt
- LMU Klinikum, Medizinische Klinik und Poliklinik IV, Department of Nephrology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Vivian Würf
- LMU Klinikum, Medizinische Klinik und Poliklinik IV, Department of Nephrology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Christoph Schmaderer
- Klinikum rechts der Isar, Department of Nephrology, Technical University Munich, Munich, Germany
| | - Clemens D. Cohen
- LMU Klinikum, Medizinische Klinik und Poliklinik IV, Department of Nephrology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Twinkle Vohra
- LMU Klinikum, Medizinische Klinik und Poliklinik IV, Department of Endocrinology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Hans-Joachim Anders
- LMU Klinikum, Medizinische Klinik und Poliklinik IV, Department of Nephrology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Maja Lindenmeyer
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maciej Lech
- LMU Klinikum, Medizinische Klinik und Poliklinik IV, Department of Nephrology, Ludwig-Maximilians-Universität München, Munich, Germany,*Maciej Lech,
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Pence BD. Growth Differentiation Factor-15 in Immunity and Aging. FRONTIERS IN AGING 2022; 3:837575. [PMID: 35821815 PMCID: PMC9261309 DOI: 10.3389/fragi.2022.837575] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/24/2022] [Indexed: 11/21/2022]
Abstract
Aging increases susceptibility to and severity of a variety of chronic and infectious diseases. Underlying this is dysfunction of the immune system, including chronic increases in low-grade inflammation (inflammaging) and age-related immunosuppression (immunosenescence). Growth differentiation factor-15 (GDF-15) is a stress-, infection-, and inflammation-induced cytokine which is increased in aging and suppresses immune responses. This mini review briefly covers existing knowledge on the immunoregulatory and anti-inflammatory roles of GDF-15, as well as its potential importance in aging and immune function.
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He YW, He CS. Association of Growth and Differentiation Factor 15 in Rheumatoid Arthritis. J Inflamm Res 2022; 15:1173-1181. [PMID: 35221707 PMCID: PMC8865901 DOI: 10.2147/jir.s350281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/28/2022] [Indexed: 01/01/2023] Open
Abstract
Purpose Rheumatoid arthritis (RA) is an inflammatory rheumatic disease, which has been demonstrated to correlate with mutated genetics. Growth and differentiation factor 15 (GDF-15) is a member of the transforming growth factor-β superfamily and is expressed in different organs, tissues and immune cells. To date, limited studies have evaluated plasma levels of GDF-15 in RA patients, and whether GDF-15 gene polymorphisms correlate with RA risk in the Chinese Han population has not been clarified. Patients and Methods This case-control study recruited 910 age- and sex-matched RA patients and healthy controls. Plasma levels of GDF-15 were examined by enzyme linked immunosorbent assay, and polymorphisms (rs1055150, rs1058587, rs3787023, and rs4808793) were genotyped by KASP method. Results RA patients had higher levels of GDF-15 as compared to that in healthy controls. Patients with positive CRP also showed higher levels of GDF-15 when compared to that in patients with negative CRP. Levels of GDF-15 correlated with disease activity score. Frequencies of GG, GC, GG+GC genotypes and G allele in GDF-15 gene rs1058587 were significantly elevated in RA patients compared to controls. Frequencies of CC genotype and C allele in GDF-15 gene rs3787023 were higher in RA patients compared to controls. Other polymorphisms did not correlate with RA susceptibility. Moreover, the four polymorphisms were not correlated with levels of GDF-15. Conclusion Plasma levels of GDF-15 were elevated in RA patients and GDF-15 gene polymorphisms were related to RA risk in the Chinese Han population.
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Affiliation(s)
- Yan-Wei He
- Department of Orthopaedics, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, 646000, People’s Republic of China
| | - Cheng-Song He
- Department of Rheumatology and Immunology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, 646000, People’s Republic of China
- Correspondence: Cheng-Song He, Department of Rheumatology and Immunology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, 646000, People’s Republic of China, Email
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Notz Q, Schmalzing M, Wedekink F, Schlesinger T, Gernert M, Herrmann J, Sorger L, Weismann D, Schmid B, Sitter M, Schlegel N, Kranke P, Wischhusen J, Meybohm P, Lotz C. Pro- and Anti-Inflammatory Responses in Severe COVID-19-Induced Acute Respiratory Distress Syndrome-An Observational Pilot Study. Front Immunol 2020; 11:581338. [PMID: 33123167 PMCID: PMC7573122 DOI: 10.3389/fimmu.2020.581338] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/21/2020] [Indexed: 12/15/2022] Open
Abstract
Objectives The severity of Coronavirus Disease 2019 (COVID-19) is largely determined by the immune response. First studies indicate altered lymphocyte counts and function. However, interactions of pro- and anti-inflammatory mechanisms remain elusive. In the current study we characterized the immune responses in patients suffering from severe COVID-19-induced acute respiratory distress syndrome (ARDS). Methods This was a single-center retrospective study in patients admitted to the intensive care unit (ICU) with confirmed COVID-19 between March 14th and May 28th 2020 (n = 39). Longitudinal data were collected within routine clinical care, including flow-cytometry of lymphocyte subsets, cytokine analysis and growth differentiation factor 15 (GDF-15). Antibody responses against the receptor binding domain (RBD) of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Spike protein were analyzed. Results All patients suffered from severe ARDS, 30.8% died. Interleukin (IL)-6 was massively elevated at every time-point. The anti-inflammatory cytokine IL-10 was concomitantly upregulated with IL-6. The cellular response was characterized by lymphocytopenia with low counts of CD8+ T cells, natural killer (NK) and naïve T helper cells. CD8+ T and NK cells recovered after 8 to 14 days. The B cell system was largely unimpeded. This coincided with a slight increase in anti-SARS-CoV-2-Spike-RBD immunoglobulin (Ig) G and a decrease in anti-SARS-CoV-2-Spike-RBD IgM. GDF-15 levels were elevated throughout ICU treatment. Conclusions Massively elevated levels of IL-6 and a delayed cytotoxic immune defense characterized severe COVID-19-induced ARDS. The B cell response and antibody production were largely unimpeded. No obvious imbalance of pro- and anti-inflammatory mechanisms was observed, with elevated GDF-15 levels suggesting increased tissue resilience.
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Affiliation(s)
- Quirin Notz
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Marc Schmalzing
- Department of Medicine II, Rheumatology and Clinical Immunology, University Hospital Würzburg, Würzburg, Germany
| | - Florian Wedekink
- Department of Gynecology, Section for Experimental Tumor Immunology, University Hospital Würzburg, Würzburg, Germany
| | - Tobias Schlesinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Michael Gernert
- Department of Medicine II, Rheumatology and Clinical Immunology, University Hospital Würzburg, Würzburg, Germany
| | - Johannes Herrmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Lena Sorger
- Department of Gynecology, Section for Experimental Tumor Immunology, University Hospital Würzburg, Würzburg, Germany
| | - Dirk Weismann
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Benedikt Schmid
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Magdalena Sitter
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Nicolas Schlegel
- Department of General, Visceral, Vascular and Pediatric Surgery (Surgery I), University Hospital Würzburg, Würzburg, Germany
| | - Peter Kranke
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Jörg Wischhusen
- Department of Gynecology, Section for Experimental Tumor Immunology, University Hospital Würzburg, Würzburg, Germany
| | - Patrick Meybohm
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Christopher Lotz
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Würzburg, Würzburg, Germany
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