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Hansrivijit P, Trongtorsak A, Gadhiya KP, Lnu K, Dimech CT, Thongprayoon C, Cheungpasitporn W, Lecker SH. Incidence and risk factors of venous thromboembolism in ANCA-associated vasculitis: a metaanalysis and metaregression. Clin Rheumatol 2021; 40:2843-2853. [PMID: 33452661 DOI: 10.1007/s10067-021-05589-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/10/2021] [Accepted: 01/11/2021] [Indexed: 12/17/2022]
Abstract
The incidence of venous thromboembolism (VTE) in ANCA-associated vasculitis patients varies in different populations. Moreover, the risk factors for VTE in these patients are poorly described due to the small number of events. Ovid MEDLINE, EMBASE, and the Cochrane Library were searched for eligible articles. The inclusion criteria included observational studies that enrolled patients age ≥ 18 years diagnosed with ANCA-associated vasculitis. The incidence of VTE is the outcome of interest. Of 1362 citations, a total of 21 studies (n = 4422) dated from 2006 to 2019 were included in the systematic review. The mean age was 54.2 ± 4.0 years. Most were male (52.0%) and Caucasian (80.9%). With a mean follow-up duration of 5.2 ± 2.8 years, the pooled incidence of VTE in ANCA-associated vasculitis patients was 12.4% (95% CI, 8.8-17.2). Of these, 63.4% (95% CI, 57.3-69.1) had deep vein thrombosis and 26.3% (95% CI, 17.6-37.4) had pulmonary embolism. Recurrent VTE occurred in 10.0% (95% CI, 5.2-18.6). From the metaregression adjusted for age, sex, and ethnicity; positive MPO-ANCA, increasing Birmingham Vasculitis Activity Score at time of vasculitis diagnosis, and presence of renal involvement were positively associated with increased VTE events. Positive PR3-ANCA profile was inversely associated with increased VTE events. Increasing follow-up duration was not associated with increased VTE events. VTE in ANCA-associated vasculitis is common. Positive MPO-ANCA, increasing vasculitis activity, and presence of renal involvement were significant risk factors for VTE while positive PR3-ANCA was inversely associated with increased VTE. Key Points • Venous thromboembolism (VTE) is common in ANCA-associated vasculitis with a pooled incidence of 12.4% • Deep vein thrombosis accounts for two-third of total VTE cases • Positive MPO-ANCA profile, higher disease activity at ANCA-associated vasculitis diagnosis, and renal involvement are risk factors for VTE • Positive PR3-ANCA profile is protective factor for VTE.
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Affiliation(s)
- Panupong Hansrivijit
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA, 17104, USA.
| | - Angkawipa Trongtorsak
- Department of Internal Medicine, Amita Health Saint Francis Hospital, Evaston, IL, 60202, USA
| | - Kinjal P Gadhiya
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA, 17104, USA
| | - Kriti Lnu
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA, 17104, USA
| | - Christina T Dimech
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA, 17104, USA
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, 55905, USA
| | | | - Stewart H Lecker
- Division of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, 02215, USA
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Kitching AR, Anders HJ, Basu N, Brouwer E, Gordon J, Jayne DR, Kullman J, Lyons PA, Merkel PA, Savage COS, Specks U, Kain R. ANCA-associated vasculitis. Nat Rev Dis Primers 2020; 6:71. [PMID: 32855422 DOI: 10.1038/s41572-020-0204-y] [Citation(s) in RCA: 438] [Impact Index Per Article: 109.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2020] [Indexed: 02/07/2023]
Abstract
The anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) are a group of disorders involving severe, systemic, small-vessel vasculitis and are characterized by the development of autoantibodies to the neutrophil proteins leukocyte proteinase 3 (PR3-ANCA) or myeloperoxidase (MPO-ANCA). The three AAV subgroups, namely granulomatosis with polyangiitis (GPA), microscopic polyangiitis and eosinophilic GPA (EGPA), are defined according to clinical features. However, genetic and other clinical findings suggest that these clinical syndromes may be better classified as PR3-positive AAV (PR3-AAV), MPO-positive AAV (MPO-AAV) and, for EGPA, by the presence or absence of ANCA (ANCA+ or ANCA-, respectively). Although any tissue can be involved in AAV, the upper and lower respiratory tract and kidneys are most commonly and severely affected. AAVs have a complex and unique pathogenesis, with evidence for a loss of tolerance to neutrophil proteins, which leads to ANCA-mediated neutrophil activation, recruitment and injury, with effector T cells also involved. Without therapy, prognosis is poor but treatments, typically immunosuppressants, have improved survival, albeit with considerable morbidity from glucocorticoids and other immunosuppressive medications. Current challenges include improving the measures of disease activity and risk of relapse, uncertainty about optimal therapy duration and a need for targeted therapies with fewer adverse effects. Meeting these challenges requires a more detailed knowledge of the fundamental biology of AAV as well as cooperative international research and clinical trials with meaningful input from patients.
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Affiliation(s)
- A Richard Kitching
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Victoria, Australia. .,Departments of Nephrology and Paediatric Nephrology, Monash Health, Clayton, Victoria, Australia.
| | - Hans-Joachim Anders
- Renal Division, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians University, Munich, Germany
| | - Neil Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Elisabeth Brouwer
- Vasculitis Expertise Centre Groningen, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Jennifer Gordon
- Department of Neuroscience and Center for Neurovirology, Temple University School of Medicine, Philadelphia, PA, USA
| | - David R Jayne
- Department of Medicine, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | | | - Paul A Lyons
- Department of Medicine, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.,Cambridge Institute for Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge, UK
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine and Division of Clinical Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Caroline O S Savage
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Renate Kain
- Department of Pathology, Medical University Vienna, Vienna, Austria
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Chang HC, Chou PC, Lai CY, Tsai HH. Antineutrophil Cytoplasmic Antibodies and Organ-Specific Manifestations in Eosinophilic Granulomatosis with Polyangiitis: A Systematic Review and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:445-452.e6. [PMID: 32771687 DOI: 10.1016/j.jaip.2020.07.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/22/2020] [Accepted: 07/23/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA), also known as Churg-Strauss syndrome, is a rare and often severe systemic vasculitis associated with antineutrophil cytoplasmic antibodies (ANCAs). EGPA can affect multiple organ systems, but the relationships between ANCA status and the organ-specific manifestations of EGPA in previous reports were inconsistent. OBJECTIVE To investigate the association of the ANCA status with organ-specific manifestations in EGPA. METHODS We performed a systematic review of studies published before March 16, 2020, in the PubMed, Embase, Web of Science, and Cochrane Library databases. The primary outcome was the association of ANCA status with organ-specific involvements of EGPA. Odds ratios (ORs) and 95% CIs were calculated using a random-effects model. RESULTS A total of 24 cross-sectional studies with 2527 patients with EGPA, including 921 ANCA-positive patients and 1606 ANCA-negative patients, were included in the meta-analysis. The significant results of pooled analyses revealed that compared with patients with EGPA with negative ANCA status, patients with EGPA with positive ANCA status had higher risks of peripheral neuropathy (OR, 1.701), renal involvement (OR, 5.097), and cutaneous purpura (OR, 1.746) and lower risks of pulmonary infiltrates (OR, 0.589) and cardiac involvement (OR, 0.427). The pooled analysis also revealed no significant association of ANCA status with asthma and involvements of the central nervous system, gastrointestinal tract, or skin. CONCLUSIONS This study provides more evidence that patients with EGPA may exhibit different features of disease based on their ANCA status.
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Affiliation(s)
- Hua-Ching Chang
- Department of Dermatology, Taipei Medical University Hospital, Taipei, Taiwan; Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Pai-Chien Chou
- Division of Pulmonary Medicine, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan; Division of Thoracic Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chun-Yu Lai
- Department of Dermatology, Taipei Medical University Hospital, Taipei, Taiwan
| | - Hsiou-Hsin Tsai
- Department of Dermatology, Taipei Medical University Hospital, Taipei, Taiwan; Department of Dermatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Kang A, Antonelou M, Wong NL, Tanna A, Arulkumaran N, Tam FWK, Pusey CD. High Incidence of Arterial and Venous Thrombosis in Antineutrophil Cytoplasmic Antibody-associated Vasculitis. J Rheumatol 2018; 46:285-293. [PMID: 30385704 DOI: 10.3899/jrheum.170896] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To determine the incidence of arterial thrombotic events (ATE) and venous thromboembolism (VTE) in antineutrophil cytoplasmic antibody-associated vasculitis (AAV). METHODS This is a retrospective cohort study presenting the incidence of ATE (coronary events or ischemic stroke) and VTE [pulmonary embolism (PE) or deep venous thrombosis (DVT)] in patients diagnosed with AAV between 2005 and 2014. RESULTS There were 204 patients with AAV who were identified. Median followup for surviving patients was 5.8 (range 1-10) years, accounting for 1088 person-years (PY). The incidence of ATE was 2.67/100 PY (1.56 for coronary events and 1.10 for ischemic stroke) and for VTE was 1.47/100 PY (0.83 for DVT only and 0.64 for PE with/without DVT). On multivariate analysis, prior ischemic heart disease (IHD) and advancing age were the only independent predictors of ATE. Among patients without prior IHD or stroke, the incidence of ATE remained elevated at 2.32/100 PY (1.26 for coronary events and 1.06 for ischemic stroke). ATE, but not VTE, was an independent predictor of all-cause mortality. Event rates for both ATE and VTE were highest in the first year after diagnosis of AAV but remained above the population incidence during the 10-year followup period. In comparison to reported rates for the UK population, the event rates in our AAV patients were 15-times higher for coronary events, 11-times higher for incident stroke, and 20-times higher for VTE. CONCLUSION Patients with AAV have a high incidence of arterial and venous thrombosis, particularly in the first year after diagnosis.
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Affiliation(s)
- Amy Kang
- From the Imperial College Renal and Transplant Centre, Imperial College Healthcare UK National Health Service (NHS) Trust, London; Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK.,A. Kang, FRACP, MBBS (Hons), Clinical Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; M. Antonelou, MRCP, BSc, Academic Clinical Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; N.L. Wong, FRACP, MBBS, Clinical Research Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; A. Tanna, MBBS, BSc, Clinical Research Training Fellow, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London; N. Arulkumaran, PhD, MBBS, Renal Specialty Registrar, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; F.W. Tam, PhD, MB BChir, Ken and Mary Minton Chair of Renal Medicine, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London; C.D. Pusey, DSc, MB BChir, Professor of Medicine, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London
| | - Marilina Antonelou
- From the Imperial College Renal and Transplant Centre, Imperial College Healthcare UK National Health Service (NHS) Trust, London; Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK.,A. Kang, FRACP, MBBS (Hons), Clinical Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; M. Antonelou, MRCP, BSc, Academic Clinical Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; N.L. Wong, FRACP, MBBS, Clinical Research Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; A. Tanna, MBBS, BSc, Clinical Research Training Fellow, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London; N. Arulkumaran, PhD, MBBS, Renal Specialty Registrar, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; F.W. Tam, PhD, MB BChir, Ken and Mary Minton Chair of Renal Medicine, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London; C.D. Pusey, DSc, MB BChir, Professor of Medicine, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London
| | - Nikki L Wong
- From the Imperial College Renal and Transplant Centre, Imperial College Healthcare UK National Health Service (NHS) Trust, London; Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK.,A. Kang, FRACP, MBBS (Hons), Clinical Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; M. Antonelou, MRCP, BSc, Academic Clinical Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; N.L. Wong, FRACP, MBBS, Clinical Research Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; A. Tanna, MBBS, BSc, Clinical Research Training Fellow, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London; N. Arulkumaran, PhD, MBBS, Renal Specialty Registrar, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; F.W. Tam, PhD, MB BChir, Ken and Mary Minton Chair of Renal Medicine, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London; C.D. Pusey, DSc, MB BChir, Professor of Medicine, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London
| | - Anisha Tanna
- From the Imperial College Renal and Transplant Centre, Imperial College Healthcare UK National Health Service (NHS) Trust, London; Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK.,A. Kang, FRACP, MBBS (Hons), Clinical Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; M. Antonelou, MRCP, BSc, Academic Clinical Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; N.L. Wong, FRACP, MBBS, Clinical Research Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; A. Tanna, MBBS, BSc, Clinical Research Training Fellow, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London; N. Arulkumaran, PhD, MBBS, Renal Specialty Registrar, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; F.W. Tam, PhD, MB BChir, Ken and Mary Minton Chair of Renal Medicine, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London; C.D. Pusey, DSc, MB BChir, Professor of Medicine, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London
| | - Nishkantha Arulkumaran
- From the Imperial College Renal and Transplant Centre, Imperial College Healthcare UK National Health Service (NHS) Trust, London; Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK.,A. Kang, FRACP, MBBS (Hons), Clinical Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; M. Antonelou, MRCP, BSc, Academic Clinical Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; N.L. Wong, FRACP, MBBS, Clinical Research Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; A. Tanna, MBBS, BSc, Clinical Research Training Fellow, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London; N. Arulkumaran, PhD, MBBS, Renal Specialty Registrar, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; F.W. Tam, PhD, MB BChir, Ken and Mary Minton Chair of Renal Medicine, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London; C.D. Pusey, DSc, MB BChir, Professor of Medicine, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London
| | - Frederick W K Tam
- From the Imperial College Renal and Transplant Centre, Imperial College Healthcare UK National Health Service (NHS) Trust, London; Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK.,A. Kang, FRACP, MBBS (Hons), Clinical Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; M. Antonelou, MRCP, BSc, Academic Clinical Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; N.L. Wong, FRACP, MBBS, Clinical Research Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; A. Tanna, MBBS, BSc, Clinical Research Training Fellow, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London; N. Arulkumaran, PhD, MBBS, Renal Specialty Registrar, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; F.W. Tam, PhD, MB BChir, Ken and Mary Minton Chair of Renal Medicine, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London; C.D. Pusey, DSc, MB BChir, Professor of Medicine, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London
| | - Charles D Pusey
- From the Imperial College Renal and Transplant Centre, Imperial College Healthcare UK National Health Service (NHS) Trust, London; Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK. .,A. Kang, FRACP, MBBS (Hons), Clinical Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; M. Antonelou, MRCP, BSc, Academic Clinical Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; N.L. Wong, FRACP, MBBS, Clinical Research Fellow, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; A. Tanna, MBBS, BSc, Clinical Research Training Fellow, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London; N. Arulkumaran, PhD, MBBS, Renal Specialty Registrar, Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust; F.W. Tam, PhD, MB BChir, Ken and Mary Minton Chair of Renal Medicine, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London; C.D. Pusey, DSc, MB BChir, Professor of Medicine, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London.
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Emmi G, Silvestri E, Squatrito D, Amedei A, Niccolai E, D'Elios MM, Della Bella C, Grassi A, Becatti M, Fiorillo C, Emmi L, Vaglio A, Prisco D. Thrombosis in vasculitis: from pathogenesis to treatment. Thromb J 2015; 13:15. [PMID: 25883536 PMCID: PMC4399148 DOI: 10.1186/s12959-015-0047-z] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 03/13/2015] [Indexed: 02/06/2023] Open
Abstract
In recent years, the relationship between inflammation and thrombosis has been deeply investigated and it is now clear that immune and coagulation systems are functionally interconnected. Inflammation-induced thrombosis is by now considered a feature not only of autoimmune rheumatic diseases, but also of systemic vasculitides such as Behçet’s syndrome, ANCA-associated vasculitis or giant cells arteritis, especially during active disease. These findings have important consequences in terms of management and treatment. Indeed, Behçet’syndrome requires immunosuppressive agents for vascular involvement rather than anticoagulation or antiplatelet therapy, and it is conceivable that also in ANCA-associated vasculitis or large vessel-vasculitis an aggressive anti-inflammatory treatment during active disease could reduce the risk of thrombotic events in early stages. In this review we discuss thrombosis in vasculitides, especially in Behçet’s syndrome, ANCA-associated vasculitis and large-vessel vasculitis, and provide pathogenetic and clinical clues for the different specialists involved in the care of these patients.
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Affiliation(s)
- Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, L.go G. Brambilla, 3, 50134 Florence, Italy
| | - Elena Silvestri
- Department of Experimental and Clinical Medicine, University of Florence, L.go G. Brambilla, 3, 50134 Florence, Italy
| | - Danilo Squatrito
- Department of Experimental and Clinical Medicine, University of Florence, L.go G. Brambilla, 3, 50134 Florence, Italy
| | - Amedeo Amedei
- Department of Experimental and Clinical Medicine, University of Florence, L.go G. Brambilla, 3, 50134 Florence, Italy.,SOD Interdisciplinary Internal Medicine, Center for Autoimmune Systemic Diseases-Behçet Center and Lupus Clinic-AOU Careggi Hospital of Florence, Florence, Italy
| | - Elena Niccolai
- Department of Experimental and Clinical Medicine, University of Florence, L.go G. Brambilla, 3, 50134 Florence, Italy
| | - Mario Milco D'Elios
- Department of Experimental and Clinical Medicine, University of Florence, L.go G. Brambilla, 3, 50134 Florence, Italy.,SOD Interdisciplinary Internal Medicine, Center for Autoimmune Systemic Diseases-Behçet Center and Lupus Clinic-AOU Careggi Hospital of Florence, Florence, Italy
| | - Chiara Della Bella
- Department of Experimental and Clinical Medicine, University of Florence, L.go G. Brambilla, 3, 50134 Florence, Italy
| | - Alessia Grassi
- Department of Experimental and Clinical Medicine, University of Florence, L.go G. Brambilla, 3, 50134 Florence, Italy
| | - Matteo Becatti
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Claudia Fiorillo
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Lorenzo Emmi
- SOD Interdisciplinary Internal Medicine, Center for Autoimmune Systemic Diseases-Behçet Center and Lupus Clinic-AOU Careggi Hospital of Florence, Florence, Italy
| | - Augusto Vaglio
- Nephrology Unit, University Hospital of Parma, Parma, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, L.go G. Brambilla, 3, 50134 Florence, Italy.,SOD Interdisciplinary Internal Medicine, Center for Autoimmune Systemic Diseases-Behçet Center and Lupus Clinic-AOU Careggi Hospital of Florence, Florence, Italy
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