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Vila R, Rubio‐San‐Simón A, Zubiaur P, Navares‐Gómez M, Gómez‐Hernández P, Arce B, Madero L. Use of glucarpidase (carboxypeptidase-G2) in pediatric cancer patients: 11-year experience of a tertiary center. EJHAEM 2023; 4:1052-1058. [PMID: 38024601 PMCID: PMC10660123 DOI: 10.1002/jha2.799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/11/2023] [Accepted: 09/19/2023] [Indexed: 12/01/2023]
Abstract
Methotrexate is an essential drug in the treatment of childhood cancer that is not exempt from toxicities. Glucarpidase is a drug used to reduce the toxic concentration of plasma methotrexate in patients with delayed elimination or at risk of toxicity. We describe the characteristics of a cohort of pediatric patients that received glucarpidase and analyze its role in the treatment of toxicity induced by high doses of methotrexate (HDMTX). Retrospective observational study of all pediatric cancer patients who received glucarpidase between 2012 and 2022 at a single center. Fifteen patients were treated with a single dose of glucarpidase, eleven of them presented with acute lymphoblastic leukemia and received HDMTX at 5 g/m2 in 24-hour infusion. In eight patients, glucarpidase was administered during the first cycle of HDMTX. The indication in thirteen cases was acute renal failure with delayed elimination of plasma methotrexate. The median maximum creatinine was 1.22 mg/dl (0.68 2.01 mg/dl), with a median increase over its baseline level of 313%. All patients normalized renal function after glucarpidase administration, with a median methotrexate excretion time of 193 hours (42-312 hours). No grade ≥2 adverse events derived from carboxypeptidase administration. Eleven patients received new doses of HDMTX in subsequent cycles, without new episodes of serious toxicity. The use of glucarpidase is effective and safe in the treatment of acute renal failure and methotrexate elimination delay in pediatric cancer patients. Further HDMTX doses may be prescribed without additional toxicities.
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Affiliation(s)
- Rocío Vila
- Oncohematology UnitNiño Jesús University Children's HospitalMadridSpain
| | | | - Pablo Zubiaur
- Clinical Pharmacology ServiceLa Princesa University HospitalAutonomous University of MadridMadridSpain
| | - Marcos Navares‐Gómez
- Clinical Pharmacology ServiceLa Princesa University HospitalAutonomous University of MadridMadridSpain
| | | | - Begoña Arce
- Hospital Pharmacy UnitNiño Jesús University Children's HospitalMadridSpain
| | - Luis Madero
- Oncohematology UnitNiño Jesús University Children's HospitalMadridSpain
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2
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Ríos Valbuena JJ, García Padilla PK, Ardila Hani C. Methotrexate nephrotoxicity in a patient with preserved renal function. Case report. CASE REPORTS 2022. [DOI: 10.15446/cr.v8n1.92651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction: Methotrexate is a drug with chemotherapeutic properties frequently used for the treatment of certain types of cancer. The following is a clinical case which, to the best of the authors’ knowledge, is the first report in Colombia on nephrotoxicity caused by this drug and describes the consequences as well as the treatment provided at a quaternary care hospital.
Case report: A 71-year-old patient with a diagnosis of non-Hodgkin’s lymphoma with normal renal function underwent chemotherapy (high-dose methotrexate intravenously) and developed stage 3 acute renal failure according to the KDIGO guidelines, which was most likely related to methotrexate intake. The patient received treatment with intravenous fluids and sodium bicarbonate as promoters of urine excretion of the toxin, and oral calcium folinate following the institutional protocol. The patient was discharged with recovery of kidney function and improved creatinine and urea nitrogen levels.
Conclusion: The treatment given to the patient in this case report shows that although methotrexate nephrotoxicity is a potentially serious entity, it can have a good prognosis if treated promptly.
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3
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Ghannoum M, Roberts DM, Goldfarb DS, Heldrup J, Anseeuw K, Galvao TF, Nolin TD, Hoffman RS, Lavergne V, Meyers P, Gosselin S, Botnaru T, Mardini K, Wood DM. Extracorporeal Treatment for Methotrexate Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup. Clin J Am Soc Nephrol 2022; 17:602-622. [PMID: 35236714 PMCID: PMC8993465 DOI: 10.2215/cjn.08030621] [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] [Indexed: 11/23/2022]
Abstract
Methotrexate is used in the treatment of many malignancies, rheumatological diseases, and inflammatory bowel disease. Toxicity from use is associated with severe morbidity and mortality. Rescue treatments include intravenous hydration, folinic acid, and, in some centers, glucarpidase. We conducted systematic reviews of the literature following published EXtracorporeal TReatments In Poisoning (EXTRIP) methods to determine the utility of extracorporeal treatments in the management of methotrexate toxicity. The quality of the evidence and the strength of recommendations (either "strong" or "weak/conditional") were graded according to the GRADE approach. A formal voting process using a modified Delphi method assessed the level of agreement between panelists on the final recommendations. A total of 92 articles met inclusion criteria. Toxicokinetic data were available on 90 patients (89 with impaired kidney function). Methotrexate was considered to be moderately dialyzable by intermittent hemodialysis. Data were available for clinical analysis on 109 patients (high-dose methotrexate [>0.5 g/m2]: 91 patients; low-dose [≤0.5 g/m2]: 18). Overall mortality in these publications was 19.5% and 26.7% in those with high-dose and low-dose methotrexate-related toxicity, respectively. Although one observational study reported lower mortality in patients treated with glucarpidase compared with those treated with hemodialysis, there were important limitations in the study. For patients with severe methotrexate toxicity receiving standard care, the EXTRIP workgroup: (1) suggested against extracorporeal treatments when glucarpidase is not administered; (2) recommended against extracorporeal treatments when glucarpidase is administered; and (3) recommended against extracorporeal treatments instead of administering glucarpidase. The quality of evidence for these recommendations was very low. Rationales for these recommendations included: (1) extracorporeal treatments mainly remove drugs in the intravascular compartment, whereas methotrexate rapidly distributes into cells; (2) extracorporeal treatments remove folinic acid; (3) in rare cases where fast removal of methotrexate is required, glucarpidase will outperform any extracorporeal treatment; and (4) extracorporeal treatments do not appear to reduce the incidence and magnitude of methotrexate toxicity.
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Affiliation(s)
- Marc Ghannoum
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, Quebec, Canada.,Department of Nephrology and Hypertension, University Medical Center Utrecht and Utrecht University, Utrecht, The Netherlands
| | - Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, New South Wales, Australia; and St Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia; and Drug Health Services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - David S Goldfarb
- Nephrology Division, NYU Langone Health and NYU Grossman School of Medicine, New York, New York
| | - Jesper Heldrup
- Childhood Cancer and Research Unit, University Children's Hospital, Lund, Sweden
| | - Kurt Anseeuw
- Department of Emergency Medicine, ZNA Stuivenberg, Antwerp, Belgium
| | - Tais F Galvao
- School of Pharmaceutical Sciences, University of Campinas, Campinas, Sao Paulo, Brazil
| | - Thomas D Nolin
- Department of Pharmacy and Therapeutics, and Department of Medicine Renal-Electrolyte Division, University of Pittsburgh Schools of Pharmacy and Medicine, Pittsburgh, Pennsylvania
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York
| | - Valery Lavergne
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Paul Meyers
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sophie Gosselin
- Centre Intégré de Santé et de Services Sociaux (CISSS) de la Montérégie-Centre Emergency Department, Hôpital Charles-Lemoyne, Greenfield Park, Quebec, McGill University Emergency Department, Montreal, Quebec and Centre Antipoison du Québec, Quebec, Canada
| | - Tudor Botnaru
- Emergency Department, Lakeshore General Hospital, CIUSSS de l'Ouest-de-l'lle-de-Montreal, McGill University, Montreal, Quebec, Canada
| | - Karine Mardini
- Pharmacy Department, Verdun Hospital, CIUSSS du Sud-Ouest-de-l'ïle-de-Montréal, University of Montreal, Montreal, Quebec, Canada
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, United Kingdom
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4
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Shirali AC, Sprangers B. Cancer Drug Dosing in Chronic Kidney Disease and Dialysis. Adv Chronic Kidney Dis 2022; 29:208-216.e1. [PMID: 35817528 DOI: 10.1053/j.ackd.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/20/2021] [Accepted: 12/08/2021] [Indexed: 11/11/2022]
Abstract
Patients with malignancies have a high prevalence of kidney disease and are often treated with antineoplastic agents that undergo kidney metabolism or excretion or clearance via renal replacement therapies. Thus, the dosing of these agents, including classic chemotherapeutic drugs, targeted therapies, and immunotherapy, must take into account patients' kidney function. In this review, we will discuss the pitfalls of accurate measurement of kidney function and how kidney disease affects both pharmacodynamic and pharmacokinetic properties of drugs. Lastly, we will discuss specific agents and summarize current dosing strategies for use in patients with chronic kidney disease and end-stage kidney disease.
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Affiliation(s)
- Anushree C Shirali
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, Laboratory of Molecular Immunology, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium; Division of Nephrology, University Hospitals Leuven, Leuven, Belgium.
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5
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Cosmai L, Porta C, Foramitti M, Perrone V, Mollica L, Gallieni M, Capasso G. Preventive strategies for acute kidney injury in cancer patients. Clin Kidney J 2020; 14:70-83. [PMID: 33564407 PMCID: PMC7857811 DOI: 10.1093/ckj/sfaa127] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Indexed: 12/13/2022] Open
Abstract
Acute kidney injury (AKI) is a common complication of cancer that occurs in up to 50% of neoplastic patients during the natural history of their disease; furthermore, it has a huge impact on key outcomes such as overall prognosis, length of hospitalization and costs. AKI in cancer patients has different causes, either patient-, tumour- or treatment-related. Patient-related risk factors for AKI are the same as in the general population, whereas tumour-related risk factors are represented by compression, obstruction, direct kidney infiltration from the tumour as well by precipitation, aggregation, crystallization or misfolding of paraprotein (as in the case of multiple myeloma). Finally, treatment-related risk factors are the most common observed in clinical practice and may present also with the feature of tumour lysis syndrome or thrombotic microangiopathies. In the absence of validated biomarkers, a multidisciplinary clinical approach that incorporates adequate assessment, use of appropriate preventive measures and early intervention is essential to reduce the incidence of this life-threatening condition in cancer patients.
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Affiliation(s)
- Laura Cosmai
- Onco-Nephrology Outpatient Clinic, Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Fatebenefratelli Hospital, Milan, Italy
| | - Camillo Porta
- Department of Biomedical Sciences and Human Oncology, University of Bari 'A. Moro', Bari, Italy.,Division of Medical Oncology, AOU Consorziale Policlinico di Bari, Bari
| | | | - Valentina Perrone
- Division of Translational Oncology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Ludovica Mollica
- Division of Medical Oncology, AOU Consorziale Policlinico di Bari, Bari.,Division of Translational Oncology, IRCCS Istituti Clinici Scientifici Maugeri, Pavia, Italy
| | - Maurizio Gallieni
- Department of Clinical and Biomedical Sciences 'Luigi Sacco', University of Milano, Milan, Italy.,Nephrology and Dialysis Unit, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Giovambattista Capasso
- Department of Translational Medical Sciences, University of Campania 'L. Vanvitelli', Naples, Italy.,Biogem Research Institute, Ariano Irpino, Italy
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Kitamura M, Kitamura S, Fujioka M, Kamijo R, Sato S, Sawayama Y, Uramatsu T, Obata Y, Mochizuki Y, Nishikido M, Sakai H, Miyazaki Y, Mukae H, Nishino T. Methotrexate-induced acute kidney injury in patients with hematological malignancies: three case reports with literature review. RENAL REPLACEMENT THERAPY 2018. [DOI: 10.1186/s41100-018-0180-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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Ramsey LB, Balis FM, O'Brien MM, Schmiegelow K, Pauley JL, Bleyer A, Widemann BC, Askenazi D, Bergeron S, Shirali A, Schwartz S, Vinks AA, Heldrup J. Consensus Guideline for Use of Glucarpidase in Patients with High-Dose Methotrexate Induced Acute Kidney Injury and Delayed Methotrexate Clearance. Oncologist 2017; 23:52-61. [PMID: 29079637 PMCID: PMC5759822 DOI: 10.1634/theoncologist.2017-0243] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 09/13/2017] [Indexed: 11/17/2022] Open
Abstract
An expert panel was convened to provide specific, expert consensus guidelines for the use of glucarpidase in patients who develop high‐dose methotrexate (HDMTX)‐induced nephrotoxicity and delayed methotrexate excretion. This guideline provides recommendations to identify the population of patients who would benefit from glucarpidase rescue by more precisely defining the absolute methotrexate concentrations associated with risk for severe or life‐threatening toxicity at several time points after the start of a HDMTX infusion. Acute kidney injury due to high‐dose methotrexate (HDMTX) is a serious, life‐threatening toxicity that can occur in pediatric and adult patients. Glucarpidase is a treatment approved by the Food and Drug Administration for high methotrexate concentrations in the context of kidney dysfunction, but the guidelines for when to use it are unclear. An expert panel was convened to provide specific, expert consensus guidelines for the use of glucarpidase in patients who develop HDMTX‐induced nephrotoxicity and delayed methotrexate excretion. The guideline provides recommendations to identify the population of patients who would benefit from glucarpidase rescue by more precisely defining the absolute methotrexate concentrations associated with risk for severe or life‐threatening toxicity at several time points after the start of an HDMTX infusion. For an HDMTX infusion ≤24 hours, if the 36‐hour concentration is above 30 µM, 42‐hour concentration is above 10 µM, or 48‐hour concentration is above 5 µM and the serum creatinine is significantly elevated relative to the baseline measurement (indicative of HDMTX‐induced acute kidney injury), glucarpidase may be indicated. After a 36‐ to 42‐hour HDMTX infusion, glucarpidase may be indicated when the 48‐hour methotrexate concentration is above 5 µM. Administration of glucarpidase should optimally occur within 48–60 hours from the start of the HDMTX infusion, because life‐threatening toxicities may not be preventable beyond this time point. Implications for Practice. Glucarpidase is a rarely used medication that is less effective when given after more than 60 hours of exposure to high‐dose methotrexate, so predicting early which patients will need it is imperative. There are no currently available consensus guidelines for the use of this medication. The indication on the label does not give specific methotrexate concentrations above which it should be used. An international group of experts was convened to develop a consensus guideline that was specific and evidence‐based to identify the population of patients who would benefit from glucarpidase.
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Affiliation(s)
- Laura B Ramsey
- Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Frank M Balis
- Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Maureen M O'Brien
- Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, and Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jennifer L Pauley
- Pharmaceutical Department, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Archie Bleyer
- Department of Radiation Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Brigitte C Widemann
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, Maryland, USA
| | - David Askenazi
- Pediatric and Infant Center for Acute Nephrology, Professor of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sharon Bergeron
- Hyundai Cancer Institute, Children's Hospital of Orange County, Orange, California, USA
| | - Anushree Shirali
- Assistant Professor of Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Stefan Schwartz
- Medizinische Klinik mit Schwerpunkt Hämatologie, Onkologie und Tumorimmunologie, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Alexander A Vinks
- Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jesper Heldrup
- Childhood Cancer and Research Unit, University Children's Hospital, Lund, Sweden
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Baker KA, Austin EB, Wang GS. Antidotes: Familiar Friends and New Approaches for the Treatment of Select Pediatric Toxicological Exposures. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2017. [DOI: 10.1016/j.cpem.2017.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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9
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Caetano-Pinto P, Jansen J, Assaraf YG, Masereeuw R. The importance of breast cancer resistance protein to the kidneys excretory function and chemotherapeutic resistance. Drug Resist Updat 2017; 30:15-27. [DOI: 10.1016/j.drup.2017.01.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 01/03/2017] [Accepted: 01/05/2017] [Indexed: 12/15/2022]
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Reshetnik A, Scheurig-Muenkler C, van der Giet M, Tölle M. High-flux hemodialysis after administering high-dose methotrexate in a patient with posttransplant lymphoproliferative disease and impaired renal function. Clin Case Rep 2015; 3:932-6. [PMID: 26576275 PMCID: PMC4641477 DOI: 10.1002/ccr3.302] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 03/31/2015] [Accepted: 04/30/2015] [Indexed: 11/07/2022] Open
Abstract
A young patient develops cerebral posttransplant lymphoproliferative disorder. Despite concurrent significantly impaired transplant kidney function use of add-on high-flux hemodialysis for additional clearance made the administration of high-dose methotrexate feasible in this patient without occurence of acute chronic kidney failure and significant hematological toxicity.
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Affiliation(s)
- Alexander Reshetnik
- Department of Nephrology, Charité - Universitaetsmedizin Berlin, Campus Benjamin Franklin Hindenburgdamm 30, 12203, Berlin, Germany
| | - Christian Scheurig-Muenkler
- Department of Radiology, Charité - Universitaetsmedizin Berlin, Campus Benjamin Franklin Hindenburgdamm 30, 12203, Berlin, Germany
| | - Markus van der Giet
- Department of Nephrology, Charité - Universitaetsmedizin Berlin, Campus Benjamin Franklin Hindenburgdamm 30, 12203, Berlin, Germany
| | - Markus Tölle
- Department of Nephrology, Charité - Universitaetsmedizin Berlin, Campus Benjamin Franklin Hindenburgdamm 30, 12203, Berlin, Germany
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11
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Ganguli A, Sawinski D, Berns JS. Kidney diseases associated with haematological cancers. Nat Rev Nephrol 2015; 11:478-90. [DOI: 10.1038/nrneph.2015.81] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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