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Abdelrahman Z, Maxwell AP, McKnight AJ. Genetic and Epigenetic Associations with Post-Transplant Diabetes Mellitus. Genes (Basel) 2024; 15:503. [PMID: 38674437 PMCID: PMC11050138 DOI: 10.3390/genes15040503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/10/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
Post-transplant diabetes mellitus (PTDM) is a common complication of solid organ transplantation. PTDM prevalence varies due to different diabetes definitions. Consensus guidelines for the diagnosis of PTDM have been published based on random blood glucose levels, glycated hemoglobin (HbA1c), and oral glucose tolerance test (OGTT). The task of diagnosing PTDM continues to pose challenges, given the potential for diabetes to manifest at different time points after transplantation, thus demanding constant clinical vigilance and repeated testing. Interpreting HbA1c levels can be challenging after renal transplantation. Pre-transplant risk factors for PTDM include obesity, sedentary lifestyle, family history of diabetes, ethnicity (e.g., African-Caribbean or South Asian ancestry), and genetic risk factors. Risk factors for PTDM include immunosuppressive drugs, weight gain, hepatitis C, and cytomegalovirus infection. There is also emerging evidence that genetic and epigenetic variation in the organ transplant recipient may influence the risk of developing PTDM. This review outlines many known risk factors for PTDM and details some of the pathways, genetic variants, and epigenetic features associated with PTDM. Improved understanding of established and emerging risk factors may help identify people at risk of developing PTDM and may reduce the risk of developing PTDM or improve the management of this complication of organ transplantation.
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Affiliation(s)
- Zeinab Abdelrahman
- Centre for Public Health, Queen’s University of Belfast, Belfast BT12 6BA, UK; (Z.A.); (A.P.M.)
| | - Alexander Peter Maxwell
- Centre for Public Health, Queen’s University of Belfast, Belfast BT12 6BA, UK; (Z.A.); (A.P.M.)
- Regional Nephrology Unit, Belfast City Hospital, Belfast BT9 7AB, UK
| | - Amy Jayne McKnight
- Centre for Public Health, Queen’s University of Belfast, Belfast BT12 6BA, UK; (Z.A.); (A.P.M.)
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2
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Munoz Pena JM, Cusi K. Posttransplant Diabetes Mellitus: Recent Developments in Pharmacological Management of Hyperglycemia. J Clin Endocrinol Metab 2023; 109:e1-e11. [PMID: 37410930 DOI: 10.1210/clinem/dgad395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/20/2023] [Accepted: 06/30/2023] [Indexed: 07/08/2023]
Abstract
CONTEXT The management of solid-organ transplantation is rapidly evolving, and posttransplant diabetes mellitus (PTDM), which is increasingly common, is a barrier to transplant success, adversely impacting infection rates, allograft survival, cardiovascular disease, quality of life, and overall mortality. Currently, the management of PTDM relies primarily on intensified insulin therapy. However, emerging studies report that several noninsulin glucose-lowering agents are safe and effective in improving metabolic control and enhancing treatment adherence. More importantly, their use in PTDM can potentially transform the long-term management of these complex patients, as some glucose-lowering agents may provide benefits beyond glycemic control. For instance, glucagon-like peptide 1 receptor agonists (GLP-1 RA) and sodium-glucose cotransporter 2 (SGLT-2) inhibitors may offer cardiorenal protection, and pioglitazone may treat nonalcoholic fatty liver disease (NAFLD). This review will focus on the pharmacological management of PTDM and the emerging evidence for noninsulin glucose-lowering agents in this population. EVIDENCE ACQUISITION Evidence from observational studies, randomized controlled trials, and meta-analyses. EVIDENCE SYNTHESIS PTDM adversely affects the outcomes of infection, organ survival, cardiovascular events, and mortality. Insulin therapy has been the drug of choice but is associated with weight gain and hypoglycemia. In contrast, noninsulin agents appear safe and may provide additional benefits, such as cardiorenal protection with SGLT-2 inhibitors and GLP-1 RA, and cardiometabolic benefits with pioglitazone, in patients undergoing solid-organ transplantation. CONCLUSIONS Optimal care of patients with PTDM requires close monitoring and the early involvement of the endocrinologist as part of a multidisciplinary team. Noninsulin glucose-lowering agents will likely play an increasing role as more long-term, controlled studies become available in this setting.
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Affiliation(s)
- Juan M Munoz Pena
- Division of Endocrinology, Diabetes & Metabolism, University of Florida, Gainesville, FL, USA
| | - Kenneth Cusi
- Division of Endocrinology, Diabetes & Metabolism, University of Florida, Gainesville, FL, USA
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3
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Heldal TF, Åsberg A, Ueland T, Reisæter A, Pischke SE, Mollnes TE, Aukrust P, Hartmann A, Heldal K, Jenssen T. Inflammation in the early phase after kidney transplantation is associated with increased long-term all-cause mortality. Am J Transplant 2022; 22:2016-2027. [PMID: 35352462 PMCID: PMC9540645 DOI: 10.1111/ajt.17047] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 03/04/2022] [Accepted: 03/24/2022] [Indexed: 01/25/2023]
Abstract
In the general population, low-grade inflammation has been established as a risk factor for all-cause mortality. We hypothesized that an inflammatory milieu beyond the time of recovery from the surgical trauma could be associated with increased long-term mortality in kidney transplant recipients (KTRs). This cohort study included 1044 KTRs. Median follow-up time post-engraftment was 10.3 years. Inflammation was assessed 10 weeks after transplantation by different composite inflammation scores based on 21 biomarkers. We constructed an overall inflammation score and five pathway-specific inflammation scores (fibrogenesis, vascular inflammation, metabolic inflammation, growth/angiogenesis, leukocyte activation). Mortality was assessed with Cox regression models adjusted for traditional risk factors. A total of 312 (29.9%) patients died during the follow-up period. The hazard ratio (HR) for death was 4.71 (95% CI: 2.85-7.81, p < .001) for patients in the highest quartile of the overall inflammation score and HRs 2.35-2.54 (95% CI: 1.40-3.96, 1.52-4.22, p = .001) for patients in the intermediate groups. The results were persistent when the score was analyzed as a continuous variable (HR 1.046, 95% CI: 1.033-1.056, p < .001). All pathway-specific analyses showed the same pattern with HRs ranging from 1.19 to 2.70. In conclusion, we found a strong and consistent association between low-grade systemic inflammation 10 weeks after kidney transplantation and long-term mortality.
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Affiliation(s)
- Torbjørn Fossum Heldal
- Department of Internal MedicineTelemark Hospital TrustSkienNorway,Institute of Clinical MedicineUniversity of OsloOsloNorway,Department of Transplantation MedicineOslo University Hospital – RikshospitaletOsloNorway
| | - Anders Åsberg
- Department of Transplantation MedicineOslo University Hospital – RikshospitaletOsloNorway,Norwegian Renal RegistryOslo University Hospital – RikshospitaletOsloNorway,Department of PharmacyUniversity of OsloOsloNorway
| | - Thor Ueland
- Institute of Clinical MedicineUniversity of OsloOsloNorway,K.G. Jebsen Thrombosis Research and Expertise CenterUniversity of TromsøTromsøNorway,Research Institute of Internal MedicineOslo University Hospital – RikshospitaletOsloNorway
| | - Anna Varberg Reisæter
- Department of Transplantation MedicineOslo University Hospital – RikshospitaletOsloNorway,Norwegian Renal RegistryOslo University Hospital – RikshospitaletOsloNorway
| | - Søren E. Pischke
- Department of ImmunologyUniversity of Oslo and Oslo University HospitalOsloNorway,Department of AnesthesiologyDivision of Emergencies and Critical CareOslo University HospitalOsloNorway
| | - Tom Eirik Mollnes
- K.G. Jebsen Thrombosis Research and Expertise CenterUniversity of TromsøTromsøNorway,Department of ImmunologyUniversity of Oslo and Oslo University HospitalOsloNorway,Research LaboratoryNordland Hospital BodøBodøNorway,Center of Molecular Inflammation ResearchNorwegian University of Science and TechnologyTrondheimNorway
| | - Pål Aukrust
- K.G. Jebsen Thrombosis Research and Expertise CenterUniversity of TromsøTromsøNorway,Research Institute of Internal MedicineOslo University Hospital – RikshospitaletOsloNorway,Section of Clinical Immunology and Infectious DiseasesOslo University Hospital – RikshospitaletOsloNorway
| | - Anders Hartmann
- Institute of Clinical MedicineUniversity of OsloOsloNorway,Department of Transplantation MedicineOslo University Hospital – RikshospitaletOsloNorway
| | - Kristian Heldal
- Department of Internal MedicineTelemark Hospital TrustSkienNorway,Department of Transplantation MedicineOslo University Hospital – RikshospitaletOsloNorway
| | - Trond Jenssen
- Institute of Clinical MedicineUniversity of OsloOsloNorway,Department of Transplantation MedicineOslo University Hospital – RikshospitaletOsloNorway
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4
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Maciel-Fiuza MF, Costa PDSS, Kowalski TW, Schuler-Faccini L, Bonamigo RR, Vetoratto R, Eidt LM, de Moraes PC, Silveira MIDS, Camargo LMA, Callegari-Jacques SM, Castro SMDJ, Vianna FSL. Evaluation of Polymorphisms in Toll-Like Receptor Genes as Biomarkers of the Response to Treatment of Erythema Nodosum Leprosum. Front Med (Lausanne) 2022; 8:713143. [PMID: 35141236 PMCID: PMC8819000 DOI: 10.3389/fmed.2021.713143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 12/09/2021] [Indexed: 01/18/2023] Open
Abstract
Erythema nodosum leprosum (ENL) is an inflammatory complication caused by a dysregulated immune response to Mycobacterium leprae. Some Toll-like receptors (TLRs) have been identified as capable of recognizing antigens from M. leprae, triggering a wide antimicrobial and inflammatory response. Genetic polymorphisms in these receptors could influence in the appearance of ENL as well as in its treatment. Thus, the objective of this work was to evaluate the association of genetic variants of TLRs genes with the response to treatment of ENL with thalidomide and prednisone. A total of 162 ENL patients were recruited from different regions of Brazil and clinical information was collected from their medical records. Genomic DNA was isolated from blood and saliva samples and genetic variants in TLR1 (rs4833095), TLR2 (rs3804099), TLR4 (rs1927914), and TLR6 (rs5743810) genes were genotyped by TaqMan real-time PCR system. In order to evaluate the variants' association with the dose of the medications used during the treatment, we applied the Generalized Estimating Equations (GEE) analysis. In the present sample, 123 (75.9%) patients were men and 86 (53.1%) were in treatment for leprosy during the ENL episode. We found an association between polymorphisms in TLR1/rs4833095, TLR2/rs3804099, TLR4/rs1927914, and TLR6/rs5783810 with the dose variation of thalidomide in a time-dependent manner, i.e., the association with the genetic variant and the dose of the drug was different depending on the moment of the treatment evaluated. In addition, we identified that the association of polymorphisms in TLR1/rs4833095, TLR2/rs3804099, and TLR6/rs5783810 with the dose variation of prednisone also were time-dependent. Despite these associations, in all the interactions found, the influence of genetic variants on dose variation was not clinically relevant for therapeutic changes. The results obtained in this study show that TLRs polymorphism might play a role in the response to ENL treatment, however, in this context, they could not be considered as useful biomarkers in the clinical setting due small differences in medication doses. A larger sample size with patients with a more genetic profile is fundamental in order to estimate the association of genetic variants with the treatment of ENL and their clinical significance.
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Affiliation(s)
- Miriãn Ferrão Maciel-Fiuza
- Postgraduate Program in Genetics and Molecular Biology, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
- Instituto Nacional de Genética Médica Populacional, Porto Alegre, Brazil
- Genomics Medicine Laboratory, Center of Experimental Research, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Laboratory of Immunobiology and Immunogenetics, Postgraduate Program in Genetics and Molecular Biology, Department of Genetics, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | | | - Thayne Woycinck Kowalski
- Postgraduate Program in Genetics and Molecular Biology, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
- Instituto Nacional de Genética Médica Populacional, Porto Alegre, Brazil
- Genomics Medicine Laboratory, Center of Experimental Research, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Laboratory of Immunobiology and Immunogenetics, Postgraduate Program in Genetics and Molecular Biology, Department of Genetics, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Lavínia Schuler-Faccini
- Postgraduate Program in Genetics and Molecular Biology, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
- Instituto Nacional de Genética Médica Populacional, Porto Alegre, Brazil
- Teratogen Information Service, Medical Genetics Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Renan Rangel Bonamigo
- Post-graduate Program in Pathology, Universidade Federal De Ciências Da Saúde de Porto Alegre, Porto Alegre, Brazil
- Dermatology Service of Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Postgraduate Program in Medicine, Medical Sciences, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Rodrigo Vetoratto
- Dermatology Service of Santa Casa Hospital of Porto Alegre, Porto Alegre, Brazil
| | - Letícia Maria Eidt
- Sanitary Dermatology Clinic, Secretaria De Saúde Do Estado Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Paulo Cezar de Moraes
- Postgraduate Program in Medicine, Medical Sciences, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
- Sanitary Dermatology Clinic, Secretaria De Saúde Do Estado Do Rio Grande Do Sul, Porto Alegre, Brazil
| | | | - Luis Marcelo Aranha Camargo
- National Reference Center for Health Dermatology Dona Libania, Fortaleza, Brazil
- Center for Research in Tropical Medicine, Porto Velho, Rondonia, Brazil
- National Institute of Science and Technology-EpiAmo, Rondonia, Brazil
- Department of Medicine, Centro Universitario São Lucas, Porto Velho, Rondônia, Brazil
- National Institute of Science and Technology/CNPq-EpiAmo, Rondonia, Brazil
| | - Sidia Maria Callegari-Jacques
- Postgraduate Program in Genetics and Molecular Biology, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
- Postgraduate Program in Medicine, Medical Sciences, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
- Department of Statistics, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Stela Maris de Jezus Castro
- Department of Statistics, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
- Postgraduate Program in Epidemiology, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Fernanda Sales Luiz Vianna
- Postgraduate Program in Genetics and Molecular Biology, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
- Instituto Nacional de Genética Médica Populacional, Porto Alegre, Brazil
- Genomics Medicine Laboratory, Center of Experimental Research, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Laboratory of Immunobiology and Immunogenetics, Postgraduate Program in Genetics and Molecular Biology, Department of Genetics, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
- Postgraduate Program in Medicine, Medical Sciences, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
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5
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Xu S, Jiang Z, Hu N. Association between Genetic Polymorphisms and Risk of Kidney Posttransplant Diabetes Mellitus: A Systematic Review and Meta-Analysis. Int J Clin Pract 2022; 2022:7140024. [PMID: 35685576 PMCID: PMC9159121 DOI: 10.1155/2022/7140024] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/27/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The purpose of this study was to clarify the role of genetic factors on posttransplant diabetes mellitus (PTDM) risk. METHODS Relevant publications were systematically retrieved from PubMed, EMBASE, and the Cochrane Library up to December 2020. Data from eligible case-control and cohort studies were extracted for qualitative and quantitative analyses. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to estimate the association between gene polymorphisms and PTDM in the quantitative meta-analysis. RESULTS A total of 43 eligible articles were identified, and 16 studies on 9 DNA variants from 8 genes were included in the meta-analysis. TCF7L2 rs7903146 was significantly associated with PTDM risk in 5 genetic models (OR (95% CI): allelic: 1.59 (1.17-2.16), P=0.003; dominant recessive: 1.62 (1.14, 2.31), P=0.007; recessive: 1.87 (1.18, 2.94), P=0.007; homozygote: 2.21 (1.23, 3.94), P=0.008; and heterozygote 1.50 (1.08, 2.10), P=0.017). KCNQ1 rs2237892 was significantly correlated with PTDM risk in 3 genetic models (allelic: 0.68 (0.58, 0.81), P < 0.001; dominant: 0.6 (049, 0.74), P < 0.001; and heterozygote: 0.61 (0.48, 0.76), P < 0.001). KCNJ11 rs5219 was significantly linked with PTDM in the recessive genetic model (1.59 (1.01, 2.50), P=0.047). No significant correlations of PTDM with TCF7L2 rs12255372, SLC30A8 rs13266634, PPARγ rs1801282, CDKN2A/B rs10811661, HHEX rs1111875, and IGF2BP2 rs4402960 polymorphisms were found. CONCLUSIONS The gene polymorphisms of TCF7L2 rs7903146, KCNQ1 rs2237892, and KCNJ11 rs5219 may predispose kidney transplant recipients to PTDM. Large sample size studies on diverse ethnic populations were warranted to confirm our findings.
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Affiliation(s)
- Shan Xu
- Department of Pharmacy, Changzhou No. 2 People's Hospital, The Affiliated Hospital of Nanjing Medical University, Changzhou, China
| | - Zhenwei Jiang
- Department of Pharmacy, The Third Affiliated Hospital of Soochow University, The First People's Hospital of Changzhou, Changzhou, China
| | - Nan Hu
- Department of Pharmacy, The Third Affiliated Hospital of Soochow University, The First People's Hospital of Changzhou, Changzhou, China
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6
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Gomes SV, Rodrigues V, Nunes-Dos-Santos DL, Pereira ALA, Peres MA. The relationship between periodontal status and hyperglycemia after kidney transplantation. Clin Oral Investig 2021; 26:397-406. [PMID: 34196853 DOI: 10.1007/s00784-021-04011-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 05/24/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Several factors have been associated with hyperglycemia after kidney transplantation (KTx), including systemic inflammation. This study aimed to investigate the relationship between periodontal status and hyperglycemia in KTx patients. MATERIALS AND METHODS Forty-four KTx patients were included in this cross-sectional study. Periodontitis severity was categorized into stage I to IV. Fasting blood glucose (FBG) was measured, and hyperglycemia was analyzed at different FBG cutoff points (100 mg/dL, 110 mg/dL, 120 mg/dL, 126 mg/dL, 140 mg/dL). Age, history of smoking, prior type 2 diabetes (T2D), and prior cardiovascular disease (CVD) were considered cofounders. Multivariable logistic regression modelling was performed with periodontitis as the exposure and hyperglycemia as the outcome. Pathway analysis was performed with FBG as a continuous outcome. RESULTS Periodontitis had increased odds of hyperglycemia from 120 mg/dL FBG cutoff, even after adjustment. In addition, periodontitis severity was positively associated with FBG level (β = 0.323, SE = 0.127, P = 0.011). CONCLUSION The findings suggest that periodontitis may be related to increase of hyperglycemia and FBG levels in KTx patients. CLINICAL RELEVANCE Periodontitis severity and cardiovascular disease were positively associated with FBG levels in KTx patients. Clinicians and patients should be aware of the potential benefit of periodontal care for better glycemic control management.
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Affiliation(s)
- Samira V Gomes
- Dentistry Graduate Program, Federal University of Maranhão, Avenida Dos Portugueses, São Luís, 196665080-805, Brazil
| | - Vandilson Rodrigues
- Dentistry Graduate Program, Federal University of Maranhão, Avenida Dos Portugueses, São Luís, 196665080-805, Brazil. .,School of Dentistry and Oral Health, Griffith University, Gold Coast, QLD, Australia.
| | - Danila L Nunes-Dos-Santos
- Dentistry Graduate Program, Federal University of Maranhão, Avenida Dos Portugueses, São Luís, 196665080-805, Brazil
| | - Antonio L A Pereira
- Dentistry Graduate Program, Federal University of Maranhão, Avenida Dos Portugueses, São Luís, 196665080-805, Brazil
| | - Marco A Peres
- School of Dentistry and Oral Health, Griffith University, Gold Coast, QLD, Australia.,National Dental Research Institute Singapore, National Dental Centre Singapore, Singapore, Singapore.,Oral Health ACP, Health Services and Systems Research Programme, Duke-NUS Medical School, Singapore, Singapore
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7
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Diabetes and Cardiovascular Risk in Renal Transplant Patients. Int J Mol Sci 2021; 22:ijms22073422. [PMID: 33810367 PMCID: PMC8036743 DOI: 10.3390/ijms22073422] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 03/05/2021] [Accepted: 03/08/2021] [Indexed: 02/06/2023] Open
Abstract
End-stage kidney disease (ESKD) is a main public health problem, the prevalence of which is continuously increasing worldwide. Due to adverse effects of renal replacement therapies, kidney transplantation seems to be the optimal form of therapy with significantly improved survival, quality of life and diminished overall costs compared with dialysis. However, post-transplant patients frequently suffer from post-transplant diabetes mellitus (PTDM) which an important risk factor for cardiovascular and cardiovascular-related deaths after transplantation. The management of post-transplant diabetes resembles that of diabetes in the general population as it is based on strict glycemic control as well as screening and treatment of common complications. Lifestyle interventions accompanied by the tailoring of immunosuppressive regimen may be of key importance to mitigate PTDM-associated complications in kidney transplant patients. More transplant-specific approach can include the exchange of tacrolimus with an alternative immunosuppressant (cyclosporine or mammalian target of rapamycin (mTOR) inhibitor), the decrease or cessation of corticosteroid therapy and caution in the prescribing of diuretics since they are independently connected with post-transplant diabetes. Early identification of high-risk patients for cardiovascular diseases enables timely introduction of appropriate therapeutic strategy and results in higher survival rates for patients with a transplanted kidney.
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8
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Li T, Jing J, Dong N, Liu X, Ma C, Yang J. TLR4 rs1927914 polymorphism contributes to serum TLR4 levels in patients with aortic aneurysm. Exp Mol Pathol 2021; 119:104609. [PMID: 33516663 DOI: 10.1016/j.yexmp.2021.104609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 12/09/2020] [Accepted: 01/20/2021] [Indexed: 12/25/2022]
Abstract
Toll-like receptor 4 (TLR4) is a crucial regulator of inflammatory reactions and vascular remodeling. Elevated TLR4 expression has been proved to be correlated with an increased risk of aortic aneurysm (AA). This study aimed to explore the influence of TLR4 gene polymorphisms on TLR4 expression levels and its probable functional significance in AA disease. A total of 294 AA patients and 285 controls were enrolled in the study and serum TLR4 levels were detected by ELISA. All the participants were genotyped for two tag-SNPs in TLR4 (rs1927914 in the promoter region and rs11536889 in the 3'-untranslated region) using the KASP method. Relative luciferase activity was measured by the dual-luciferase reporter assay system. The rs1927914 TC, TC/CC genotypes and C allele showed associations with increased serum TLR4 levels in the total population and AA patients (all P<0.05). Further stratified analysis demonstrated that AA subjects with TC or TC/CC genotype of rs1927914 had significantly higher serum levels of TLR4 than those with TT genotype in male, age>60y, hypertension, diabetes, TAA type and size>5.0 cm subgroups (all P<0.05). In binary logistic analysis, rs1927914 TC genotype and dominant model presented significant associations with high TLR4 levels (OR = 1.579 and 1.431, P = 0.020 and 0.049, respectively) after adjusting age, hypertension and diabetes. However, rs11536889 polymorphism had no significant influence on serum TLR4 levels. Regarding rs1927914, luciferase activity of the C allele construct was significantly increased in comparison with the T allele construct (0.589 ± 0.004 vs. 0.340 ± 0.014, P<0.001). Our results provided evidence that rs1927914 polymorphism contributed to serum TLR4 levels, possibly by influencing promoter activity of TLR4, and could be a novel genetic factor in the formation of AA.
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Affiliation(s)
- Tan Li
- Department of Cardiovascular Ultrasound, the First Hospital of China Medical University, Shenyang 110001, China
| | - Jingjing Jing
- Tumor Etiology and Screening Department of Cancer Institute and General Surgery, the First Hospital of China Medical University, Shenyang 110001, China
| | - Nannan Dong
- Tumor Etiology and Screening Department of Cancer Institute and General Surgery, the First Hospital of China Medical University, Shenyang 110001, China
| | - Xiaozheng Liu
- Department of Cardiovascular Ultrasound, the First Hospital of China Medical University, Shenyang 110001, China
| | - Chunyan Ma
- Department of Cardiovascular Ultrasound, the First Hospital of China Medical University, Shenyang 110001, China.
| | - Jun Yang
- Department of Cardiovascular Ultrasound, the First Hospital of China Medical University, Shenyang 110001, China.
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9
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Ren Q, Cheng L, Yi J, Ma L, Pan J, Gou SJ, Fu P. Toll-like Receptors as Potential Therapeutic Targets in Kidney Diseases. Curr Med Chem 2020; 27:5829-5854. [PMID: 31161985 DOI: 10.2174/0929867325666190603110907] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/15/2019] [Accepted: 05/13/2019] [Indexed: 02/08/2023]
Abstract
Toll-like Receptors (TLRs) are members of pattern recognition receptors and serve a pivotal role in host immunity. TLRs response to pathogen-associated molecular patterns encoded by pathogens or damage-associated molecular patterns released by dying cells, initiating an inflammatory cascade, where both beneficial and detrimental effects can be exerted. Accumulated evidence has revealed that TLRs are closely associated with various kidney diseases but their roles are still not well understood. This review updated evidence on the roles of TLRs in the pathogenesis of kidney diseases including urinary tract infection, glomerulonephritis, acute kidney injury, transplant allograft dysfunction and chronic kidney diseases.
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Affiliation(s)
- Qian Ren
- Kidney Research Laboratory, Division of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Lu Cheng
- Kidney Research Laboratory, Division of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Jing Yi
- Kidney Research Laboratory, Division of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Liang Ma
- Kidney Research Laboratory, Division of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Jing Pan
- Kidney Research Laboratory, Division of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Shen-Ju Gou
- Kidney Research Laboratory, Division of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Ping Fu
- Kidney Research Laboratory, Division of Nephrology, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Chengdu 610041, China
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10
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Zmonarski SC, Banasik M, Golebiowski T, Madziarska K, Mazanowska O, Myszka M, Zmonarska J, Letachowicz K, Dawiskiba T, Krajewska M. Toll-like 4 receptor (TLR4) expression on peripheral blood mononuclear cells in renal transplant recipients with pre-transplant chronic interstitial nephritis indicates patients at risk of graft deterioration. Transpl Immunol 2020; 62:101319. [PMID: 32693120 DOI: 10.1016/j.trim.2020.101319] [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: 11/14/2019] [Revised: 07/08/2020] [Accepted: 07/12/2020] [Indexed: 10/23/2022]
Abstract
Data binding the expression of Toll-like 4 receptor (TLR4ex), transplanted kidney function, and the cause of pre-transplant end-stage renal disease are scarcely available. OBJECTIVE To investigate the relationship between pre-transplant chronic interstitial nephritis (CIN), TLR4ex and transplanted kidney function. MATERIALS AND METHODS TLR4ex was measured in peripheral blood mononuclear cells of 43 CIN kidney transplant recipients. We compared TLR4ex among 33 patients with pre-transplant chronic non-infectious interstitial nephritis (NIN) and 10 patients with pre-transplant chronic pyelonephritis (Py). At the beginning (Day-0) TLR4ex, as well as concentrations of cyclosporin A (CyA) and tacrolimus (TAC) were determined. Both CIN and NIN patients were divided according to the respective median of TLR4ex into groups of low-TLR4 expression (L-TLR4ex) and high-TLR4 expression (H-TLR4ex). Serum creatinine/glomerular filtration rate (sCr/EGFR) was assessed on Day-0 and after the follow-up (F-up). The magnitudes of sCr/EGFR change (ΔsCr/ΔEGFR) were evaluated. The treatment was maintained stable along the F-up period (median 11.9 months). RESULTS Day-0: in CIN with L-TLR4ex TAC was lower but sCr/EGFR were not different from H-TLR4ex; in Py TLR4ex and TAC were lower than in NIN with no difference in sCR/eGFR. After F-up: in CIN with L-TLR4ex sCR/EGFR and ΔsCr/ΔEGFR were worse than in H-TLR4ex; in Py sCR/EGFR and ΔsCr/ΔEGFR were worse than in NIN. The regression analysis points out prospective impact of Py and TLR4ex on sCR/eGFR and ΔsCr/ΔeGFR. CONCLUSION In CIN, both TLR4ex and Tac appear to be a useful positive predictor of the effectiveness of immunosuppression. Chronic pyelonephritis indirectly promotes faster progression of chronic transplanted kidney disease.
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Affiliation(s)
- Sławomir C Zmonarski
- Wroclaw Medical University, Department of Nephrology and Transplantation Medicine, Borowska 213 Str., 50-553 Wroclaw, Poland.
| | - Miroslaw Banasik
- Wroclaw Medical University, Department of Nephrology and Transplantation Medicine, Borowska 213 Str., 50-553 Wroclaw, Poland.
| | - Tomasz Golebiowski
- Wroclaw Medical University, Department of Nephrology and Transplantation Medicine, Borowska 213 Str., 50-553 Wroclaw, Poland.
| | - Katarzyna Madziarska
- Wroclaw Medical University, Department of Nephrology and Transplantation Medicine, Borowska 213 Str., 50-553 Wroclaw, Poland.
| | - Oktawia Mazanowska
- Wroclaw Medical University, Department of Nephrology and Transplantation Medicine, Borowska 213 Str., 50-553 Wroclaw, Poland.
| | - Marta Myszka
- Wroclaw Medical University, Department of Nephrology and Transplantation Medicine, Borowska 213 Str., 50-553 Wroclaw, Poland.
| | - Joanna Zmonarska
- Wroclaw Medical University, Faculty of Medicine, wyb. Ludwika Pasteura 1, 50-367 Wroclaw, Poland.
| | - Krzysztof Letachowicz
- Wroclaw Medical University, Department of Nephrology and Transplantation Medicine, Borowska 213 Str., 50-553 Wroclaw, Poland.
| | - Tomasz Dawiskiba
- Wroclaw Medical University, Department of Vascular, General and Transplant Surgery, Borowska 213 Str., 50-553 Wroclaw, Poland.
| | - Magdalena Krajewska
- Wroclaw Medical University, Department of Nephrology and Transplantation Medicine, Borowska 213 Str., 50-553 Wroclaw, Poland.
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11
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Abstract
Solid organ transplantation (SOT) is a life-saving procedure and an established treatment for patients with end-stage organ failure. However, transplantation is also accompanied by associated cardiovascular risk factors, of which post-transplant diabetes mellitus (PTDM) is one of the most important. PTDM develops in 10-20% of patients with kidney transplants and in 20-40% of patients who have undergone other SOT. PTDM increases mortality, which is best documented in patients who have received kidney and heart transplants. PTDM results from predisposing factors (similar to type 2 diabetes mellitus) but also as a result of specific post-transplant risk factors. Although PTDM has many characteristics in common with type 2 diabetes mellitus, the prevention and treatment of the two disorders are often different. Over the past 20 years, the lifespan of patients who have undergone SOT has increased, and PTDM becomes more common over the lifespan of these patients. Accordingly, PTDM becomes an important condition not only to be aware of but also to treat. This Review presents the current knowledge on PTDM in patients receiving kidney, heart, liver and lung transplants. This information is not only for transplant health providers but also for endocrinologists and others who will meet these patients in their clinics.
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Affiliation(s)
- Trond Jenssen
- Department of Transplantation Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Anders Hartmann
- Department of Transplantation Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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12
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Lima C, Grden A, Skare T, Jaworski P, Nisihara R. Risk factors for new-onset diabetes mellitus after kidney transplantation (NODAT): a Brazilian single center study. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2019; 62:597-601. [PMID: 30624499 PMCID: PMC10118672 DOI: 10.20945/2359-3997000000084] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 12/13/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVES This study aims to verify the new-onset diabetes after kidney transplant (NODAT) incidence in recipients within 1 year after kidney transplantation from a single center in Southern Brazil and to assess the associated conditions. SUBJECTS AND METHODS A retrospective study of 258 post-renal transplant patients was performed. Demographic (gender, age, ethnic background) and clinical (origin of graft, associated infections, body mass index (BMI) at transplant time and 6 and 12 months after, causes of renal failure, and comorbidities) data were analyzed. All patients were on tacrolimus, mycophenolate mofetil, and prednisone treatment. Patients with and without NODAT were compared. RESULTS A NODAT incidence of 31.2% was noted 1 year post transplantation. In the univariate analysis, patients with NODAT were older (p = 0.001), mostly had African-American ethnic background (p = 0.02), and had renal failure secondary to high blood pressure (HBP) (p = 0.001). The group of patients with NODAT also had more incidence of post-transplant HBP (p = 0.01), heart failure (p = 0.02), and dyslipidemia (p = 0.001). Logistic regression showed that African-American ethnic background, post-transplant HBP, and dyslipidemia were independently associated with NODAT. CONCLUSION This study shows a NODAT incidence that is greater in patients with African-American ethnic background and that is associated with HBP and dyslipidemia.
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Affiliation(s)
- Camila Lima
- Universidade Evangélica, Departamento de Medicina, Curitiba, PR, Brasil
| | - Amanda Grden
- Universidade Evangélica, Departamento de Medicina, Curitiba, PR, Brasil
| | - Thelma Skare
- Universidade Evangélica, Departamento de Medicina, Curitiba, PR, Brasil
| | - Paulo Jaworski
- Universidade Evangélica, Departamento de Medicina, Curitiba, PR, Brasil
| | - Renato Nisihara
- Universidade Evangélica, Departamento de Medicina, Curitiba, PR, Brasil.,Universidade Positivo, Departamento de Medicina, Curitiba, PR, Brasil
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13
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Zmonarski SC, Madziarska K, Golebiowski T, Banasik M, Mazanowska O, Madziarski M, Krajewska M. Can the Toll-like receptors 4 expression in peripheral blood mononuclear cells help assess the effectiveness of immunosuppression and the chance of a future good renal transplant function? Transpl Immunol 2018; 53:43-50. [PMID: 30592973 DOI: 10.1016/j.trim.2018.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 12/24/2018] [Accepted: 12/24/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND A small percentage of peripheral blood mononuclear cells (PBMCs) circulating during the kidney transplantation (KT) period remain in the blood long after transplantation. A part of the PBMCs penetrates the graft. AIM To examine if the choice of immunosuppression may change TLR4ex and how TLR4ex affects the transplant function in the future. MATERIAL The study population-143 transplanted patients (pts) (55 females, 88 males), mean age on recruitment day 50.33 ± 12.8 years old, mean BMI 25.04 ± 4.18. 41 pts. experienced delayed graft function (DGF+). 55 pts. were treated with cyclosporine A (CsA) and 88 with tacrolimus (Tac). All were treated with mofetil mycophenolate (MMF). The PBMCs acquisition and starting point of the follow-up (TLR-day) was at least one month after KT. METHOD We investigated averaged mRNA expression of Toll-like receptors 4 (TLR4ex) in non-stimulated peripheral blood mononuclear cells with the use of real-time polymerase chain reaction. The KT pts. (All, Tac, CsA, DGF+) were divided by the respective median of their TLR4ex (lower: L-TLR4ex, higher: H-TLR4ex). Main clinical parameters and transplant biopsy files (if available) were assessed on TLR-day and post follow-up. RESULTS We found that TLR4ex was reduced for a long time in patients who experienced delayed graft function. L-TLR4ex had a higher proportion of DGF+ patients, and patients treated with CsA but lower of those treated with Tac than in H-TLR4ex. The amplitude of changes in renal function parameters (ΔEGFR%/ΔsCr/ΔsCr%) was clearly less favorable for L-TLR4ex. Tacrolimus expressed a stabilizing effect. Both the positive vasculitis score and chronic graft nephropathy were more frequent in the L-TLR4ex group. On TLR-day an association of renal function and Tac concentration with TLR4ex was clear only in the tacrolimus population. The TLR4ex was lower in patients with a future deterioration of the graft function. CONCLUSION In kidney transplant recipients the occurrence of DGF results in a long-term reduction of the averaged TLR4ex in PBMC. Tacrolimus exerts a clear, stabilizing, positive and dose-dependent effect on TLR4ex. An improvement in renal transplant function may be expected in KT patients with high TLR4ex. Evaluation of the averaged TLR4ex can be used to assess the efficacy of immunosuppression in the treatment with tacrolimus and to estimate the likelihood of deterioration in renal function.
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Affiliation(s)
- Slawomir C Zmonarski
- Dept. of Nephrology and Transplantation Medicine, Medical University Wroclaw, Poland
| | - Katarzyna Madziarska
- Dept. of Nephrology and Transplantation Medicine, Medical University Wroclaw, Poland.
| | - Tomasz Golebiowski
- Dept. of Nephrology and Transplantation Medicine, Medical University Wroclaw, Poland
| | - Miroslaw Banasik
- Dept. of Nephrology and Transplantation Medicine, Medical University Wroclaw, Poland
| | - Oktawia Mazanowska
- Faculty of Medicine and Dentistry, Dept. of Nephrology and Transplantation Medicine, Medical University Wroclaw, Poland
| | - Marcin Madziarski
- Dept. of Nephrology and Transplantation Medicine, Medical University Wroclaw, Poland
| | - Magdalena Krajewska
- Dept. of Nephrology and Transplantation Medicine, Medical University Wroclaw, Poland
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14
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Heldal TF, Ueland T, Jenssen T, Hartmann A, Reisaeter AV, Aukrust P, Michelsen A, Åsberg A. Inflammatory and related biomarkers are associated with post-transplant diabetes mellitus in kidney recipients: a retrospective study. Transpl Int 2018; 31:510-519. [PMID: 29341300 DOI: 10.1111/tri.13116] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Revised: 10/23/2017] [Accepted: 12/31/2017] [Indexed: 12/11/2022]
Abstract
In this study, we investigate the association between selected inflammatory-related biomarkers and post-transplant hyperglycemia in kidney transplant recipients. This retrospective analysis comprises 852 patients receiving a kidney transplant at the Norwegian national transplant center between 2007 and 2012, all having a normal oral glucose tolerance test (OGTT) before transplantation. A diagnostic OGTT was performed 10 weeks post-transplant to examine the association between inflammation-related biomarkers and two-hour plasma glucose (2HPG) by multivariable linear regression models adjusting for BMI, age, graft function, fasting insulin levels, dosage of prednisolone, and concentration of calcineurin inhibitors. Six of 20 biomarkers were significantly associated with 2HPG in multivariate analyses showing strong associations with soluble tumor necrosis factor type 1 (P = 0.027), Pentraxin 3 (P = 0.019), macrophage migration inhibitory factor (P = 0.024), and endothelial protein C receptor (P = 0.001). These associated markers reflect several distinct but also overlapping pathways including activation of tumor necrosis factor, macrophages, and endothelial cells. The multinomial logistic regression model showed a clear association between the inflammatory biomarkers and post-transplant diabetes mellitus (PTDM). The association between a range of inflammation markers and PTDM suggests that these markers may be target for future studies on pathogenesis and perhaps also treatment of PTDM.
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Affiliation(s)
- Torbjørn F Heldal
- Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Thor Ueland
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Research Institute of Internal Medicine Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,K. G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Tromsø, Norway.,K. G. Jebsen Inflammatory Research Center, University of Oslo, Oslo, Norway
| | - Trond Jenssen
- Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Metabolic and Renal Research Group, UiT The Arctic University of Norway, Tromsø, Norway
| | - Anders Hartmann
- Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anna V Reisaeter
- Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Norwegian Renal Registry, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Pål Aukrust
- Faculty of Medicine, University of Oslo, Oslo, Norway.,Research Institute of Internal Medicine Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,K. G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø, Tromsø, Norway.,K. G. Jebsen Inflammatory Research Center, University of Oslo, Oslo, Norway.,Section of Clinical Immunology and Infectious Disease, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Annika Michelsen
- Research Institute of Internal Medicine Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Anders Åsberg
- Department of Transplantation Medicine, Section of Nephrology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Norwegian Renal Registry, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,School of Pharmacy, University of Oslo, Oslo, Norway
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15
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Xu H, Jiang G, Shen H, Li W, Mao J, Pan Y. Association of TLR4 gene polymorphisms with childhood Henoch-Schönlein purpura in a Chinese population. Rheumatol Int 2017; 37:1909-1915. [PMID: 28905155 DOI: 10.1007/s00296-017-3815-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 09/06/2017] [Indexed: 02/07/2023]
Abstract
Recent studies demonstrated that aberrant activation of Toll-like receptor (TLR) 4 was involved in the pathogenesis of Henoch-Schönlein purpura (HSP). In this study, we evaluated the association between TLR4 gene polymorphisms and the risk of childhood HSP in a Chinese population. A total of 175 HSP patients and 186 controls were recruited in this case-control study. Three single-nucleotide polymorphisms of the TLR4 gene (rs1927914, rs10759932 and rs1927907) were genotyped using the matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) and Sequenom MassARRAY system. Our results revealed that a significantly reduced risk for HSP was associated with the G allele (OR = 0.71; p = 0.023) and G/G genotype (OR = 0.49; p = 0.021) of rs1927914. We also showed that rs1927914 variant decreased the risk of HSP in recessive inheritance model (OR = 0.55; p = 0.035, G/G vs A/A + A/G). In addition, we observed that a significantly decreased frequency of the haplotype GTC (rs1927914-rs10759932-rs1927907) in HSP patients compared with controls (OR = 0.56; p = 0.028). Our data suggested that TLR 4 rs1927914 polymorphism was associated with the decreased susceptibility to HSP in the Chinese children.
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Affiliation(s)
- Hui Xu
- Department of Clinical Laboratory, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Guizhen Jiang
- Department of Clinical Laboratory, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Hongqiang Shen
- Department of Clinical Laboratory, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Li
- Department of Clinical Laboratory, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jianhua Mao
- Department of Nephrology, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, 310006, Zhejiang Province, China.
| | - Yanxiang Pan
- Department of Clinical Laboratory, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
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