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Shen N, Zhang L, Yang J, Lin Y, Liu X, Cai X, Cao J, Zhu Q, Luo X, Wan X, Wu H, Ye J, Shan C, Xie H, Wu Y, Cao Y, Wang J, Yu X, Wang H, He J, Tian S, Wu F, Jiang X, Li L, Zuo L, Wang Z, Xing C, Yin X, Zhao J, Ma C, Long G, Li Q, Hu Y, Shi Y, Lin H. Effectiveness, safety, and treatment pattern of sodium zirconium cyclosilicate in Chinese patients with hyperkalemia: interim analysis from a multicenter, prospective, real-world study (Actualize Study). Front Pharmacol 2024; 15:1398953. [PMID: 39135788 PMCID: PMC11317418 DOI: 10.3389/fphar.2024.1398953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 07/12/2024] [Indexed: 08/15/2024] Open
Abstract
Introduction: Sodium zirconium cyclosilicate (SZC) is a nonabsorbed cation-exchanger approved in China for the treatment of hyperkalemia [HK; serum potassium (sK+) levels >5.0 mmol/L]. This is the first real-world study aimed to assess the effectiveness, safety, and treatment patterns of SZC in Chinese patients with HK. Here we present the results of the first interim analysis. Methods: This multicenter, prospective, cohort study included patients aged ≥18 years with documented HK within 1-year before study enrollment day. These patients were followed up for 6 months from the enrollment day after initiating SZC treatment. The treatment was categorized into correction phase (FAS-P1) and maintenance phase (FAS-P2 new and ongoing users). Subgroup analysis was performed in patients on hemodialysis (FAS-H). The primary objective was evaluation of safety profile of SZC; secondary objectives included assessment of treatment patterns of SZC and its effectiveness. Results: Of 421 screened patients, 193, 354, and 162 patients were enrolled in the FAS-P1, FAS-P2, and FAS-H groups, respectively. sK+ levels were reduced significantly from 5.9 mmol/L to 5.0 mmol/L after the correction phase. For the maintenance phase, the mean sK+ levels were maintained at 5.2 mmol/L and 5.0 mmol/L in the FAS-P2 new and ongoing user, respectively, and 5.3 mmol/L in the FAS-H subgroup. A considerable proportion of patients showed normokalemia after 48 h of SZC treatment (FAS-P1:51.3%) which was maintained up to 6 months in the maintenance phase (FAS-P2:44%). SZC was well-tolerated. Conclusion: SZC was effective and safe for the treatment of HK in real-world clinical practice in China.
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Affiliation(s)
- Nan Shen
- The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Lihong Zhang
- The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jing Yang
- Hefei First People’s Hospital, Hefei, Anhui, China
| | - Yongqiang Lin
- Wenzhou Integrated Chinese and Western Medicine Hospital, Wenzhou, Zhejiang, China
| | - Xinyu Liu
- Nanyang Central Hospital, Nanyang, Henan, China
| | - Xudong Cai
- Ningbo Traditional Chinese Medicine Hospital, Ningbo, Zhejiang, China
| | - Juan Cao
- Taixing People’s Hospital, Taizhou, Jiangsu, China
| | - Qiang Zhu
- Xinghua People’s Hospital, Taizhou, China
| | - Xun Luo
- Hunan Provincial People’s Hospital, Changsha, Hunan, China
| | - Xin Wan
- The First Hospital of Nanjing, Nanjing, Jiangsu, China
| | - Henglan Wu
- The First Hospital of Jiaxing, Jiaxing, Zhejiang, China
| | - Jianming Ye
- The First People’s Hospital of Kunshan, Suzhou, Jiangsu, China
| | - Chunyan Shan
- Chu Hsien-I Memorial Hospital of Tianjin Medical University, Tianjin, China
| | - Hua Xie
- Dalian Ruikaer Renal Disease Hospital, Dalian, Liaoning, China
| | - Yifan Wu
- Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, Guangdong, China
| | - Yanping Cao
- Handan First Hospital, Handan, Heibei, China
| | | | - Xiaoyong Yu
- Shanxi Provincial Hospital of Chinese Medicine, Shanxi, China
| | - Huimin Wang
- Liaoning Health Industry Group Bensteel General Hospital, Benxi, Liaoning, China
| | - Jingdong He
- Nuclear Industry 416 Hospital, Chengdu, Sichuan, China
| | | | - Fenglei Wu
- Qidong People’s Hospital Affiliated Qidong Hospital of Nantong University, Jiangsu, China
| | - Xinxin Jiang
- Sandun District of Zhejiang Hospital, Zhejiang, China
| | - Lu Li
- The First Affiliated Hospital of Xi’an Medical University, Xi’an, Shaanxi, China
| | - Li Zuo
- Peking University People’s Hospital, Beijing, China
| | - Zhaohua Wang
- Taian City Central Hospital, Tai’an, Shandong, China
| | - Changying Xing
- Jiangsu Province Official Hospital, Nanjing, Jiangsu, China
| | - Xun Yin
- Changshu No.2 People’s Hospital, Suzhou, Jiangsu, China
| | - Jianrong Zhao
- The Affiliated Hospital of Inner Mongolia Medical University, Hohho, Inner Mongolia, China
| | - Cong Ma
- Anshan Central Hospital, Anshan, Liaoning, China
| | - Gang Long
- Tianjin People’s Hospital, Tianjin, China
| | - Qing Li
- Tianjin Teda Hospital, Tianjin, China
| | - Yao Hu
- Clinical Medical College and Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Yifan Shi
- AstraZeneca Investment China Co., Medical Affairs, Shanghai, China
| | - Hongli Lin
- The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
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Ash SR, Batlle D, Kendrick J, Oluwatosin Y, Kooienga L, Eudicone JM, Sundin AK, Guerrieri E, Fried LF. Sodium Zirconium Cyclosilicate in CKD, Hyperkalemia, and Metabolic Acidosis: NEUTRALIZE Randomized Study. KIDNEY360 2024; 5:812-820. [PMID: 38622759 PMCID: PMC11219110 DOI: 10.34067/kid.0000000000000446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/09/2024] [Indexed: 04/17/2024]
Abstract
Key Points Sodium zirconium cyclosilicate effectively lowers serum potassium and maintains normokalemia in patients with CKD with concomitant hyperkalemia and metabolic acidosis. Despite high screen failure and small sample size, a nominally significant increase in sHCO3– was seen for sodium zirconium cyclosilicate versus placebo. Further studies on the basis of an appropriate cohort size may help validate the trend observed in sHCO3– levels, supporting these clinically relevant findings. Background Metabolic acidosis and hyperkalemia are common in CKD. A potential dual effect of sodium zirconium cyclosilicate (SZC), a selective binder of potassium in the gastrointestinal tract, on serum potassium (sK+) and serum bicarbonate (sHCO3−) was evaluated in patients with hyperkalemia and metabolic acidosis associated with CKD. Methods In the NEUTRALIZE study (NCT04727528 ), non-dialysis patients with stage 3–5 CKD, hyperkalemia (sK+>5.0 to ≤5.9 mmol/L), and metabolic acidosis (sHCO3− 16–20 mmol/L) received open-label SZC 10 g three times daily for ≤48 hours. Patients achieving normokalemia (sK+ 3.5–5.0 mmol/L) were randomized 1:1 to SZC 10 g or placebo daily for 4 weeks. The primary end point was patients (%) maintaining normokalemia at the end of treatment (EOT) without rescue. Secondary end points included mean change in sHCO3− at EOT (day 29) and patients (%) with normokalemia with a ≥3-mmol/L increase in sHCO3− without rescue. Results Of 229 patients screened, 37 were randomized (SZC, n =17; placebo, n =20). High screen failure led to early study termination. At EOT, 88.2% (SZC) versus 20.0% (placebo) of patients maintained normokalemia (odds ratio, 56.2; P = 0.001). Low enrollment rendered secondary end point P values nominal. SZC treatment provided nominally significant increases in sHCO3– versus placebo from day 15 onward. Patients with normokalemia with a ≥3-mmol/L increase in sHCO3− without rescue were 35.3% (SZC) and 5.0% (placebo; P < 0.05). No new safety concerns were reported. Conclusions SZC effectively lowered sK+ and maintained normokalemia, with nominally significant increases in sHCO3– observed for SZC versus placebo.
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Affiliation(s)
- Stephen R. Ash
- Nephrology Department, Indiana University Health Arnett, Lafayette, Indiana
| | - Daniel Batlle
- Division of Nephrology and Hypertension, Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jessica Kendrick
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | | | - James M. Eudicone
- BioPharmaceuticals Medical (Evidence), AstraZeneca, Wilmington, Delaware
| | | | | | - Linda F. Fried
- Renal Section, Veterans Affairs Pittsburgh Healthcare System and Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania
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Janjua H. Management of hyperkalemia in children. Curr Opin Pediatr 2024; 36:204-210. [PMID: 38001558 DOI: 10.1097/mop.0000000000001321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2023]
Abstract
PURPOSE OF REVIEW Hyperkalemia is a potentially fatal electrolyte abnormality with no standardized management. The purpose of this review is to provide the knowledge needed for timely and effective management of hyperkalemia in children. It describes the utility of existing and novel therapies. RECENT FINDINGS Two newer oral potassium binding agents, patiromer sorbitex calcium and sodium zirconium cyclosilicate, have been FDA-approved for the management of hyperkalemia in adults. These newer agents offer hope for improved management, even though their use in pediatric patients requires further exploration. SUMMARY This review highlights the causes and life-threatening effects of hyperkalemia and provides a comprehensive overview of the management of hyperkalemia in both acute and chronic settings along with upcoming treatment strategies.
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Affiliation(s)
- Halima Janjua
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Sinnathamby ES, Banh KT, Barham WT, Hernandez TD, De Witt AJ, Wenger DM, Klapper VG, McGregor D, Paladini A, Ahmadzadeh S, Shekoohi S, Kaye AD, Varrassi G. Hyperkalemia: Pharmacotherapies and Clinical Considerations. Cureus 2024; 16:e52994. [PMID: 38406030 PMCID: PMC10894645 DOI: 10.7759/cureus.52994] [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: 12/12/2023] [Accepted: 01/26/2024] [Indexed: 02/27/2024] Open
Abstract
Hyperkalemia has been defined as a condition where a serum potassium level is >5.5 mmol/l. It is associated with fatal dysrhythmias and muscular dysfunction. Certain medical conditions, such as chronic kidney disease (CKD), diabetes mellitus, and others, can lead to hyperkalemia. Many of the signs of hyperkalemia are nonspecific. A history and physical examination can be beneficial in the diagnosis of the condition. In this regard, certain characteristic electrocardiogram findings are associated with hyperkalemia along with laboratory potassium levels. In acute and potentially lethal conditions, hyperkalemia treatments include glucose and insulin, bicarbonate, calcium gluconate, beta-2 agonists, hyperventilation, and dialysis. There are several drugs, both old and new, that can additionally aid in the reduction of serum potassium levels. The present investigation evaluated some of these different drugs, including sodium polystyrene sulfonate (SPS), sodium zirconium cyclosilicate (SZC), and patiromer. These drugs each have increased selectivity for potassium and work primarily in the gastrointestinal (GI) tract. Each of these medications has unique benefits and contraindications. Clinicians must be aware of these medications when managing patients with hyperkalemia.
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Affiliation(s)
- Evan S Sinnathamby
- Medicine, Louisiana State University Health Sciences Center, New Orleans, USA
| | - Kelly T Banh
- Medicine, Louisiana State University Health Sciences Center, New Orleans, USA
| | - William T Barham
- Medicine, Louisiana State University Health Sciences Center, New Orleans, USA
| | - Tyler D Hernandez
- Medicine, Louisiana State University Health Sciences Center, New Orleans, USA
| | - Audrey J De Witt
- Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Danielle M Wenger
- Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, USA
| | - Vincent G Klapper
- Internal Medicine, Louisiana State University Health Sciences Center, Shreveport, USA
| | - David McGregor
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Antonella Paladini
- Life, Health and Environmental Sciences (MESVA), University of L'Aquila, L'Aquila, ITA
| | - Shahab Ahmadzadeh
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Sahar Shekoohi
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Alan D Kaye
- Anesthesiology, Louisiana State University Health Sciences Center, Shreveport, USA
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Shen N, Meng Q, Zhang L, Xie H, Zhao J, Xing C, Zuo L, Long G, Zhu Q, Shan C, Cai X, Yang J, Luo X, Wang J, Ye J, Wan X, Tian S, Wu Y, Lin Y, Yu X, Li Q, Liu X, Shi Z, Zhou J, Liu C, Cao Y, Wang N, Jiang X, Wu H, Hu Y, Li L, Wang Z, He J, Cao J, Wu F, Ma C, Yin X, Li Z, Wang H, Lin H. Evaluation of safety, effectiveness and treatment patterns of sodium zirconium cyclosilicate in management of hyperkalaemia in China: a real-world study protocol. BMJ Open 2023; 13:e070530. [PMID: 36889826 PMCID: PMC10008460 DOI: 10.1136/bmjopen-2022-070530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
Abstract
INTRODUCTION Hyperkalaemia (HK) is a potentially life-threatening electrolyte imbalance associated with several adverse clinical outcomes. The efficacy and negative effects of currently existing treatment options have made HK management questionable. Sodium zirconium cyclosilicate (SZC), a novel highly selective potassium binder, is approved for the treatment of HK. The present study will be aimed to assess the safety, effectiveness and treatment patterns of SZC in Chinese patients with HK in a real-world clinical setting as it is required by China's drug review and approval process. METHODS AND ANALYSIS This is a multicentre, prospective cohort study which plans to enrol 1000 patients taking SZC or willing to take SZC from approximately 40 sites in China. Patients ≥18 years of age at the time of signing the written informed consent and with documented serum potassium levels ≥5.0 mmol/L within 1 year before study enrolment day will be included. Eligible patients will receive SZC treatment and will be followed up for 6 months from enrolment day. The primary objective will be to evaluate the safety of SZC for the management of HK in Chinese patients in terms of adverse events (AEs), serious AEs as well as discontinuation of SZC. The secondary objectives will include understanding the SZC dosage information in terms of its effectiveness and treatment patterns under real-world clinical practice and assessing effectiveness of SZC during the observational period. ETHICS AND DISSEMINATION This study protocol was approved by the Ethics Committee of the First Affiliated Hospital of Dalian Medical University (approval number: YJ-JG-YW-2020). All the participating sites have received the ethics approval. Results will be disseminated through national and international presentations and peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT05271266.
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Affiliation(s)
- Nan Shen
- Department of Nephrology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Qingyang Meng
- Department of Nephrology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Lihong Zhang
- Department of Nephrology, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hua Xie
- Department of Nephrology, Dalian Ruikaier Renal Disease Hospital, Dalian, China
| | - Jianrong Zhao
- Department of Nephrology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Changying Xing
- Department of Nephrology, Jiangsu Province Official Hospital, Nanjing, China
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Gang Long
- Department of Nephrology, Tianjin People's Hospital, Tianjin, China
| | - Qiang Zhu
- Department of Nephrology, Xinghua People's Hospital, Xinghua, China
| | - Chunyan Shan
- Department of Nephrology, Chu Hsien-I Memorial Hospital of Tianjin Medical University, Tianjin, China
| | - Xudong Cai
- Department of Nephrology, Ningbo Traditional Chinese Medicine Hospital, Ningbo, China
| | - Jing Yang
- Department of Nephrology, Hefei First People's Hospital, Hefei, China
| | - Xun Luo
- Department of Nephrology, Hunan Provincial People's Hospital, Changsha, China
| | - Jianmin Wang
- Department of Nephrology, Linfen Central Hospital, Linfen, China
| | - Jianming Ye
- Department of Nephrology, First People's Hospital of Kunshan, Kunshan, China
| | - Xin Wan
- Department of Nephrology, The First Hospital of Nanjing, Nanjing, China
| | - Shaojiang Tian
- Department of Nephrology, Shiyan People's Hospital, Shiyan, China
| | - Yifan Wu
- Department of Nephrology, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, China
| | - Yongqiang Lin
- Department of Nephrology, Wenzhou Integrated Chinese and Western Medicine Hospital, Wenzhou, China
| | - Xiaoyong Yu
- Department of Nephrology, Shanxi Provincial Hospital of Chinese Medicine, Xi'an, China
| | - Qing Li
- Department of Nephrology, Tianjin Teda Hospital, Tianjin, China
| | - Xinyu Liu
- Department of Nephrology, Nanyang Central Hospital, Nanyang, China
| | - Zhenwei Shi
- Department of Nephrology, The First Hospital of Tsinghua University, Beijing, China
| | - Jingwei Zhou
- Dongzhimen Hospital Beijing University of Chinese Medicine, Beijing, China
| | - Chunyan Liu
- Department of Nephrology, Second Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yanping Cao
- Department of Nephrology, Handan First Hospital, Handan, China
| | - Niansong Wang
- Department of Nephrology, The Sixth People's Hospital Affiliated to Medical College of Shanghai Jiaotong University, Shanghai, China
| | - Xinxin Jiang
- Department of Nephrology, Sandun District of Zhejiang Hospital, Hangzhou, China
| | - Henglan Wu
- Department of Nephrology, First Hospital of Jiaxing, Jiaxing, China
| | - Yao Hu
- Department of Nephrology, Clinical Medical College and Affiliated Hospital of Chengdu University, Chengdu, China
| | - Lu Li
- Department of Nephrology, Xi'an First Hospital Affiliated to Xi'an Medical University, Xi'an, China
| | - Zhaohua Wang
- Department of Nephrology, Taian City Central Hospital, Taian, China
| | - Jingdong He
- Department of Nephrology, Nuclear Industry 416 Hospital, Chengdu, China
| | - Juan Cao
- Department of Nephrology, Taixing People's Hospital, Taizhou, China
| | - Fenglei Wu
- Department of Nephrology, Qidong People's Hospital, Qidong, China
| | - Cong Ma
- Department of Nephrology, Anshan Central Hospital, Anshan, China
| | - Xun Yin
- Department of Nephrology, Changshu No 2 People's Hospital, Changshu, China
| | - Zhongxin Li
- Department of Nephrology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Huimin Wang
- Department of Nephrology, Liaoning Health Industry Group Bensteel General Hospital, Liaoning, China
| | - Hongli Lin
- Department of Nephrology, First Affiliated Hospital of Dalian Medical University, Dalian, China
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Nakayama T, Yamaguchi S, Hayashi K, Uchiyama K, Tajima T, Azegami T, Morimoto K, Yoshida T, Yoshino J, Monkawa T, Kanda T, Itoh H. Compared effectiveness of sodium zirconium cyclosilicate and calcium polystyrene sulfonate on hyperkalemia in patients with chronic kidney disease. Front Med (Lausanne) 2023; 10:1137981. [PMID: 36950508 PMCID: PMC10025387 DOI: 10.3389/fmed.2023.1137981] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/20/2023] [Indexed: 03/08/2023] Open
Abstract
Hyperkalemia is a well-recognized electrolyte abnormality in patients with chronic kidney disease (CKD). Potassium binders are often used to prevent and treat hyperkalemia. However, few studies have evaluated the difference in serum potassium (K+) level-lowering effect during the post-acute phase between the novel potassium binder, sodium zirconium cyclosilicate (ZSC), and conventional agents. This retrospective study included patients who received potassium binders (either ZSC or calcium polystyrene sulfonate [CPS]) in our hospital between May 2020 and July 2022. The patients were divided into the ZSC and CPS groups. After propensity score matching, we compared changes from baseline to the first follow-up point, at least 4 weeks after initiating potassium binders, in electrolytes including K+ level between the two groups. Of the 132 patients, ZSC and CPS were administered in 48 and 84 patients, respectively. After matching, 38 patients were allocated to each group. The ZSC group showed greater reduction in K+ levels than did the CPS group (P < 0.05). Moreover, a significant increase in serum sodium minus chloride levels, a surrogate marker for metabolic acidosis, was observed in the ZSC group (P < 0.05). Our results demonstrated that ZSC could potentially improve hyperkalemia and metabolic acidosis in patients with CKD.
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Affiliation(s)
- Takashin Nakayama
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Yamaguchi
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
- *Correspondence: Shintaro Yamaguchi
| | - Kaori Hayashi
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kiyotaka Uchiyama
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takaya Tajima
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuhiko Azegami
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
- Keio University Health Center, Yokohama, Japan
| | - Kohkichi Morimoto
- Apheresis and Dialysis Center, Keio University School of Medicine, Tokyo, Japan
| | - Tadashi Yoshida
- Apheresis and Dialysis Center, Keio University School of Medicine, Tokyo, Japan
| | - Jun Yoshino
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Toshiaki Monkawa
- Medical Education Center, Keio University School of Medicine, Tokyo, Japan
| | - Takeshi Kanda
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hiroshi Itoh
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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