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Sang Y, Niu C, Xu J, Zhu T, You S, Wang J, Zhang L, Du X, Zhang H. PI4KIIIβ-Mediated Phosphoinositides Metabolism Regulates Function of the VTA Dopaminergic Neurons and Depression-Like Behavior. J Neurosci 2024; 44:e0555232024. [PMID: 38267258 PMCID: PMC10941068 DOI: 10.1523/jneurosci.0555-23.2024] [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: 03/27/2023] [Revised: 12/18/2023] [Accepted: 01/11/2024] [Indexed: 01/26/2024] Open
Abstract
Phosphoinositides, including phosphatidylinositol-4,5-bisphosphate (PIP2), play a crucial role in controlling key cellular functions such as membrane and vesicle trafficking, ion channel, and transporter activity. Phosphatidylinositol 4-kinases (PI4K) are essential enzymes in regulating the turnover of phosphoinositides. However, the functional role of PI4Ks and mediated phosphoinositide metabolism in the central nervous system has not been fully revealed. In this study, we demonstrated that PI4KIIIβ, one of the four members of PI4Ks, is an important regulator of VTA dopaminergic neuronal activity and related depression-like behavior of mice by controlling phosphoinositide turnover. Our findings provide new insights into possible mechanisms and potential drug targets for neuropsychiatric diseases, including depression. Both sexes were studied in basic behavior tests, but only male mice could be used in the social defeat depression model.
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Affiliation(s)
- Yuqi Sang
- Department of Pharmacology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of Neural and Vascular Biology, Ministry of Education, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of New Drug Pharmacology and Toxicology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- Collaborative Innovation Center of Hebei Province for Mechanism, Diagnosis and Treatment of Neuropsychiatric Diseases, Hebei Medical University, Shijiazhuang, Hebei 050011, China
| | - Chenxu Niu
- Department of Pharmacology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of Neural and Vascular Biology, Ministry of Education, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of New Drug Pharmacology and Toxicology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- Collaborative Innovation Center of Hebei Province for Mechanism, Diagnosis and Treatment of Neuropsychiatric Diseases, Hebei Medical University, Shijiazhuang, Hebei 050011, China
| | - Jiaxi Xu
- Department of Pharmacology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- Department of Physiology and Pathophysiology, Xi'an Jiaotong University Health Science Center, Xi'an, Shanxi 710061, China
| | - Tiantian Zhu
- Department of Pharmacology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of Neural and Vascular Biology, Ministry of Education, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of New Drug Pharmacology and Toxicology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- Collaborative Innovation Center of Hebei Province for Mechanism, Diagnosis and Treatment of Neuropsychiatric Diseases, Hebei Medical University, Shijiazhuang, Hebei 050011, China
| | - Shuangzhu You
- Department of Pharmacology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of Neural and Vascular Biology, Ministry of Education, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of New Drug Pharmacology and Toxicology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- Collaborative Innovation Center of Hebei Province for Mechanism, Diagnosis and Treatment of Neuropsychiatric Diseases, Hebei Medical University, Shijiazhuang, Hebei 050011, China
| | - Jing Wang
- Department of Pharmacology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of Neural and Vascular Biology, Ministry of Education, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of New Drug Pharmacology and Toxicology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- Collaborative Innovation Center of Hebei Province for Mechanism, Diagnosis and Treatment of Neuropsychiatric Diseases, Hebei Medical University, Shijiazhuang, Hebei 050011, China
| | - Ludi Zhang
- Department of Pharmacology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of Neural and Vascular Biology, Ministry of Education, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of New Drug Pharmacology and Toxicology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- Collaborative Innovation Center of Hebei Province for Mechanism, Diagnosis and Treatment of Neuropsychiatric Diseases, Hebei Medical University, Shijiazhuang, Hebei 050011, China
| | - Xiaona Du
- Department of Pharmacology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of Neural and Vascular Biology, Ministry of Education, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of New Drug Pharmacology and Toxicology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- Collaborative Innovation Center of Hebei Province for Mechanism, Diagnosis and Treatment of Neuropsychiatric Diseases, Hebei Medical University, Shijiazhuang, Hebei 050011, China
| | - Hailin Zhang
- Department of Pharmacology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of Neural and Vascular Biology, Ministry of Education, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- The Key Laboratory of New Drug Pharmacology and Toxicology, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- Collaborative Innovation Center of Hebei Province for Mechanism, Diagnosis and Treatment of Neuropsychiatric Diseases, Hebei Medical University, Shijiazhuang, Hebei 050011, China
- Department of Psychiatry, The First Hospital of Hebei Medical University, Mental Health Institute of Hebei Medical University, Shijiazhuang, Hebei 050000, China
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2
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Curry RN, Aiba I, Meyer J, Lozzi B, Ko Y, McDonald MF, Rosenbaum A, Cervantes A, Huang-Hobbs E, Cocito C, Greenfield JP, Jalali A, Gavvala J, Mohila C, Serin Harmanci A, Noebels J, Rao G, Deneen B. Glioma epileptiform activity and progression are driven by IGSF3-mediated potassium dysregulation. Neuron 2023; 111:682-695.e9. [PMID: 36787748 PMCID: PMC9991983 DOI: 10.1016/j.neuron.2023.01.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/11/2022] [Accepted: 01/17/2023] [Indexed: 02/15/2023]
Abstract
Seizures are a frequent pathophysiological feature of malignant glioma. Recent studies implicate peritumoral synaptic dysregulation as a driver of brain hyperactivity and tumor progression; however, the molecular mechanisms that govern these phenomena remain elusive. Using scRNA-seq and intraoperative patient ECoG recordings, we show that tumors from seizure patients are enriched for gene signatures regulating synapse formation. Employing a human-to-mouse in vivo functionalization pipeline to screen these genes, we identify IGSF3 as a mediator of glioma progression and dysregulated neural circuitry that manifests as spreading depolarization (SD). Mechanistically, we discover that IGSF3 interacts with Kir4.1 to suppress potassium buffering and found that seizure patients exhibit reduced expression of potassium handlers in proliferating tumor cells. In vivo imaging reveals that dysregulated synaptic activity emanates from the tumor-neuron interface, which we confirm in patients. Our studies reveal that tumor progression and seizures are enabled by ion dyshomeostasis and identify SD as a driver of disease.
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Affiliation(s)
- Rachel Naomi Curry
- The Integrative Molecular and Biomedical Sciences Graduate Program, Baylor College of Medicine, Houston, TX 77030, USA; Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX 77030, USA; Center for Cancer Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA
| | - Isamu Aiba
- Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Jochen Meyer
- Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Brittney Lozzi
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX 77030, USA; Center for Cancer Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA; Program in Genetics and Genomics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Yeunjung Ko
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX 77030, USA; Center for Cancer Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA; Program in Immunology and Microbiology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Malcolm Ford McDonald
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX 77030, USA; Center for Cancer Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA; Program in Development, Disease, Models, and Therapeutics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Anna Rosenbaum
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX 77030, USA; Center for Cancer Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA
| | - Alexis Cervantes
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX 77030, USA; Center for Cancer Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA
| | - Emmet Huang-Hobbs
- The Integrative Molecular and Biomedical Sciences Graduate Program, Baylor College of Medicine, Houston, TX 77030, USA; Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX 77030, USA; Center for Cancer Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA
| | - Carolina Cocito
- Department of Pediatric Neurological Surgery, Weill Cornell Medicine, New York, NY 10065, USA
| | | | - Ali Jalali
- Center for Cancer Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA; Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Jay Gavvala
- Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Carrie Mohila
- Department of Pathology, Texas Children's Hospital, Houston, TX 77030, USA
| | - Akdes Serin Harmanci
- Center for Cancer Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA; Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Jeffrey Noebels
- Center for Cancer Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA; Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Ganesh Rao
- Center for Cancer Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA; Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Benjamin Deneen
- The Integrative Molecular and Biomedical Sciences Graduate Program, Baylor College of Medicine, Houston, TX 77030, USA; Center for Cell and Gene Therapy, Baylor College of Medicine, Houston, TX 77030, USA; Center for Cancer Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA; Program in Development, Disease, Models, and Therapeutics, Baylor College of Medicine, Houston, TX 77030, USA; Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030, USA.
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Ehtesham N, Mosallaei M, Beheshtian M, Khoshbakht S, Fadaee M, Vazehan R, Faraji Zonooz M, Karimzadeh P, Kahrizi K, Najmabadi H. Characterizing Genotypes and Phenotypes Associated with Dysfunction of Channel-Encoding Genes in a Cohort of Patients with Intellectual Disability. ARCHIVES OF IRANIAN MEDICINE 2022; 25:788-797. [PMID: 37543906 PMCID: PMC10685845 DOI: 10.34172/aim.2022.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/20/2021] [Indexed: 08/08/2023]
Abstract
BACKGROUND Ion channel dysfunction in the brain can lead to impairment of neuronal membranes and generate several neurological diseases, especially neurodevelopmental disorders. METHODS In this study, we set out to delineate the genotype and phenotype spectrums of 14 Iranian patients from 7 families with intellectual disability (ID) and/or developmental delay (DD) in whom genetic mutations were identified by next-generation sequencing (NGS) in 7 channel-encoding genes: KCNJ10, KCNQ3, KCNK6, CACNA1C, CACNA1G, SCN8A, and GRIN2B. Moreover, the data of 340 previously fully reported ID and/or DD cases with a mutation in any of these seven genes were combined with our patients to clarify the genotype and phenotype spectrum in this group. RESULTS In total, the most common phenotypes in 354 cases with ID/DD in whom mutation in any of these 7 channel-encoding genes was identified were as follows: ID (77.4%), seizure (69.8%), DD (59.8%), behavioral abnormality (29.9%), hypotonia (21.7%), speech disorder (21.5%), gait disturbance (20.9%), and ataxia (20.3%). Electroencephalography abnormality (33.9%) was the major brain imaging abnormality. CONCLUSION The results of this study broaden the molecular spectrum of channel pathogenic variants associated with different clinical presentations in individuals with ID and/or DD.
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Affiliation(s)
- Naeim Ehtesham
- Genetics Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Meysam Mosallaei
- Genetics Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Maryam Beheshtian
- Genetics Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Shahrouz Khoshbakht
- Genetics Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Mahsa Fadaee
- Kariminejad – Najmabadi Pathology & Genetics Center, Tehran, Iran
| | - Raheleh Vazehan
- Kariminejad – Najmabadi Pathology & Genetics Center, Tehran, Iran
| | | | - Parvaneh Karimzadeh
- Department of Pediatric Neurology, School of Medicine, Pediatric Neurology Research Center, Mofid Children’s Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Kimia Kahrizi
- Genetics Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Hossein Najmabadi
- Genetics Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
- Kariminejad – Najmabadi Pathology & Genetics Center, Tehran, Iran
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Lo J, Forst AL, Warth R, Zdebik AA. EAST/SeSAME Syndrome and Beyond: The Spectrum of Kir4.1- and Kir5.1-Associated Channelopathies. Front Physiol 2022; 13:852674. [PMID: 35370765 PMCID: PMC8965613 DOI: 10.3389/fphys.2022.852674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/08/2022] [Indexed: 12/13/2022] Open
Abstract
In 2009, two groups independently linked human mutations in the inwardly rectifying K+ channel Kir4.1 (gene name KCNJ10) to a syndrome affecting the central nervous system (CNS), hearing, and renal tubular salt reabsorption. The autosomal recessive syndrome has been named EAST (epilepsy, ataxia, sensorineural deafness, and renal tubulopathy) or SeSAME syndrome (seizures, sensorineural deafness, ataxia, intellectual disability, and electrolyte imbalance), accordingly. Renal dysfunction in EAST/SeSAME patients results in loss of Na+, K+, and Mg2+ with urine, activation of the renin-angiotensin-aldosterone system, and hypokalemic metabolic alkalosis. Kir4.1 is highly expressed in affected organs: the CNS, inner ear, and kidney. In the kidney, it mostly forms heteromeric channels with Kir5.1 (KCNJ16). Biallelic loss-of-function mutations of Kir5.1 can also have disease significance, but the clinical symptoms differ substantially from those of EAST/SeSAME syndrome: although sensorineural hearing loss and hypokalemia are replicated, there is no alkalosis, but rather acidosis of variable severity; in contrast to EAST/SeSAME syndrome, the CNS is unaffected. This review provides a framework for understanding some of these differences and will guide the reader through the growing literature on Kir4.1 and Kir5.1, discussing the complex disease mechanisms and the variable expression of disease symptoms from a molecular and systems physiology perspective. Knowledge of the pathophysiology of these diseases and their multifaceted clinical spectrum is an important prerequisite for making the correct diagnosis and forms the basis for personalized therapies.
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Affiliation(s)
- Jacky Lo
- Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Anna-Lena Forst
- Medical Cell Biology, Institute of Physiology, University of Regensburg, Regensburg, Germany
| | - Richard Warth
- Medical Cell Biology, Institute of Physiology, University of Regensburg, Regensburg, Germany
| | - Anselm A. Zdebik
- Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
- Centre for Nephrology, University College London, London, United Kingdom
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5
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Kinboshi M, Ikeda A, Ohno Y. Role of Astrocytic Inwardly Rectifying Potassium (Kir) 4.1 Channels in Epileptogenesis. Front Neurol 2020; 11:626658. [PMID: 33424762 PMCID: PMC7786246 DOI: 10.3389/fneur.2020.626658] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/08/2020] [Indexed: 12/25/2022] Open
Abstract
Astrocytes regulate potassium and glutamate homeostasis via inwardly rectifying potassium (Kir) 4.1 channels in synapses, maintaining normal neural excitability. Numerous studies have shown that dysfunction of astrocytic Kir4.1 channels is involved in epileptogenesis in humans and animal models of epilepsy. Specifically, Kir4.1 channel inhibition by KCNJ10 gene mutation or expressional down-regulation increases the extracellular levels of potassium ions and glutamate in synapses and causes hyperexcitation of neurons. Moreover, recent investigations demonstrated that inhibition of Kir4.1 channels facilitates the expression of brain-derived neurotrophic factor (BDNF), an important modulator of epileptogenesis, in astrocytes. In this review, we summarize the current understanding on the role of astrocytic Kir4.1 channels in epileptogenesis, with a focus on functional and expressional changes in Kir4.1 channels and their regulation of BDNF secretion. We also discuss the potential of Kir4.1 channels as a therapeutic target for the prevention of epilepsy.
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Affiliation(s)
- Masato Kinboshi
- Department of Pharmacology, Osaka University of Pharmaceutical Sciences, Takatsuki, Japan.,Department of Epilepsy, Movement Disorders and Physiology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akio Ikeda
- Department of Epilepsy, Movement Disorders and Physiology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yukihiro Ohno
- Department of Pharmacology, Osaka University of Pharmaceutical Sciences, Takatsuki, Japan
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Morin M, Forst AL, Pérez-Torre P, Jiménez-Escrig A, Barca-Tierno V, García-Galloway E, Warth R, Lopez-Sendón Moreno JL, Moreno-Pelayo MA. Novel mutations in the KCNJ10 gene associated to a distinctive ataxia, sensorineural hearing loss and spasticity clinical phenotype. Neurogenetics 2020; 21:135-143. [PMID: 32062759 DOI: 10.1007/s10048-020-00605-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 02/01/2020] [Indexed: 12/31/2022]
Abstract
KCNJ10 encodes the inward-rectifying potassium channel (Kir4.1) that is expressed in the brain, inner ear, and kidney. Loss-of-function mutations in KCNJ10 gene cause a complex syndrome consisting of epilepsy, ataxia, intellectual disability, sensorineural deafness, and tubulopathy (EAST/SeSAME syndrome). Patients with EAST/SeSAME syndrome display renal salt wasting and electrolyte imbalance that resemble the clinical features of impaired distal tubular salt transport in Gitelman's syndrome. A key distinguishing feature between these two conditions is the additional neurological (extrarenal) manifestations found in EAST/SeSAME syndrome. Recent reports have further expanded the clinical and mutational spectrum of KCNJ10-related disorders including non-syndromic early-onset cerebellar ataxia. Here, we describe a kindred of three affected siblings with early-onset ataxia, deafness, and progressive spasticity without other prominent clinical features. By using targeted next-generation sequencing, we have identified two novel missense variants, c.488G>A (p.G163D) and c.512G>A (p.R171Q), in the KCNJ10 gene that, in compound heterozygosis, cause this distinctive EAST/SeSAME phenotype in our family. Electrophysiological characterization of these two variants confirmed their pathogenicity. When expressed in CHO cells, the R171Q mutation resulted in 50% reduction of currents compared to wild-type KCNJ10 and G163D showed a complete loss of function. Co-expression of G163D and R171Q had a more pronounced effect on currents and membrane potential than R171Q alone but less severe than single expression of G163D. Moreover, the effect of the mutations seemed less pronounced in the presence of Kir5.1 (encoded by KCNJ16), with whom the renal Kir4.1 channels form heteromers. This partial functional rescue by co-expression with Kir5.1 might explain the lack of renal symptoms in the patients. This report illustrates that a spectrum of disorders with distinct clinical symptoms may result from mutations in different parts of KCNJ10, a gene initially associated only with the EAST/SeSAME syndrome.
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Affiliation(s)
- Matias Morin
- Servicio de Genética, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) and Hospital Universitario Ramón y Cajal, CIBERER, 28034, Madrid, Spain
| | - Anna-Lena Forst
- Medical Cell Biology, University of Regensburg, 93053, Regensburg, Germany
| | - Paula Pérez-Torre
- Servicio de Neurología, Hospital Universitario Ramón y Cajal, 28034, Madrid, Spain
| | | | - Verónica Barca-Tierno
- Servicio de Genética, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) and Hospital Universitario Ramón y Cajal, CIBERER, 28034, Madrid, Spain
| | - Eva García-Galloway
- Servicio de Genética, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) and Hospital Universitario Ramón y Cajal, CIBERER, 28034, Madrid, Spain
| | - Richard Warth
- Medical Cell Biology, University of Regensburg, 93053, Regensburg, Germany
| | | | - Miguel Angel Moreno-Pelayo
- Servicio de Genética, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS) and Hospital Universitario Ramón y Cajal, CIBERER, 28034, Madrid, Spain.
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