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Zhang S, Ding Y, Feng F, Gao Y. The role of blood CXCL12 level in prognosis of coronary artery disease: A meta-analysis. Front Cardiovasc Med 2022; 9:938540. [PMID: 35966557 PMCID: PMC9363627 DOI: 10.3389/fcvm.2022.938540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 06/29/2022] [Indexed: 11/17/2022] Open
Abstract
Objective The role of C-X-C motif chemokine 12 (CXCL12) in atherosclerotic cardiovascular diseases (ASCVDs) has emerged as one of the research hotspots in recent years. Studies reported that the higher blood CXCL12 level was associated with increased major adverse cardiovascular events (MACEs), but the results were inconsistent. The objective of this study was to clarify the prognostic value of the blood CXCL12 level in patients with coronary artery disease (CAD) through meta-analysis. Methods All related studies about the association between the blood CXCL12 level and the prognosis of CAD were comprehensively searched and screened according to inclusion criteria and exclusion criteria. The quality of the included literature was evaluated using the Newcastle-Ottawa Scale (NOS). The heterogeneity test was conducted, and the pooled hazard risk (HR) or the odds ratio (OR) with a 95% confidence interval (CI) was calculated using the fixed-effect or random-effects model accordingly. Publication bias was evaluated using Begg's funnel plot and Egger's test. Sensitivity analysis and subgroup analysis were also conducted. Results A total of 12 original studies with 2,959 CAD subjects were included in the final data combination. The pooled data indicated a significant association between higher CXCL12 levels and MACEs both in univariate analysis (HR 5.23, 95% CI 2.48–11.04) and multivariate analysis (HR 2.53, 95% CI 2.03–3.16) in the CXCL12 level as the category variable group. In the CXCL12 level as the continuous variable group, the result also indicated that the higher CXCL12 level significantly predicted future MACEs (multivariate OR 1.55, 95% CI 1.02–2.35). Subgroup analysis of the CXCL12 level as the category variable group found significant associations in all acute coronary syndrome (ACS) (univariate HR 9.72, 95% CI 4.69–20.15; multivariate HR 2.47, 95% CI 1.79–3.40), non-ACS (univariate HR 2.73, 95% CI 1.65–4.54; multivariate HR 3.49, 95% CI 1.66–7.33), Asian (univariate HR 7.43, 95% CI 1.70–32.49; multivariate HR 2.21, 95% CI 1.71–2.85), Caucasian (univariate HR 3.90, 95% CI 2.73–5.57; multivariate HR 3.87, 95% CI 2.48–6.04), short-term (univariate HR 9.36, 95% CI 4.10–21.37; multivariate HR 2.72, 95% CI 1.97–3.76), and long-term (univariate HR 2.86, 95% CI 1.62–5.04; multivariate HR 2.38, 95% CI 1.76–3.22) subgroups. Subgroup analysis of the CXCL12 level as the continuous variable group found significant associations in non-ACS (multivariate OR 1.53, 95% CI 1.23–1.92), Caucasian (multivariate OR 3.83, 95% CI 1.44–10.19), and long-term (multivariate OR 1.62, 95% CI 1.37–1.93) subgroups, but not in ACS (multivariate OR 1.36, 95% CI 0.67–2.75), Asian (multivariate OR 1.40, 95% CI 0.91–2.14), and short-term (multivariate OR 1.16, 95% CI 0.28–4.76) subgroups. No significant publication bias was found in this meta-analysis. Conclusion The higher blood CXCL12 level is associated with increased MACEs in patients with CAD, and the blood CXCL12 level may serve as an important prognostic index for CAD. Integrating the blood CXCL12 level into CAD risk assessment tools may provide more comprehensive messages for evaluating and managing patients with CAD.
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Affiliation(s)
- Shunrong Zhang
- Department of Geriatrics, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yu Ding
- Central Laboratory, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Fei Feng
- Department of Geriatrics, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yue Gao
- Department of Geriatrics, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Yue Gao
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Marcos-Jubilar M, Orbe J, Roncal C, Machado FJD, Rodriguez JA, Fernández-Montero A, Colina I, Rodil R, Pastrana JC, Páramo JA. Association of SDF1 and MMP12 with Atherosclerosis and Inflammation: Clinical and Experimental Study. Life (Basel) 2021; 11:life11050414. [PMID: 34062730 PMCID: PMC8147178 DOI: 10.3390/life11050414] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 04/26/2021] [Accepted: 04/29/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Atherosclerosis is the main etiology of cardiovascular diseases (CVD), associated to systemic inflammation. Matrix metalloproteinases (MMPs) are related to atherosclerosis progression through the SDF1/CXCR4 axis promoting macrophages recruitment within the vascular wall. The goal was to assess new circulatory inflammatory markers in relation to atherosclerosis. METHODS Measurement of SDF1, MMP12 and CRP in blood samples of 298 prospective patients with cardiovascular risk. To explore atherosclerosis progression, CXCR4/SDF1 axis and MMP12 expression were determined by RT-qPCR and by immunohistochemistry in the aorta of accelerated and delayed atherosclerosis mice models (Apoe-/- and Apoe-/-Mmp10-/-). RESULTS SDF1, MMP12 and CRP were elevated in patients with clinical atherosclerosis, but after controlling by confounding factors, only SDF1 and CRP remained increased. Having high levels of both biomarkers showed 2.8-fold increased risk of presenting clinical atherosclerosis (p = 0.022). Patients with elevated SDF1, MMP12 and CRP showed increased risk of death in follow-up (HR = 3.2, 95%CI: 1.5-7.0, p = 0.004). Gene and protein expression of CXCR4 and MMP12 were increased in aortas from Apoe-/- mice. CONCLUSIONS The combination of high circulating SDF1, MMP12 and CRP identified patients with particular inflammatory cardiovascular risk and increased mortality. SDF1/CXCR4 axis and MMP12 involvement in atherosclerosis development suggests that they could be possible atherosclerotic targets.
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Affiliation(s)
- María Marcos-Jubilar
- Haematology Service, Clínica Universidad de Navarra, 31008 Pamplona, Spain
- Correspondence: (M.M.-J.); (J.A.P.)
| | - Josune Orbe
- Laboratory of Atherothrombosis, Program of Cardiovascular Diseases, Cima Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, 31008 Pamplona, Spain; (J.O.); (C.R.); (F.J.D.M.); (J.A.R.)
- CIBERCV, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Carmen Roncal
- Laboratory of Atherothrombosis, Program of Cardiovascular Diseases, Cima Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, 31008 Pamplona, Spain; (J.O.); (C.R.); (F.J.D.M.); (J.A.R.)
- CIBERCV, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Florencio J. D. Machado
- Laboratory of Atherothrombosis, Program of Cardiovascular Diseases, Cima Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, 31008 Pamplona, Spain; (J.O.); (C.R.); (F.J.D.M.); (J.A.R.)
| | - José Antonio Rodriguez
- Laboratory of Atherothrombosis, Program of Cardiovascular Diseases, Cima Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, 31008 Pamplona, Spain; (J.O.); (C.R.); (F.J.D.M.); (J.A.R.)
- CIBERCV, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | | | - Inmaculada Colina
- Internal Medicine Department, Clínica Universidad de Navarra, 31008 Pamplona, Spain; (I.C.); (J.C.P.)
| | - Raquel Rodil
- Internal Medicine Department, Complejo Hospitalario de Navarra, 31008 Pamplona, Spain;
| | - Juan C. Pastrana
- Internal Medicine Department, Clínica Universidad de Navarra, 31008 Pamplona, Spain; (I.C.); (J.C.P.)
| | - José A. Páramo
- Haematology Service, Clínica Universidad de Navarra, 31008 Pamplona, Spain
- Laboratory of Atherothrombosis, Program of Cardiovascular Diseases, Cima Universidad de Navarra, Instituto de Investigación Sanitaria de Navarra, 31008 Pamplona, Spain; (J.O.); (C.R.); (F.J.D.M.); (J.A.R.)
- CIBERCV, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence: (M.M.-J.); (J.A.P.)
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Peiró ÓM, Farré N, Cediel G, Bonet G, Rojas S, Quintern V, Bardají A. Stromal cell derived factor-1 and long-term prognosis in acute coronary syndrome. Biomark Med 2019; 13:1187-1198. [PMID: 31559838 DOI: 10.2217/bmm-2019-0133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To explore long-term prognostic value of SDF-1 in acute coronary syndrome (ACS). Materials & methods: We included 254 patients with ACS. Plasma SDF-1 was measured and patients were classified into tertiles of SDF-1. Results: Multivariate analysis showed third tertile of SDF-1 as an independent predictor of all-cause death (HR: 2.5; 95% CI: 1.2-5.2; p = 0.011) and the composite of major adverse cardiovascular and cerebrovascular events (HR: 1.8; 95% CI: 1.1-3.1; p = 0.031). SDF-1 added to a clinical model can improve all-cause death prediction (net reclassification improvement 0.362; 95% CI: 0.423-0.681; p = 0.027). Conclusion: SDF-1 is an independent predictor of all-cause mortality and major adverse cardiovascular and cerebrovascular events in long-term follow-up of patients with ACS and adds prognostic information beyond traditional cardiovascular risks factors.
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Affiliation(s)
- Óscar M Peiró
- Department of Cardiology, Joan XXIII University Hospital, Tarragona, Spain.,Pere Virgili Health Research Institute, Rovira i Virgili University, Tarragona, Spain
| | - Nuria Farré
- Heart Failure Unit, Department of Cardiology, Hospital del Mar, Barcelona, Spain.,Heart Diseases Biomedical Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - German Cediel
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Gil Bonet
- Department of Cardiology, Joan XXIII University Hospital, Tarragona, Spain.,Pere Virgili Health Research Institute, Rovira i Virgili University, Tarragona, Spain
| | - Sergio Rojas
- Department of Cardiology, Joan XXIII University Hospital, Tarragona, Spain.,Pere Virgili Health Research Institute, Rovira i Virgili University, Tarragona, Spain
| | - Verónica Quintern
- Department of Cardiology, Joan XXIII University Hospital, Tarragona, Spain.,Pere Virgili Health Research Institute, Rovira i Virgili University, Tarragona, Spain
| | - Alfredo Bardají
- Department of Cardiology, Joan XXIII University Hospital, Tarragona, Spain.,Pere Virgili Health Research Institute, Rovira i Virgili University, Tarragona, Spain
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The homing of bone marrow stem cells is differentially activated in ischemic and valvular heart diseases and influenced by beta-blockers. J Transl Med 2018; 16:133. [PMID: 29784000 PMCID: PMC5963100 DOI: 10.1186/s12967-018-1520-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 05/16/2018] [Indexed: 12/24/2022] Open
Abstract
Background Cell homing is the mechanism by which an injury releases signaling molecules that cause recruitment, proliferation, migration and differentiation of progenitor cells. Stromal derived factor-1 (SDF-1) and its receptor CXCR4 are key molecules involved in homing and little is known about their activation in cardiopathies. Here, we assessed the homing activation status of bone marrow cells (BMC) concerning the SDF-1 and CXCR4 expression in ischemic (IHD) and valvular (VHD) heart diseases. Methods The SDF-1 and inflammatory profile were analyzed by ELISA from plasma obtained bone marrow of ischemic heart patients (IHD, n = 41), valvular heart patients (VHD, n = 30) and healthy controls (C, n = 9). Flow cytometry was used to evaluate CXCR4 (CD184) expression on the surface of bone marrow cells, and the CXCR4 expression was estimated by real-time quantitative PCR. Results The SDF-1 levels in the groups IHD, VHD and control were, respectively, 230, 530 and 620 pg/mL (P = 0.483), and was decreased in VHD patients using beta-blockers (263 pg/mL) when compared with other (844 pg/mL) (P = 0.023). Compared with IHD, the VHD group showed higher CXCR4 (P = 0.071) and CXCR7 (P = 0.082) mRNA expression although no difference in the level of CXCR4+ bone marrow cells was found between groups (P = 0.360). Conclusion In conclusion, pathophysiological differences between IHD and VHD can affect the molecules involved in the activation of homing. In addition, the use of beta-blockers appears to interfere in this mechanism, a fact that should be considered in protocols that use BMC.
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Yoshizaki T, Uematsu M, Obata JE, Nakamura T, Fujioka D, Watanabe K, Nakamura K, Kugiyama K. Angiotensin II receptor blockers suppress the release of stromal cell-derived factor-1α from infarcted myocardium in patients with acute myocardial infarction. J Cardiol 2017; 71:367-374. [PMID: 29129394 DOI: 10.1016/j.jjcc.2017.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 09/08/2017] [Accepted: 10/02/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Although angiotensin II receptor blockers (ARBs) have been shown to have anti-inflammatory effects on infarcted myocardium in experimental models, little is known in humans. Stromal cell-derived factor-1α (SDF-1α), a pro-inflammatory chemokine, is released from infarcted tissue in patients with acute myocardial infarction (AMI). This study examined whether ARBs suppress SDF-1α production in the infarcted lesion in patients with AMI. METHODS SDF-1α levels were measured by enzyme-linked immunosorbent assays in plasma obtained from the aortic root (AO) and the anterior interventricular vein (AIV) in 50 patients with an anterior AMI. Measurement of SDF-1α levels and left ventriculography were repeated at discharge and 6 months after AMI. Patients were divided into 2 groups according to treatment with ARBs, which were administered at the discretion of the attending physician after admission. RESULTS The AIV-AO gradient of SDF-1α, reflecting SDF-1α release from the infarcted myocardial region, decreased between the time of discharge and 6 months after AMI in patients taking an ARB. In contrast, the SDF-1α transcardiac gradient did not change in patients not taking an ARB. Among the clinical parameters tested, only the use of ARBs was significantly associated with percent changes in the SDF-1α transcardiac gradient from the time of discharge to 6 months after AMI in a linear regression analysis (r=-0.31, p=0.03). The SDF-1α transcardiac gradient 6 months after AMI was inversely correlated with the percent change in left ventricular (LV) ejection fraction (r=-0.52, p<0.01) and positively correlated with the percent change in LV end-diastolic volume index (r=0.57, p<0.01) and LV end-systolic volume index (r=0.54, p<0.01) during 6 months after AMI. CONCLUSIONS ARB treatment suppressed SDF-1α release from the infarcted myocardial region, which was associated with improvement in LV dysfunction and adverse remodeling in AMI survivors.
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Affiliation(s)
- Toru Yoshizaki
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
| | - Manabu Uematsu
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
| | - Jun-Ei Obata
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
| | - Takamitsu Nakamura
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
| | - Daisuke Fujioka
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
| | - Kazuhiro Watanabe
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
| | - Kazuto Nakamura
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
| | - Kiyotaka Kugiyama
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan.
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Bromage DI, Taferner S, Pillai M, Yellon DM, Davidson SM. A novel recombinant antibody specific to full-length stromal derived factor-1 for potential application in biomarker studies. PLoS One 2017; 12:e0174447. [PMID: 28379992 PMCID: PMC5381782 DOI: 10.1371/journal.pone.0174447] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 03/09/2017] [Indexed: 11/21/2022] Open
Abstract
Background Stromal derived factor-1α (SDF-1α/CXCL12) is a chemokine that is up-regulated in diseases characterised by tissue hypoxia, including myocardial infarction, ischaemic cardiomyopathy and remote ischaemic conditioning (RIC), a technique of cyclical, non-injurious ischaemia applied remote from the heart that protects the heat from lethal ischaemia-reperfusion injury. Accordingly, there is considerable interest in SDF-1α as a potential biomarker of such conditions. However, SDF-1α is rapidly degraded and inactivated by dipeptidyl peptidase 4 and other peptidases, and the kinetics of intact SDF-1α remain unknown. Methods & results To facilitate investigation of full-length SDF-1α we established an ELISA using a novel recombinant human antibody we developed called HCI.SDF1. HCI.SDF1 is specific to the N-terminal sequence of all isoforms of SDF-1 and has a comparable KD to commercially available antibodies. Together with a detection antibody specific to the α-isoform, HCI.SDF1 was used to specifically quantify full-length SDF-1α in blood for the first time. Using RIC applied to the hind limb of Sprague-Dawley rats or the arms of healthy human volunteers, we demonstrate an increase in SDF-1α using a commercially available antibody, as previously reported, but an unexpected decrease in full-length SDF-1α after RIC in both species. Conclusions We report for the first time the development of a novel recombinant antibody specific to full-length SDF-1. Applied to RIC, we demonstrate a significant decrease in SDF-1α that is at odds with the literature and suggests a need to investigate the kinetics of full-length SDF-1α in conditions characterised by tissue hypoxia.
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Affiliation(s)
- Daniel I. Bromage
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - Stasa Taferner
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - Mahesh Pillai
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - Derek M. Yellon
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - Sean M. Davidson
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
- * E-mail:
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Matsuoka S, Uematsu M, Nakamura T, Shimizu T, Futamata M, Obata JE, Fujioka D, Nakamura K, Yoshizaki T, Kugiyama K. High levels of stromal cell-derived factor-1α predict secondary cardiac events in stable patients with a history of myocardial infarction. J Cardiol 2017; 69:320-325. [DOI: 10.1016/j.jjcc.2016.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 06/23/2016] [Accepted: 06/24/2016] [Indexed: 10/21/2022]
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Uematsu M, Yoshizaki T, Shimizu T, Obata JE, Nakamura T, Fujioka D, Watanabe K, Watanabe Y, Kugiyama K. Sustained myocardial production of stromal cell-derived factor-1α was associated with left ventricular adverse remodeling in patients with myocardial infarction. Am J Physiol Heart Circ Physiol 2015; 309:H1764-71. [PMID: 26408542 DOI: 10.1152/ajpheart.00493.2015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 09/23/2015] [Indexed: 11/22/2022]
Abstract
The role of stromal cell-derived factor-1α (SDF-1α) expressed in infarcted myocardium is unknown in humans. We examined whether SDF-1α produced in an infarcted myocardial lesion may play a role in left ventricle (LV) remodeling and dysfunction in patients with acute myocardial infarction (AMI). We measured SDF-1α levels in plasma obtained from aortic root (AO) and anterior interventricular vein (AIV) in the early phase (2 wk after MI) and the chronic phase (6 mo after MI) in 80 patients with anterior MI. An increment in SDF-1α level from AO to AIV, reflecting SDF-1α release from infarcted myocardium, was more frequent in patients with MI in the early phase of MI [n = 52 (65%), P = 0.03] but not in the chronic phase of MI [n = 46 (58%), P = 0.11] compared with that in control patients [n = 6/17 (35%)]. On linear regression analysis, the transmyocardial gradient in SDF-1α level in the chronic phase of MI was correlated with percentage changes in LV end-diastolic volume index (r = 0.39, P < 0.001), LV end-systolic volume index (r = 0.38, P < 0.001), and LV ejection fraction (r = -0.26, P = 0.01) 6 mo after AMI. By contrast, the transmyocardial gradient of SDF-1α in the early phase of MI had no significant correlations. In conclusion, the production of SDF-1α in infarcted myocardium in the chronic phase of MI was associated with LV adverse remodeling and progressive dysfunction in AMI survivors.
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Affiliation(s)
- Manabu Uematsu
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
| | - Toru Yoshizaki
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
| | - Takuya Shimizu
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
| | - Jun-ei Obata
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
| | - Takamitsu Nakamura
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
| | - Daisuke Fujioka
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
| | - Kazuhiro Watanabe
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
| | - Yosuke Watanabe
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
| | - Kiyotaka Kugiyama
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
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