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Leask MP, Crișan TO, Ji A, Matsuo H, Köttgen A, Merriman TR. The pathogenesis of gout: molecular insights from genetic, epigenomic and transcriptomic studies. Nat Rev Rheumatol 2024; 20:510-523. [PMID: 38992217 DOI: 10.1038/s41584-024-01137-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2024] [Indexed: 07/13/2024]
Abstract
The pathogenesis of gout involves a series of steps beginning with hyperuricaemia, followed by the deposition of monosodium urate crystal in articular structures and culminating in an innate immune response, mediated by the NLRP3 inflammasome, to the deposited crystals. Large genome-wide association studies (GWAS) of serum urate levels initially identified the genetic variants with the strongest effects, mapping mainly to genes that encode urate transporters in the kidney and gut. Other GWAS highlighted the importance of uncommon genetic variants. More recently, genetic and epigenetic genome-wide studies have revealed new pathways in the inflammatory process of gout, including genetic associations with epigenomic modifiers. Epigenome-wide association studies are also implicating epigenomic remodelling in gout, which perhaps regulates the responsiveness of the innate immune system to monosodium urate crystals. Notably, genes implicated in gout GWAS do not include those encoding components of the NLRP3 inflammasome itself, but instead include genes encoding molecules involved in its regulation. Knowledge of the molecular mechanisms underlying gout has advanced through the translation of genetic associations into specific molecular mechanisms. Notable examples include ABCG2, HNF4A, PDZK1, MAF and IL37. Current genetic studies are dominated by participants of European ancestry; however, studies focusing on other population groups are discovering informative population-specific variants associated with gout.
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Affiliation(s)
- Megan P Leask
- Department of Physiology, University of Otago, Dunedin, Aotearoa, New Zealand
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tania O Crișan
- Department of Medical Genetics, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Aichang Ji
- Affiliated Hospital of Qingdao University, Qingdao University, Qingdao, China
| | - Hirotaka Matsuo
- Department of Integrative Physiology and Bio-Nano Medicine, National Defense Medical College, Saitama, Japan
| | - Anna Köttgen
- Institute of Genetic Epidemiology, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Tony R Merriman
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA.
- Department of Microbiology and Immunology, University of Otago, Dunedin, Aotearoa, New Zealand.
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Yang Y, Wu Z, An Z, Li S. Association between oxidative balance score and serum uric acid and hyperuricemia: a population-based study from the NHANES (2011-2018). Front Endocrinol (Lausanne) 2024; 15:1414075. [PMID: 38966221 PMCID: PMC11222604 DOI: 10.3389/fendo.2024.1414075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 06/07/2024] [Indexed: 07/06/2024] Open
Abstract
Background Oxidative Balance Score (OBS) is a novel indicator of the overall antioxidant/oxidant balance, providing a comprehensive reflection of the body's overall oxidative stress status, with higher OBS suggesting more substantial antioxidant exposures. We aimed to investigate the possible relationship between OBS with serum uric acid (SUA) and hyperuricemia. Methods Data utilized in this study were sourced from the 2011-2018 National Health and Nutrition Examination Survey (NHANES). Participants under 18 years old, those with ≤16 complete data out of 20 OBS components, incomplete serum uric acid data, and missing covariates were excluded from the analysis. OBS was computed by evaluating 16 nutrients and 4 lifestyle factors, encompassing 5 pro-oxidants and 15 antioxidants, guided by a priori knowledge of their relationship with oxidative stress. Results A total of 1,5096 individuals were included in our analysis with 49.7% being male, and an average age of 49.05 ± 17.56 years. The mean OBS was 19.76 ± 7.17. Hyperuricemia was present in 19.28% of participants. Due to the right-skewed distribution of the OBS, a natural log transformation was applied to address this issue, and Quartiles of lnOBS 1, 2, 3, and 4 were 1.10-2.56 (N=3526), 2.64-2.94 (N=3748), 3.00-3.22 (N=4026), and 3.26-3.61 (N=3796), respectively. Multivariable logistic regression showed that higher lnOBS quantiles were correlated with lower serum uric acid levels. Compared with the lowest lnOBS quantile, participants in the highest lnOBS quantile had a significant serum uric acid decrease of 16.94 μmol/L for each unit increase in lnOBS (β=-16.94, 95% CI: -20.44, -13.45). Similar negative associations were observed in the second-highest (β=-8.07, 95% CI: -11.45, -4.69) and third-highest (β=-11.69, 95% CI: -15.05, -8.34) lnOBS quantiles. The adjusted odds ratios (ORs) for hyperuricemia in Quartiles 1, 2, 3, and 4 were 1.00, 0.84 (95% CI: 0.75, 0.95), 0.78 (95% CI: 0.69, 0.88), and 0.62 (95% CI: 0.55, 0.71), respectively. Compared to Quartile 1, participants in Quartile 4 had a 38% lower prevalence of hyperuricemia. Subgroup analysis and interaction test showed that there was a significant dependence of sex between OBS and serum uric acid (p for interaction <0.05), but not hyperuricemia (p for interaction >0.05). Subgroup analysis stratified by age, BMI, hypertension, diabetes, and hyperlipidemia showed there is no significant dependence on these negative correlations (all p for interaction >0.05). Conclusions The serum uric acid levels and prevalence of hyperuricemia in US adults exhibited a negative association with OBS. By exploring this connection, our research aims to gain a better understanding of how oxidative balance affects the prevalence of hyperuricemia. This could provide valuable insights for developing preventive strategies and interventions for hyperuricemia. Additional large-scale prospective studies are required to explore the role of OBS in hyperuricemia further.
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Affiliation(s)
- Yuhao Yang
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, China
| | - Zengxiang Wu
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, China
| | - Zhenmei An
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Shuangqing Li
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, China
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Guo Q, Zhao J, Yu S. Clinical Features and Analysis in Pituitary Stalk Interruption Syndrome. Int J Endocrinol 2024; 2024:2493083. [PMID: 38828392 PMCID: PMC11142856 DOI: 10.1155/2024/2493083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/23/2024] [Accepted: 05/07/2024] [Indexed: 06/05/2024] Open
Abstract
Objective Pituitary stalk interruption syndrome (PSIS) is characterized by the absence of pituitary stalk, pituitary hypoplasia, and ectopic posterior pituitary. Because the etiology and clinical cognition of PSIS remain elusive, we analyzed the clinical features of PSIS in Chinese patients. Methods A retrospective analysis was conducted on the clinical presentation, laboratory data, imaging examination, and management of 24 PSIS inpatients from our center over 10 years. Results Among the 24 PSIS patients, there were 22 males (91.7%) and 2 females (8.3%). Growth hormone deficiency was present in all 24 cases (100%), hypogonadism in 24 cases (100%), secondary adrenal insufficiency in 22 cases (91.2%), and hypothyroidism in 21 cases (87.5%). 20 cases (83.3%) of PSIS patients exhibited deficiencies in four anterior pituitary hormones, 3 cases (12.5%) exhibited deficiencies in three anterior pituitary hormones, and 1 case (4.2%) exhibited deficiencies in two anterior pituitary hormones, with none exhibiting deficiencies in posterior pituitary hormones. Among the 24 PSIS patients, 12 had a history of growth hormone therapy before admission, and 12 had no such history. Additionally, 19 cases (79.2%) with PSIS were complicated by dyslipidemia, 15 cases (62.5%) were complicated by nonalcoholic fatty liver disease, and 9 cases (37.5%) were complicated by hyperuricemia. Conclusions PSIS often presents with growth retardation and hypogonadotropic hypogonadism, but in some cases, short stature is not exhibited. PSIS is prone to complications such as dyslipidemia, nonalcoholic fatty liver disease, and hyperuricemia, increasing the risk of cardiovascular and cerebrovascular diseases. In clinical practice, the diagnostic ability of PSIS should be improved, and pituitary function and complications should be evaluated in a timely manner to avoid delayed treatment.
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Affiliation(s)
- Qiuxuan Guo
- Department of Endocrinology, Fuqing City Hospital Affiliated to Fujian Medical University, Fuqing 350300, Fujian, China
| | - Jing Zhao
- Department of Radiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, Guangdong, China
| | - Shuang Yu
- Department of Endocrinology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, Guangdong, China
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Mount DB. Requiem for Urate Lowering in CKD? J Am Soc Nephrol 2024; 35:525-527. [PMID: 38598292 PMCID: PMC11149040 DOI: 10.1681/asn.0000000000000352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024] Open
Affiliation(s)
- David B Mount
- Renal Division, Brigham and Women's Hospital, Boston, Massachusetts, and Renal Division, VA Boston Healthcare System, Harvard Medical School, Boston, Massachusetts
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Gaal OI, Liu R, Marginean D, Badii M, Cabău G, Hotea I, Nica V, Colcear D, Pamfil C, Merriman TR, Rednic S, Popp RA, Crișan TO, Joosten LAB. GWAS-identified hyperuricemia-associated IGF1R variant rs6598541 has a limited role in urate mediated inflammation in human mononuclear cells. Sci Rep 2024; 14:3565. [PMID: 38347000 PMCID: PMC10861580 DOI: 10.1038/s41598-024-53209-7] [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: 06/29/2023] [Accepted: 01/29/2024] [Indexed: 02/15/2024] Open
Abstract
Gout is a common autoinflammatory joint diseases characterized by deposition of monosodium urate (MSU) crystals which trigger an innate immune response mediated by inflammatory cytokines. IGF1R is one of the loci associated with both urate levels and gout susceptibility in GWAS to date, and IGF-1-IGF-1R signaling is implicated in urate control. We investigate the role of IGF-1/IGF1R signaling in the context of gouty inflammation. Also, we test the gout and urate-associated IGF1R rs6598541 polymorphism for association with the inflammatory capacity of mononuclear cells. For this, freshly isolated human peripheral blood mononuclear cells (PBMCs) were exposed to recombinant IGF-1 or anti-IGF1R neutralizing antibody in the presence or absence of solubilized urate, stimulated with LPS/MSU crystals. Also, the association of rs6598541 with IGF1R and protein expression and with ex vivo cytokine production levels after stimulation with gout specific stimuli was tested. Urate exposure was not associated with IGF1R expression in vitro or in vivo. Modulation of IGF1R did not alter urate-induced inflammation. Developing urate-induced trained immunity in vitro was not influenced in cells challenged with IGF-1 recombinant protein. Moreover, the IGF1R rs6598541 SNP was not associated with cytokine production. Our results indicate that urate-induced inflammatory priming is not regulated by IGF-1/IGF1R signaling in vitro. IGF1R rs6598541 status was not asociated with IGF1R expression or cytokine production in primary human PBMCs. This study suggests that the role of IGF1R in gout is tissue-specific and may be more relevant in the control of urate levels rather than in inflammatory signaling in gout.
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Affiliation(s)
- Orsolya I Gaal
- Department of Medical Genetics, Iuliu Hațieganu University of Medicine and Pharmacy, Str. Pasteur Nr.6, 400349, Cluj-Napoca, Romania
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ruiqi Liu
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Dragoș Marginean
- Department of Medical Genetics, Iuliu Hațieganu University of Medicine and Pharmacy, Str. Pasteur Nr.6, 400349, Cluj-Napoca, Romania
| | - Medeea Badii
- Department of Medical Genetics, Iuliu Hațieganu University of Medicine and Pharmacy, Str. Pasteur Nr.6, 400349, Cluj-Napoca, Romania
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Georgiana Cabău
- Department of Medical Genetics, Iuliu Hațieganu University of Medicine and Pharmacy, Str. Pasteur Nr.6, 400349, Cluj-Napoca, Romania
| | - Ioana Hotea
- Department of Rheumatology, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Valentin Nica
- Department of Medical Genetics, Iuliu Hațieganu University of Medicine and Pharmacy, Str. Pasteur Nr.6, 400349, Cluj-Napoca, Romania
| | - Doina Colcear
- Clinical Infectious Disease Hospital, Cluj-Napoca, Romania
| | - Cristina Pamfil
- Department of Rheumatology, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Tony R Merriman
- Department of Microbiology, University of Otago, Dunedin, New Zealand
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Simona Rednic
- Department of Rheumatology, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Radu A Popp
- Department of Medical Genetics, Iuliu Hațieganu University of Medicine and Pharmacy, Str. Pasteur Nr.6, 400349, Cluj-Napoca, Romania
| | - Tania O Crișan
- Department of Medical Genetics, Iuliu Hațieganu University of Medicine and Pharmacy, Str. Pasteur Nr.6, 400349, Cluj-Napoca, Romania.
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Leo A B Joosten
- Department of Medical Genetics, Iuliu Hațieganu University of Medicine and Pharmacy, Str. Pasteur Nr.6, 400349, Cluj-Napoca, Romania
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Terkeltaub R. Emerging Urate-Lowering Drugs and Pharmacologic Treatment Strategies for Gout: A Narrative Review. Drugs 2023; 83:1501-1521. [PMID: 37819612 DOI: 10.1007/s40265-023-01944-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 10/13/2023]
Abstract
Hyperuricemia with consequent monosodium urate crystal deposition leads to gout, characterized by painful, incapacitating inflammatory arthritis flares that are also associated with increased cardiovascular event and related mortality risk. This narrative review focuses on emerging pharmacologic urate-lowering treatment (ULT) and management strategies in gout. Undertreated, gout can progress to palpable tophi and joint damage. In oral ULT clinical trials, target serum urate of < 6.0 mg/dL can be achieved in ~ 80-90% of subjects, with flare burden reduction by 1-2 years. However, real-world ULT results are far less successful, due to both singular patient nonadherence and prescriber undertreatment, particularly in primary care, where most patients are managed. Multiple dose titrations commonly needed to optimize first-line allopurinol ULT monotherapy, and substantial potential toxicities and other limitations of approved, marketed oral monotherapy ULT drugs, promote hyperuricemia undertreatment. Common gout comorbidities with associated increased mortality (e.g., moderate-severe chronic kidney disease [CKD], type 2 diabetes, hypertension, atherosclerosis, heart failure) heighten ULT treatment complexity and emphasize unmet needs for better and more rapid clinically significant outcomes, including attenuated gout flare burden. The gout drug armamentarium will be expanded by integrating sodium-glucose cotransporter-2 (SGLT2) inhibitors with uricosuric and anti-inflammatory properties as well as clinically indicated antidiabetic, nephroprotective, and/or cardioprotective effects. The broad ULT developmental pipeline is loaded with multiple uricosurics that selectively target uric acid transporter 1 (URAT1). Evolving ULT approaches include administering selected gut anaerobic purine degrading bacteria (PDB), modulating intestinal urate transport, and employing liver-targeted xanthine oxidoreductase mRNA knockdown. Last, emerging measures to decrease the immunogenicity of systemically administered recombinant uricases should simplify treatment regimens and further improve outcomes in managing the most severe gout phenotypes.
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Affiliation(s)
- Robert Terkeltaub
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA, 92093, USA.
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Mo C, Chen H, Wang F, Guo Y, Wang Y, Tong T, Zhong L. Uric acid levels correlate with disease activity in growth hormone-secreting pituitary adenoma patients. Front Endocrinol (Lausanne) 2023; 14:1230852. [PMID: 37818085 PMCID: PMC10561298 DOI: 10.3389/fendo.2023.1230852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/05/2023] [Indexed: 10/12/2023] Open
Abstract
Objective Few studies reported the effects of growth hormone-secreting pituitary adenoma (GHPA) on uric acid (UA) metabolism and the relationship between growth hormone (GH)/insulin-like growth factor-1 (IGF-1) levels and UA are controversial. This study aimed to evaluate the relationship between IGF-1 and UA in patients with GHPA and to further clarify whether UA levels are associated with GHPA disease activity by follow-up. Methods A longitudinal study of 424 GHPA patients presenting to Beijing Tiantan Hospital, Capital Medical University between January 2015 and January 2023 was conducted. Spearman's correlation tests were performed to examine the relationship between IGF-1 and UA at baseline. Univariate and multivariate linear regression analysis was conducted to investigate the independent association between UA and IGF-1. Changes in postoperative IGF-1 and UA levels were followed prospectively, and the differences in UA levels between the biochemical remission and nonremission groups were compared. Results At baseline, male patients, the lower the age, the higher the IGF-1 and body mass index (BMI), and the higher the UA levels. IGF-1 was significantly associated with UA after controlling for sex, age, and BMI (r = 0.122, P = 0.012). In adjusted multiple linear regression analysis, IGF-1 was independently associated with UA, and UA levels increased significantly with increasing IGF-1. During postoperative follow-up, UA decreased gradually as IGF-1 levels decreased. At 12 months postoperatively, UA levels were significantly lower in the biochemical remission group than in the nonremission group (P = 0.038). Conclusions In patients with GHPA, UA levels are associated with disease activity. Changes in UA levels should be taken into account in the comprehensive treatment of GHPA, patients presenting with HUA should be given lifestyle guidance and appropriate urate-lowering treatment according to their condition to better improve their prognosis.
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Affiliation(s)
| | | | | | | | | | | | - Liyong Zhong
- Department of Endocrinology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Perdomo-Ramirez A, Cordoba-Lanus E, Trujillo-Frias CJ, Gonzalez-Navasa C, Ramos-Trujillo E, Luis-Yanes MI, Garcia-Nieto V, Claverie-Martin F. Pathogenic Variants of SLC22A12 (URAT1) and SLC2A9 (GLUT9) in Spanish Patients with Renal Hypouricemia: Founder Effect of SLC2A9 Variant c.374C>T; p.(T125M). Int J Mol Sci 2023; 24:ijms24098455. [PMID: 37176161 PMCID: PMC10179447 DOI: 10.3390/ijms24098455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/02/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
Renal hypouricemia (RHUC) is a rare inherited disorder characterized by impaired urate reabsorption in the proximal tubule resulting in low urate serum levels and increased urate excretion. Some patients may present severe complications such as exercise-induced acute renal failure and nephrolithiasis. RHUC is caused by inactivating mutations in the SLC22A12 (RHUC type 1) or SLC2A9 (RHUC type 2) genes, which encode urate transporters URAT1 and GLUT9, respectively. In this study, our goal was to identify mutations associated with twenty-one new cases with RHUC through direct sequencing of SLC22A12 and SLC2A9 coding exons. Additionally, we carried out an SNPs-haplotype analysis to determine whether the rare SLC2A9 variant c.374C>T; p.(T125M), which is recurrent in Spanish families with RHUC type 2, had a common-linked haplotype. Six intragenic informative SNPs were analyzed using PCR amplification from genomic DNA and direct sequencing. Our results showed that ten patients carried the SLC22A12 mutation c.1400C>T; p.(T467M), ten presented the SLC2A9 mutation c.374C>T, and one carried a new SLC2A9 heterozygous mutation, c.593G>A; p.(R198H). Patients carrying the SLC2A9 mutation c.374C>T share a common-linked haplotype, confirming that it emerged due to a founder effect.
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Affiliation(s)
- Ana Perdomo-Ramirez
- Unidad de Investigacion, Hospital Universitario Nuestra Señora de Candelaria, 38010 Santa Cruz de Tenerife, Spain
| | - Elizabeth Cordoba-Lanus
- Unidad de Investigacion, Hospital Universitario Nuestra Señora de Candelaria, 38010 Santa Cruz de Tenerife, Spain
- Instituto Universitario de Enfermedades Tropicales y Salud Publica de Canarias (IUETSPC), Universidad de La Laguna, 38296 Santa Cruz de Tenerife, Spain
| | - Carmen Jane Trujillo-Frias
- Unidad de Investigacion, Hospital Universitario Nuestra Señora de Candelaria, 38010 Santa Cruz de Tenerife, Spain
| | - Carolina Gonzalez-Navasa
- Unidad de Investigacion, Hospital Universitario Nuestra Señora de Candelaria, 38010 Santa Cruz de Tenerife, Spain
- Seccion Medicina, Departamento de Medicina Fisica y Farmacologia, Facultad de Ciencias de la Salud, Universidad de La Laguna, 38200 Santa Cruz de Tenerife, Spain
| | - Elena Ramos-Trujillo
- Unidad de Investigacion, Hospital Universitario Nuestra Señora de Candelaria, 38010 Santa Cruz de Tenerife, Spain
- Seccion Medicina, Departamento de Medicina Fisica y Farmacologia, Facultad de Ciencias de la Salud, Universidad de La Laguna, 38200 Santa Cruz de Tenerife, Spain
| | - Maria Isabel Luis-Yanes
- Unidad de Nefrologia Pediatrica, Hospital Universitario Nuestra Señora de Candelaria, 38010 Santa Cruz de Tenerife, Spain
| | - Victor Garcia-Nieto
- Unidad de Nefrologia Pediatrica, Hospital Universitario Nuestra Señora de Candelaria, 38010 Santa Cruz de Tenerife, Spain
| | - Felix Claverie-Martin
- Unidad de Investigacion, Hospital Universitario Nuestra Señora de Candelaria, 38010 Santa Cruz de Tenerife, Spain
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