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Delrue C, Dendooven A, Vandendriessche A, Speeckaert R, De Bruyne S, Speeckaert MM. Advancing Renal Amyloidosis Care: The Role of Modern Diagnostic Techniques with the Potential of Enhancing Patient Outcomes. Int J Mol Sci 2024; 25:5875. [PMID: 38892061 PMCID: PMC11172584 DOI: 10.3390/ijms25115875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Renal amyloidosis is a set of complex disorders characterized by the deposition of amyloid proteins in the kidneys, which causes gradual organ damage and potential kidney failure. Recent developments in diagnostic methods, particularly mass spectrometry and proteome profiling, have greatly improved the accuracy of amyloid typing, which is critical for disease management. These technologies provide extensive insights into the specific proteins involved, allowing for more targeted treatment approaches and better patient results. Despite these advances, problems remain, owing to the heterogeneous composition of amyloid proteins and the varying efficacy of treatments based on amyloid type. Access to sophisticated diagnostics and therapy varies greatly, highlighting the global difference in renal amyloidosis management. Future research is needed to investigate next-generation sequencing and gene-editing technologies, like clustered regularly interspaced short palindromic repeats (CRISPR), which promise more profound insights into the genetic basis of amyloidosis.
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Affiliation(s)
- Charlotte Delrue
- Department of Nephrology, Ghent University Hospital, 9000 Ghent, Belgium;
| | - Amélie Dendooven
- Department of Pathology, Ghent University Hospital, 9000 Ghent, Belgium; (A.D.); (A.V.)
- Faculty of Medicine, University of Antwerp, 2610 Wilrijk, Belgium
| | | | | | - Sander De Bruyne
- Department of Laboratory Medicine, Ghent University Hospital, 9000 Ghent, Belgium;
| | - Marijn M. Speeckaert
- Department of Nephrology, Ghent University Hospital, 9000 Ghent, Belgium;
- Research Foundation-Flanders (FWO), 1000 Brussels, Belgium
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Leung N, Nasr SH. 2024 Update on Classification, Etiology, and Typing of Renal Amyloidosis: A Review. Am J Kidney Dis 2024:S0272-6386(24)00679-6. [PMID: 38514011 DOI: 10.1053/j.ajkd.2024.01.530] [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: 07/25/2023] [Revised: 12/20/2023] [Accepted: 01/29/2024] [Indexed: 03/23/2024]
Abstract
Amyloidosis is a protein folding disease that causes organ injuries and even death. In humans, 42 proteins are now known to cause amyloidosis. Some proteins become amyloidogenic as a result of a pathogenic variant as seen in hereditary amyloidoses. In acquired forms of amyloidosis, the proteins form amyloid in their wild-type state. Four types (serum amyloid A, transthyretin, apolipoprotein A-IV, and β2-macroglobulin) of amyloid can occur either as acquired or as a mutant. Iatrogenic amyloid from injected protein medications have also been reported and AIL1RAP (anakinra) has been recently found to involve the kidney. Finally, the mechanism of how leukocyte cell-derived chemotaxin 2 (ALECT2) forms amyloid remains unknown. This article reviews the amyloids that involve the kidney and how they are typed.
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Affiliation(s)
- Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota; Division of Hematology, Mayo Clinic, Rochester, Minnesota.
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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Temmoku J, Sasajima T, Kuroda T, Sumichika Y, Saito K, Yoshida S, Matsumoto H, Fujita Y, Matsuoka N, Asano T, Sato S, Yamada T, Hashimoto Y, Migita K. Rapid Clinical Improvement of Multicentric Castleman Disease (MCD) with Renal Involvement Following Treatment with Tocilizumab: AA Amyloidosis as a Possible Renal Involvement of MCD. TOHOKU J EXP MED 2023; 259:285-291. [PMID: 36653160 DOI: 10.1620/tjem.2023.j003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Castleman disease (CD) is a lymphoproliferative disorder that manifests as hypergammaglobulinemia and severe inflammation with multiorgan involvement. However, renal involvement has been infrequently described in CD. We present a case of a 63-year-old Japanese male patient with multicentric CD (MCD) in whom kidney involvement, including impaired renal function and massive proteinuria, is present. He had a 2-year history of inflammatory arthritis and was referred to our clinic with newly developed proteinuria, renal dysfunction, and elevated levels of acute-phase proteins. Abdominal computed tomography scan revealed hepatosplenomegaly, including mesenteric and inguinal lymph node enlargements. The patient underwent inguinal lymph node resection. Excisional biopsy of the inguinal lymph node showed multiple lymphoid follicles and expansion of interfollicular areas by marked plasmacytosis consistent with mixed type CD. The patient was diagnosed with human herpes virus 8-negative MCD according to the international diagnostic criteria for CD. Diagnostic renal biopsy was not performed following the medical viewpoint. Tocilizumab (TCZ) treatment was highly effective in reducing proteinuria and stabilizing renal function, as well as improving other clinical symptoms. The patient responded to TCZ treatment, and the renal involvement was rapidly improved. Our preliminary immunohistochemical analysis indicated AA amyloid deposits in urinary epithelial cells suggesting a possible renal involvement of AA amyloidosis. TCZ could potentially be one of the therapeutic options in patients with MCD with renal involvement.
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Affiliation(s)
- Jumpei Temmoku
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | | | - Takeshi Kuroda
- Department of Rheumatology and Nephrology, Niigata University Graduate School of Medical and Dental Sciences
| | - Yuya Sumichika
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Kenji Saito
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Shuhei Yoshida
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Haruki Matsumoto
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Yuya Fujita
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Naoki Matsuoka
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Tomoyuki Asano
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Shuzo Sato
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Toshiyuki Yamada
- Department of Clinical Laboratory Medicine, Jichi Medical University
| | - Yuko Hashimoto
- Department of Pathology, Fukushima Medical University School of Medicine
| | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine
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Kojima D, Yamaguchi S, Hashiguchi A, Hayashi K, Uchiyama K, Yoshimoto N, Adachi K, Nakayama T, Nishioka K, Tajima T, Morimoto K, Yoshino J, Yoshida T, Monkawa T, Kanda T, Itoh H. Case report: Importance of early and continuous tocilizumab therapy in nephrotic syndrome associated with idiopathic multicentric Castleman disease: A case series. Front Med (Lausanne) 2023; 9:1037032. [PMID: 36698794 PMCID: PMC9868391 DOI: 10.3389/fmed.2022.1037032] [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: 09/05/2022] [Accepted: 12/14/2022] [Indexed: 01/10/2023] Open
Abstract
Idiopathic multicentric Castleman disease (iMCD) is a systemic and polyclonal lymphoproliferative disease involving multiple organs, including the kidneys, due to the overproduction of interleukin-6 (IL-6). Recently, several reports have suggested that excessive IL-6 actions in iMCD could have a causal relationship with the development of diverse histopathological renal manifestations that cause nephrotic syndrome. However, the treatment for such cases remains unclear. We report a series of three cases of nephrotic syndrome due to iMCD that helps to delineate the importance of early and continuous therapy with the anti-interleukin-6 receptor antibody tocilizumab. First, treatment was suspended for infectious control, and the patient presented with nephrotic syndrome due to diffuse mesangial and endocapillary hypercellularity without immune deposits complicating acute kidney injury. Second, iMCD was treated with prednisolone alone. The patient suddenly developed nephrotic syndrome due to immune-complex glomerulonephritis, not otherwise specified, complicated with acute kidney injury. In the third case, nephrotic syndrome secondary to membranous glomerulonephritis was diagnosed, with a skin rash and IgE antibodies to tocilizumab, and was therefore treated with prednisolone alone. In contrast to the first two cases, the third progressed to end-stage renal disease on hemodialysis. Taken together, this series suggests that clinicians should maintain clinical vigilance for iMCD as a possible underlying component of nephrotic syndrome, since iMCD presents with a variety of renal pathologies. Prompt initiation and continuous administration of tocilizumab are likely key determinants of renal outcomes in such cases. In particular, when tocilizumab is suspended due to infection or in the perioperative period, consideration of its expeditious resumption should be made, taking into account both the withdrawal period and systemic conditions.
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Affiliation(s)
- Daiki Kojima
- 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,
| | - Akinori Hashiguchi
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - 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
| | - Norifumi Yoshimoto
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Keika Adachi
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takashin Nakayama
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Ken Nishioka
- 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
| | - Kohkichi Morimoto
- 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
| | - Tadashi Yoshida
- Apheresis and Dialysis Center, Keio University School of Medicine, Tokyo, Japan
| | - Toshiaki Monkawa
- Division of Endocrinology, Metabolism, and Nephrology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan,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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Membranous nephropathy associated with multicentric Castleman's disease that was successfully treated with tocilizumab: a case report and review of the literature. BMC Nephrol 2021; 22:216. [PMID: 34107915 PMCID: PMC8191014 DOI: 10.1186/s12882-021-02423-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 06/03/2021] [Indexed: 12/14/2022] Open
Abstract
Background Multicentric Castleman’s disease is a life-threatening disorder involving a systemic inflammatory response and multiple organ failure caused by the overproduction of interleukin-6. Although renal complications of Castleman’s disease include AA amyloidosis, thrombotic microangiopathy, and membranoproliferative glomerulonephritis, membranous nephropathy is relatively rare. We experienced a case of secondary membranous nephropathy associated with Castleman’s disease. Case presentation The patient was a 43-year-old Japanese man who had shown a high zinc sulfate value in turbidity test, polyclonal hypergammaglobulinemia, anemia, and proteinuria. A physical examination revealed diffuse lymphadenopathy, an enlarged spleen and papulae of the body trunk. A skin biopsy of a papule on the patient’s back showed plasma cells in the perivascular area and he was diagnosed with multicentric Castleman’s disease, plasma cell variant. Kidney biopsy showed the appearance of bubbling in the glomerular basement membranes in Periodic acid methenamine silver stain and electron microscopy revealed electron dense deposits within and outside the glomerular basement membranes. Since immunofluorescence study showed predominant granular deposition of IgG1 and IgG2, he was diagnosed with secondary membranous nephropathy associated with Castleman’s disease. He was initially treated with prednisolone alone, however his biochemical abnormalities did not improve. After intravenous tocilizumab (700 mg every 2 weeks) was started, his C-reactive protein elevation, anemia, and polyclonal gammopathy improved. Furthermore, his urinary protein level declined from 1.58 g/gCr to 0.13 g/gCr. The prednisolone dose was gradually tapered, then discontinued. He has been stable without a recurrence of proteinuria for more than 6 months. Conclusions Tocilizumab might be a treatment option for secondary membranous nephropathy associated with Castleman’s disease.
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Furutera N, Fukunaga N, Okita J, Suzuki T, Suenaga Y, Oyama Y, Aoki K, Fukuda A, Nakata T, Uesugi N, Daa T, Hisano S, Shibata H. Two cases of idiopathic multicentric Castleman disease with nephrotic syndrome treated with tocilizumab. CEN Case Rep 2020; 10:35-41. [PMID: 32715375 DOI: 10.1007/s13730-020-00511-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 07/14/2020] [Indexed: 01/11/2023] Open
Abstract
We report two cases of idiopathic multicentric Castleman disease (iMCD) with nephrotic syndrome (NS) treated with tocilizumab. Case 1 was a 58-year-old man diagnosed with iMCD prior to the onset of NS. Renal biopsy revealed membranous nephropathy, which was considered to be secondary membranous nephropathy associated with iMCD. Case 2 was a 49-year-old woman diagnosed with iMCD prior to NS. Renal biopsy revealed renal amyloidosis positive for Congo red staining and amyloid A protein immunostaining. In both the cases, the proteinuria improved after the initiation of glucocorticoid and tocilizumab therapy. Tocilizumab may be a good therapeutic choice for iMCD with NS.
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Affiliation(s)
- Norihiro Furutera
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan
| | - Naoya Fukunaga
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan.
| | - Jun Okita
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan
| | - Tomoko Suzuki
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan
| | - Yuko Suenaga
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan
| | - Yuzo Oyama
- Department of Diagnostic Pathology, Faculty of Medicine, Oita University, Oita, Japan
| | - Kohei Aoki
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan
| | - Akihiro Fukuda
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan
| | - Takeshi Nakata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan
| | - Noriko Uesugi
- Department of Pathology, Faculty of Medicine, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Tsutomu Daa
- Department of Diagnostic Pathology, Faculty of Medicine, Oita University, Oita, Japan
| | - Satoshi Hisano
- Department of Pathology, Faculty of Medicine, Fukuoka University School of Medicine, Fukuoka, Japan
| | - Hirotaka Shibata
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hsama-machi Yufu, Oita, 879-5593, Japan
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Use of tocilizumab in amyloid a nephropathy associated with Sweet syndrome: a case report and literature review. CEN Case Rep 2020; 10:23-29. [PMID: 32681397 DOI: 10.1007/s13730-020-00507-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/01/2020] [Indexed: 10/23/2022] Open
Abstract
Amyloid A nephropathy is a possible complication of chronic inflammatory disease. Proteinuria and kidney failure are the main features of the disease. Tocilizumab (TCZ), an IL6-R antibody approved for rheumatoid arthritis, is a promising choice for histologically demonstrated nephropathy. We describe a case of kidney amyloid associated with Sweet syndrome treated with TCZ. The patient was affected by Sweet syndrome associated with proteinuria. Kidney biopsy showed amyloid deposits. During the follow-up, cutaneous and renal findings were refractory to many immunosuppressive regimen (cyclophosphamide, leflunomide, interferon and steroid). After few years, the patient developed rapidly progressive nephropathy associated with nephrotic syndrome (proteinuria up to 6 g/die). A second kidney biopsy was performed and it showed worsening of amyloid nephropathy. Thus, TCZ was administrated (8 mg/kg once a month) and it stabilized kidney function and induced partial remission of the nephrotic syndrome in the following 2 years.
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Bernabei L, Waxman A, Caponetti G, Fajgenbaum DC, Weiss BM. AA amyloidosis associated with Castleman disease: A case report and review of the literature. Medicine (Baltimore) 2020; 99:e18978. [PMID: 32028407 PMCID: PMC7015640 DOI: 10.1097/md.0000000000018978] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 11/27/2019] [Accepted: 12/30/2019] [Indexed: 12/01/2022] Open
Abstract
RATIONALE AA amyloidosis (AA) is caused by a wide variety of inflammatory states, but is infrequently associated with Castleman disease (CD). CD describes a heterogeneous group of hematologic disorders that share characteristic lymph node histopathology. CD can present with a solitary enlarged lymph node (unicentric CD, UCD) or with multicentric lymphadenopathy (MCD), constitutional symptoms, cytopenias, and multiple organ dysfunction due to an interleukin-6 driven cytokine storm. PATIENT CONCERNS We are reporting a case of a 26-year-old woman with no significant past medical history who presented with a 3-month history of fatigue and an unintentional 20-pound weight loss. DIAGNOSIS A CT-scan of the abdomen and pelvis revealed hepatosplenomegaly and a mesenteric mass. Congo Red staining from a liver biopsy showed apple-green birefringence and serum markers were suggestive of an inflammatory process. Post-excision examination of the resected mass revealed a reactive lymph node with follicular hyperplasia with kappa and lambda stains showing polyclonal plasmacytosis consistent with CD. INTERVENTIONS The patient underwent surgery to remove the affected lymph node. OUTCOMES IL-6, anemia, leukocytosis, and thrombocytosis resolved or normalized 2 weeks after resection; creatinine normalized 9 months postsurgery. Twenty two months post-surgery her IFN-γ normalized, her fatigue resolved, her proteinuria was reduced by >90% and she had returned to her baseline weight. LESSONS Our case and literature review suggest that patients presenting with UCD or MCD along with organ failure should prompt consideration of concurrent AA amyloidosis.
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Affiliation(s)
| | - Adam Waxman
- Penn Amyloidosis Program, Abramson Cancer Center
| | | | - David C. Fajgenbaum
- Division of Translational Medicine and Human Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Wang ST, Wang QP, Li J, Zhang T, Zhang L, Mao YY. Amyloidosis secondary to intrapulmonary Castleman disease mimicking pulmonary hyalinizing granuloma-like clinical features: A rare case report. Medicine (Baltimore) 2019; 98:e15039. [PMID: 30946344 PMCID: PMC6456117 DOI: 10.1097/md.0000000000015039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
RATIONALE Amyloidosis secondary to intrapulmonary Castleman disease (CD) is a rare benign disease diagnosed by histopathology. It seems to be associated with chronic inflammation, and large amounts of IL-6 produced in the germinal center of CD may enhance the production of precursor of amyloid. PATIENT CONCERNS We reported a case of an 18-year-old woman presenting with dry cough and dyspnea on exertion for 6 months and detailed exams revealed multiple pulmonary nodules, positive antinuclear antibodies, hypocomplementemia, and thrombocytopenia. DIAGNOSES A computed tomography-guided percutaneous lung biopsy revealed the histopathological features of pulmonary hyalinizing granuloma (PHG), but video-assisted pulmonary wedge resection for biopsy with immunohistochemical stains finally demonstrated a corrected diagnosis of intrapulmonary CD with secondary amyloidosis. INTERVENTIONS The patient had received prednisone and Tacrolimus for 6 months. OUTCOMES There was no significant improvement in pulmonary lesions or platelet level. Chemotherapy to CD was needed. LESSONS Intrapulmonary CD should be considered in patients with multiple pulmonary nodules irresponsive to corticosteroid and diagnosis of PHG should be carefully considered based on small lung biopsy sample. The treatment of amyloidosis secondary to CD remains to be uncertain.
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Affiliation(s)
| | | | | | | | - Lu Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yue-Ying Mao
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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