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Csikány N, Kiss Á, Déri M, Fekete F, Minus A, Tóth K, Temesvári M, Sárváry E, Bihari L, Gerlei Z, Kóbori L, Monostory K. Clinical significance of personalized tacrolimus dosing by adjusting to donor CYP3A-status in liver transplant recipients. Br J Clin Pharmacol 2020; 87:1790-1800. [PMID: 32986876 DOI: 10.1111/bcp.14566] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/02/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
Donor's CYP3A-status (CYP3A5 genotype and CYP3A4 expression) can provide prognostic information regarding tacrolimus-metabolizing capacity of the liver graft and initial tacrolimus dosing for therapeutic blood concentrations in liver transplants. The present work prospectively investigated whether CYP3A-status guided tacrolimus therapy has any potential clinical benefit for recipients in the early postoperative period. METHODS The contribution of preliminary assaying of donor CYP3A-status to the optimization of initial tacrolimus therapy and to the reduction of adverse events (acute rejection, infection, nephrotoxicity) was investigated in 112 liver transplant recipients (CYPtest group) comparing to 101 control patients on tacrolimus concentration guided therapy. RESULTS The time for achieving therapeutic tacrolimus concentration was significantly reduced, confirming potential benefit of initial tacrolimus therapy adjusted to donor's CYP3A-status over classical clinical practice of tacrolimus concentration guided treatment (4 vs 8 days, P < 0.0001). Acute rejection episodes (3.6 vs 23.8%, P < 0.0001) and tacrolimus induced nephrotoxicity (8 vs 27%, P = 0.0004) were less frequent in CYPtest group than in control patients, whereas occurrence of infectious disease was not influenced by tacrolimus dosing strategy (3.6 vs 5.9% in CYPtest and control groups, P > 0.05). Acute rejection was often accompanied with tacrolimus blood concentrations lower than 10 ng mL-1 (20/24 of control and 2/4 of CYPtest patients), while nephrotoxicity was associated with high tacrolimus concentrations (>20 ng mL-1 ) in the first week after transplantation (13/27 of control and 2/9 of CYPtest patients). CONCLUSION CYP3A-status guided therapy significantly improved the risk of misdosing induced early adverse effects (acute rejection, nephrotoxicity).
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Affiliation(s)
- Nóra Csikány
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary.,Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Ádám Kiss
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Máté Déri
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Ferenc Fekete
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Annamária Minus
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Katalin Tóth
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Manna Temesvári
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
| | - Enikő Sárváry
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - László Bihari
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Zsuzsa Gerlei
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - László Kóbori
- Department of Transplantation and Surgery, Semmelweis University, Budapest, Hungary
| | - Katalin Monostory
- Institute of Enzymology, Research Centre for Natural Sciences, Budapest, Hungary
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Monostory K, Tóth K, Kiss Á, Háfra E, Csikány N, Paulik J, Sárváry E, Kóbori L. Personalizing initial calcineurin inhibitor dosing by adjusting to donor CYP3A-status in liver transplant patients. Br J Clin Pharmacol 2015; 80:1429-37. [PMID: 26271661 DOI: 10.1111/bcp.12747] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 08/10/2015] [Accepted: 08/11/2015] [Indexed: 12/14/2022] Open
Abstract
AIMS Inter-individual variability in dose requirements of calcineurin inhibitors (CNI) has been linked to genetic polymorphisms of CYP3A enzymes. CYP3A5*3, CYP3A4*1B and CYP3A4*22 alleles of liver grafts may explain about one third of the inter-individual differences in pharmacokinetics of ciclosporin and tacrolimus in recipients. However, non-genetic factors, influencing CYP3A expression, can contribute to the variability of CYP3A function due to phenoconversion. The present study evaluated the association between CYP3A4 expression combined with CYP3A5 genotype of donor livers and recipients' CNI therapy after transplantation. METHODS The contribution of donors' CYP3A5 genotype and CYP3A4 expression to the blood concentrations and dose requirements of CNIs was evaluated in 131 liver transplant recipients. RESULTS The recipients with grafts from normal CYP3A4 expresser donors carrying CYP3A5*3/*3 required CNI maintenance doses more or less similar to the bodyweight-controlled starting doses (9.1 mg kg(-1) of ciclosporin and 0.1 mg kg(-1) of tacrolimus). The patients transplanted with grafts from low CYP3A4 expressers required substantial reduction (by about 50%, 4.2 mg kg(-1) of ciclosporin, 0.047 mg kg(-1) of tacrolimus, P < 0.001), while the recipients with grafts from high expressers or with grafts carrying at least one copy of the functional CYP3A5*1 allele required an increase (by about 50% [12.8-13.8 mg kg(-1)] for ciclosporin and 100% [0.21 mg kg(-1) ] for tacrolimus, P < 0.001) of the initial CNI dose for achieving target blood concentrations. CONCLUSIONS Donor livers' CYP3A-status, taking both CYP3A5 allelic variations and CYP3A4 expression into account, can better identify the risk of CNI over- or underexposure, and may contribute to the avoidance of misdosing-induced graft injury in the early post-operative period.
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Affiliation(s)
- Katalin Monostory
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Magyar Tudósok 2, H-1117, Budapest
| | - Katalin Tóth
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Magyar Tudósok 2, H-1117, Budapest
| | - Ádám Kiss
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Magyar Tudósok 2, H-1117, Budapest
| | - Edit Háfra
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Magyar Tudósok 2, H-1117, Budapest
| | - Nóra Csikány
- Research Centre for Natural Sciences, Hungarian Academy of Sciences, Magyar Tudósok 2, H-1117, Budapest
| | - József Paulik
- Nucleotest Bio Ltd., Tündérliget 3/2, H-1038, Budapest
| | - Enikő Sárváry
- Department of Transplantation and Surgery, Semmelweis University, Baross 23, H-1082, Budapest, Hungary
| | - László Kóbori
- Department of Transplantation and Surgery, Semmelweis University, Baross 23, H-1082, Budapest, Hungary
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Kuper CF, Vogels J, Kemmerling J, Fehlert E, Rühl-Fehlert C, Vohr HW, Krul C. Integrated analysis of toxicity data of two pharmaceutical immunosuppressants and two environmental pollutants with immunomodulating properties to improve the understanding of side effects-A toxicopathologist׳s view. Eur J Pharmacol 2015; 759:343-55. [PMID: 25824899 DOI: 10.1016/j.ejphar.2015.03.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Revised: 02/03/2015] [Accepted: 03/12/2015] [Indexed: 12/19/2022]
Abstract
Data in a toxicity test are evaluated generally per parameter. Information on the response per animal in addition to per parameter can improve the evaluation of the results. The results from the six studies in rats, described in the paper by Kemmerling, J., Fehlert, E., Rühl-Fehlert, C., Kuper, C.F., Stropp, G., Vogels, J., Krul, C., Vohr, H.-W., 2015. The transferability from rat subacute 4-week oral toxicity study to translational research exemplified by two pharmaceutical immunosuppressants and two environmental pollutants with immunomodulating properties (In this issue), have been subjected to principal component analysis (PCA) and principal component discriminant analysis (PC-DA). The two pharmaceuticals azathioprine (AZA) and cyclosporine A (CSA) and the two environmental pollutants hexachlorobenzene (HCB) and benzo(a)pyrene (BaP) all modulate the immune system, albeit that their mode of immunomodulation is quite diverse. PCA illustrated the similarities between the two independent studies with AZA (AZA1 and AZA2) and CSA (CSA1 and CSA2). The PC-DA on data of the AZA2 study did not increase substantially the information on dose levels. In general, the no-effect levels were lower upon single parameter analysis than indicated by the distances between the dose groups in the PCA. This was mostly due to the expert judgment in the single parameter evaluation, which took into account outstanding pathology in only one or two animals. The PCA plots did not reveal sex-related differences in sensitivity, but the key pathology for males and females differed. The observed variability in some of the control groups was largely a peripheral blood effect. Most importantly, PCA analysis identified several animals outside the 95% confidence limit indicating high-responders; also low-to-non-responders were identified. The key pathology enhanced the understanding of the response of the animals to the four model compounds.
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Affiliation(s)
| | - Jack Vogels
- TNO, PO Box 360, 3700 AJ Zeist, The Netherlands
| | - Jessica Kemmerling
- Bayer Pharma AG, GDD-GED-TOX-IT-Immunotoxicology, Aprather Weg, 42096 Wuppertal, Germany
| | - Ellen Fehlert
- Department of Medicine IV, Eberhard-Karls University, Otfried-Mueller Strasse 10, 72076 Tuebingen, Germany
| | | | - Hans-Werner Vohr
- Bayer Pharma AG, GDD-GED-TOX-IT-Immunotoxicology, Aprather Weg, 42096 Wuppertal, Germany
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Maluf DG, Dumur CI, Suh JL, Lee JK, Cathro EP, King AL, Gallon L, Brayman KL, Mas VR. Evaluation of molecular profiles in calcineurin inhibitor toxicity post-kidney transplant: input to chronic allograft dysfunction. Am J Transplant 2014; 14:1152-1163. [PMID: 24698514 PMCID: PMC4377109 DOI: 10.1111/ajt.12696] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 01/21/2014] [Accepted: 01/28/2014] [Indexed: 02/05/2023]
Abstract
The molecular basis of calcineurin inhibitor toxicity (CNIT) in kidney transplantation (KT) and its contribution to chronic allograft dysfunction (CAD) with interstitial fibrosis (IF) and tubular atrophy (TA) were evaluated by: (1) identifying specific CNIT molecular pathways that associate with allograft injury (cross-sectional study) and (2) assessing the contribution of the identified CNIT signature in the progression to CAD with IF/TA (longitudinal study). Kidney biopsies from well-selected transplant recipients with histological diagnosis of CNIT (n = 14), acute rejection (n = 13) and CAD with IF/TA (n = 10) were evaluated. Normal allografts (n = 18) were used as controls. To test CNIT contribution to CAD progression, an independent set of biopsies (n = 122) from 61 KT patients collected at 3 and ~12 months post-KT (range = 9-18) were evaluated. Patients were classified based on 2-year post-KT graft function and histological findings as progressors (n = 30) or nonprogressors to CAD (n = 31). Molecular signatures characterizing CNIT samples were identified. Patients classified as progressors showed an overlap of 7% and 22% with the CNIT signature at 3 and at ~12 months post-KT, respectively, while the overlap was <1% and 1% in nonprogressor patients, showing CNIT at the molecular level as a nonimmunological factor involved in the progression to CAD.
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Affiliation(s)
- DG Maluf
- University of Virginia, Department of Surgery PO Box 800679, Charlottesville, VA 22908-0679
| | - CI Dumur
- University of Virginia, Department of Pathology PO Box 800904, VA 22908-0214
| | - JL Suh
- University of Virginia, Department of Surgery PO Box 800679, Charlottesville, VA 22908-0679
| | - JK Lee
- University of Virginia, Division of Biostatistics PO Box 800717, VA 22298-0717
| | - EP Cathro
- University of Virginia, Department of Pathology PO Box 800904, VA 22908-0214
| | - AL King
- Virginia Commonwealth University, Division of Nephrology PO Box 980662, VA 23298-0662
| | - L Gallon
- Northwestern University, Division of Nephrology, Department of Internal Medicine, Comprehensive Transplant Center Chicago, IL 60611
| | - KL Brayman
- University of Virginia, Department of Surgery PO Box 800679, Charlottesville, VA 22908-0679
| | - VR Mas
- University of Virginia, Department of Surgery PO Box 800679, Charlottesville, VA 22908-0679
- Corresponding author: Valeria Mas, Ph.D. Associate Professor Research Surgery Co-Director Transplant Research Director Translational Genomics Transplant Laboratory Transplant Division, Department of Surgery University of Virginia PO Box 800679 Charlottesville, VA 22908-0679
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CRAC channel inhibition produces greater anti-inflammatory effects than glucocorticoids in CD8 cells from COPD patients. Clin Sci (Lond) 2013; 126:223-32. [PMID: 23905758 DOI: 10.1042/cs20130152] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
There are increased numbers of pulmonary CD8 lymphocytes in COPD (chronic obstructive pulmonary disease). CRAC (calcium release-activation calcium) channels play a central role in lymphocyte activation though the regulation of the transcription factor NFAT (nuclear factor of activated T-cells). We studied the expression of NFAT in lungs from COPD patients compared with controls, and evaluated the effects of CRAC channel inhibition compared with corticosteroids on NFAT activation and cytokine production in CD8 cells from COPD patients. The effects of the corticosteroid dexamethasone, the calcineurin inhibitor cyclosporin and the CRAC channel inhibitor Synta 66 were studied on cytokine production and NFAT activation using peripheral blood and isolated pulmonary CD8 cells. NFAT1 and CD8 co-expression in the lungs was compared in COPD patients and controls using combined immunohistochemistry and immunofluorescence. NFAT inhibition with either cyclosporin or Synta 66 resulted in significantly greater maximal inhibition of cytokines than dexamethasone in both peripheral blood and pulmonary CD8 cells [e.g. >95% inhibition of IFNγ (interferon γ) production from pulmonary CD8 cells using cyclosporin and Synta 66 compared with <50% using dexamethasone]. The absolute number of pulmonary CD8 cells co-expressing NFAT1 was significantly raised in lungs from COPD patients compared with controls, but the percentage of CD8 cells co-expressing NFAT1 was similar between COPD patients and controls (80.7% compared with 78.5% respectively, P=0.3). Inhibition of NFAT using the CRAC channel Synta 66 produces greater anti-inflammatory effects on CD8 cells from COPD patients than corticosteroids. NFAT is expressed at a high level in pulmonary CD8 cells in COPD.
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Stefan CP, Cunningham KW. Kch1 family proteins mediate essential responses to endoplasmic reticulum stresses in the yeasts Saccharomyces cerevisiae and Candida albicans. J Biol Chem 2013; 288:34861-70. [PMID: 24142703 DOI: 10.1074/jbc.m113.508705] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The activation of a high affinity Ca(2+) influx system (HACS) in the plasma membrane is required for survival of yeast cells exposed to natural or synthetic inhibitors of essential processes (secretory protein folding or sterol biosynthesis) in the endoplasmic reticulum (ER). The mechanisms linking ER stress to HACS activation are not known. Here we show that Kch1, a recently identified low affinity K(+) transporter in the plasma membrane of Saccharomyces cerevisiae, is up-regulated in response to several ER stressors and necessary for HACS activation. The activation of HACS required extracellular K(+) and was also dependent on the high affinity K(+) transporters Trk1 and Trk2. However, a paralog of Kch1 termed Kch2 was not expressed and not necessary for HACS activation in these conditions. The pathogenic yeast Candida albicans carries only one homolog of Kch1/Kch2, and homozygous knock-out mutants were similarly deficient in the activation of HACS during the responses to tunicamycin. However, the Kch1 homolog was not necessary for HACS activation or cell survival in response to several clinical antifungals (azoles, allylamines, echinocandins) that target the ER or cell wall. Thus, Kch1 family proteins represent a conserved linkage between HACS and only certain classes of ER stress in these yeasts.
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Affiliation(s)
- Christopher P Stefan
- From the Department of Biology, The Johns Hopkins University, Baltimore, Maryland 21218
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Wollina U. Letter to the editor: Temporary renal insufficiency associated with topical tacrolimus treatment of multilocal pyoderma gangrenosum. J Dermatol Case Rep 2013; 7:106-7. [PMID: 24133568 DOI: 10.3315/jdcr.2013.1154] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Accepted: 03/27/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Uwe Wollina
- Department of Dematology and Allergology, Academic Teaching Hospital Dresden-Friedrichstadt, Freidrichstrasse 41, 01067 Dresden, Germany
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Heemann U, Viklicky O. The role of belataceptin transplantation: results and implications of clinical trials in the context of other new biological immunosuppressant agents. Clin Transplant 2012. [DOI: 10.1111/ctr.12044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Uwe Heemann
- Department of Nephrology; Klinikum Rechts der Isar der; Technischen Universität München; München; Germany
| | - Ondrej Viklicky
- Department of Nephrology, Transplant Center; Institute for Clinical and Experimental Medicine; Prague; Czech Republic
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Berzal S, Alique M, Ruiz-Ortega M, Egido J, Ortiz A, Ramos AM. GSK3, Snail, and Adhesion Molecule Regulation by Cyclosporine A in Renal Tubular Cells. Toxicol Sci 2012; 127:425-37. [DOI: 10.1093/toxsci/kfs108] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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Lee WG, Kim WS, Park SG, Kim H, Hong J, Ko H, Kim YC. Immunosuppressive effects of subglutinol derivatives. ChemMedChem 2011; 7:218-22. [PMID: 22114006 DOI: 10.1002/cmdc.201100409] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 10/28/2011] [Indexed: 11/08/2022]
Affiliation(s)
- Won-Gil Lee
- School of Life Sciences, Gwangju Institute of Science and Technology (GIST), 261 Cheomdan-gwagiro(Oryong- dong), Buk-gu, Gwangju 500-712, Republic of Korea
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Josephson MA. Monitoring and managing graft health in the kidney transplant recipient. Clin J Am Soc Nephrol 2011; 6:1774-80. [PMID: 21734093 DOI: 10.2215/cjn.01230211] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Ongoing monitoring of kidney transplants is a widely accepted and practiced part of posttransplantation management. One reason to monitor is to evaluate whether the transplant is stable. The transplant community evaluates stability by checking kidney function. Despite problems with sensitivity and specificity, obtaining serial serum creatinine levels is the most common approach to assessing kidney function. Some programs supplement serial serum creatinine levels with surveillance kidney biopsies. Although not uniformly accepted as beneficial, surveillance biopsies are useful in select subsets of patients such as highly sensitized recipients. Recent biopsy studies shed light on which histopathology findings portend poor prognoses. The Long-Term Deterioration of Kidney Allograft Function Study (DeKAF) and similar studies that will prospectively evaluate therapeutic interventions should help the transplant community better define how to monitor and manage the kidney transplant optimally. In the meantime, Kidney Diseases: Improving Global Outcomes (KDIGO) provides an evidence-based approach toward monitoring and managing the kidney transplant.
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Cui Y, Huang Q, Auman JT, Knight B, Jin X, Blanchard KT, Chou J, Jayadev S, Paules RS. Genomic-derived markers for early detection of calcineurin inhibitor immunosuppressant-mediated nephrotoxicity. Toxicol Sci 2011; 124:23-34. [PMID: 21865292 DOI: 10.1093/toxsci/kfr217] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Calcineurin inhibitor (CI) therapy has been associated with chronic nephrotoxicity, which limits its long-term utility for suppression of allograft rejection. In order to understand the mechanisms of the toxicity, we analyzed gene expression changes that underlie the development of CI immunosuppressant-mediated nephrotoxicity in male Sprague-Dawley rats dosed daily with cyclosporine (CsA; 2.5 or 25 mg/kg/day), FK506 (0.6 or 6 mg/kg/day), or rapamycin (1 or 10 mg/kg/day) for 1, 7, 14, or 28 days. A significant increase in blood urea nitrogen was observed in animals treated with CsA (high) or FK506 (high) for 14 and 28 days. Histopathological examination revealed tubular basophilia and mineralization in animals given CsA (high) or FK506 (low and high). We identified a group of genes whose expression in rat kidney is correlated with CI-induced kidney injury. Among these genes are two genes, Slc12a3 and kidney-specific Wnk1 (KS-Wnk1), that are known to be involved in sodium transport in the distal nephrons and could potentially be involved in the mechanism of CI-induced nephrotoxicity. The downregulation of NCC (the Na-Cl cotransporter coded by Slc12a3) in rat kidney following CI treatment was confirmed by immunohistochemical staining, and the downregulation of KS-Wnk1 was confirmed by quantitative real-time-polymerase chain reaction (qRT-PCR). We hypothesize that decreased expression of Slc12a3 and KS-Wnk1 could alter the sodium chloride reabsorption in the distal tubules and contribute to the prolonged activation of the renin-angiotensin system, a demonstrated contributor to the development of CI-induced nephrotoxicity in both animal models and clinical settings. Therefore, if validated as biomarkers in humans, SLC12A3 and KS-WNK1 could potentially be useful in the early detection and reduction of CI-related nephrotoxicity in immunosuppressed transplant patients when monitoring the health of kidney xenographs in clinical practice.
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Affiliation(s)
- Yuxia Cui
- Environmental Stress and Cancer Group, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, North Carolina 27709, USA
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