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Effects of Acute Fructose Loading on Markers of Inflammation-A Pilot Study. Nutrients 2021; 13:nu13093110. [PMID: 34578989 PMCID: PMC8465001 DOI: 10.3390/nu13093110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/30/2021] [Accepted: 09/01/2021] [Indexed: 11/16/2022] Open
Abstract
Inflammation plays a role in development of diabetic complications. The postprandial state has been linked to chronic low grade inflammation. We therefore aimed to investigate the acute effects of fructose loading, with and without a pizza, on metabolic and inflammatory markers in patients with type 2 diabetes (T2D) (n = 7) and in healthy subjects (HS) (n = 6), age 47–76 years. Drinks consumed were blueberry drink (18 g fructose), Coca-Cola (17.5 g fructose), and fructose drink (35 g fructose). The levels of glucose, insulin, insulin-like growth factor binding protein-1 (IGFBP-1) and inflammatory markers: Interleukin-6 (IL-6), Monocyte chemoattractant protein-1 (MCP-1), Interleukin-18 (IL-18), Intercellular Adhesion Molecule 1 (ICAM-1), vascular cell adhesion molecule 1 (VCAM-1), and bacterial lipopolysaccharides (LPS) were analyzed in blood. The postprandial responses were assessed using Wilcoxon’s matched-pairs test, Friedman’s ANOVA and Mann–Whitney U test. There was no difference in baseline levels of inflammatory markers between the groups. In T2D, MCP-1 decreased following blueberry drink and Coca-Cola (p = 0.02), Coca-Cola + pizza and fructose + pizza (p = 0.03). In HS, IL-6 increased following blueberry + pizza and fructose + pizza (p = 0.03), there was a decrease in MCP-1 following blueberry drink and Coca-Cola (p = 0.03), and in ICAM-1 following blueberry + pizza (p = 0.03). These results may indicate a role for MCP-1 as a link between postprandial state and diabetes complications, however further mechanistic studies on larger population of patients with T2D are needed for confirmation of these results.
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Hilderman M, Qureshi AR, Abtahi F, Witt N, Jägren C, Olbers J, Delle M, Lindecrantz K, Bruchfeld A. The cholinergic anti-inflammatory pathway in resistant hypertension treated with renal denervation. Mol Med 2019; 25:39. [PMID: 31416428 PMCID: PMC6694612 DOI: 10.1186/s10020-019-0097-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 06/02/2019] [Indexed: 12/14/2022] Open
Abstract
Background Renal denervation (RDN) reduces sympathetic tone and may alter the sympathetic-parasympathetic balance. The autonomic nervous system is partly a regulator of innate immunity via the cholinergic anti-inflammatory pathway (CAP) which inhibits inflammation via the vagus nerve. Placental Growth Factor (PlGF) influences a neuro-immunological pathway in the spleen which may contribute to hypertension. The aim of this study was to investigate if modulation of renal sympathetic nerve activity affects CAP in terms of cytokine release as well as levels of PlGF. Methods Ten patients treated with RDN (Medtronic Inc), were analyzed for TNF, IL-1b and IL-10 and Lipopolysaccharide (LPS)-stimulated cytokine release before RDN, 1 day after and at 3- and 6-months follow-up. Four patients who underwent elective coronary angiography served as disease controls (DC). Results Baseline TNF was significantly lower 1 day after RDN (p = 0.03). LPS-stimulated (0, 10 and 100 ng/mL) TNF and IL-1b were significantly lower 1 day after RDN (TNF p = 0.0009, p = 0.0009 and p = 0.001, IL-1b; p = 0.0001, p = 0.002 and p = 0.005). IL-10 was significantly higher one day after RDN (p = ns, p = 0.02 and p = 0.01). These differences however declined during follow up. A more marked TNF reduction was achieved with a cholinergic analogue, GTS-21, in LPS-stimulated whole blood as compared with samples without GTS-21. Cytokine levels in controls did not differ before and 1 day after coronary angiography. PlGF was significantly higher in RDN patients and DC compared with healthy controls but did not change during follow-up. Conclusion RDN has an immediate effect on TNF in vivo and cytokine release ex vivo but seems to wane over time suggesting that current RDN techniques may not have long-lasting immunomodulatory effect. Repeated and extended stimulation of CAP in resistant hypertension by targeting neural circuits may be a potential therapeutic strategy for treatment of both hypertension and inflammation. Electronic supplementary material The online version of this article (10.1186/s10020-019-0097-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marie Hilderman
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden.
| | - Abdul Rashid Qureshi
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Farhad Abtahi
- Institute of Environmental Medicine, Division of Occupational Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Nils Witt
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Insititutet, Södersjukhuset, Stockholm, Sweden
| | - Christina Jägren
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Insititutet, Södersjukhuset, Stockholm, Sweden
| | - Joakim Olbers
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Insititutet, Södersjukhuset, Stockholm, Sweden
| | - Martin Delle
- Department of Radiology, Interventional Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Kaj Lindecrantz
- Institute of Environmental Medicine, Division of Occupational Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Annette Bruchfeld
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden
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Olofsson C, Anderstam B, Bragfors-Helin AC, Eriksson M, Qureshi AR, Lindholm B, Hilding A, Wiczkowski W, Orsini N, Stenvinkel P, Rajamand Ekberg N. Effects of acute fructose loading on levels of serum uric acid-a pilot study. Eur J Clin Invest 2019; 49:e13040. [PMID: 30368775 DOI: 10.1111/eci.13040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 09/28/2018] [Accepted: 10/22/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Fructose intake may lead to hyperuricaemia, which is associated with increased risk and progression of kidney disease. We aimed to explore the acute effects of fructose loading from different sources, with and without a pizza, on levels of serum uric acid in patients with chronic kidney disease (CKD), type 2 diabetes (T2D) without CKD, and in healthy subjects (HS). METHODS The study included six HS, and three CKD stage 4-5 and seven T2D patients. Drinks consumed were blueberry drink (17.5 g fructose), Coca-Cola (18 g fructose) and fructose drink (35 g fructose). The drinks were also combined with pizza, in total six interventions. Serum samples were collected fasting and 30, 60, 90 and 120 minutes after intake and also 240 minutes after drink + pizza, and analysed for fructose, uric acid and triglycerides. Postprandial responses were explored using repeated-measure ANOVA. RESULTS Baseline serum uric acid levels were increased in CKD (P = 0.037). There were significant differences in serum fructose and serum uric levels over time between drinks and drinks + pizza for all groups (P < 0.001 and P < 0.05, respectively). The highest peak in serum fructose followed the fructose drink interventions and the lowest the blueberry drink. The fructose drink interventions gave the highest responses in serum uric acid and the lowest responses followed the blueberry drink. Triglycerides increased following pizza interventions (P < 0.001). CONCLUSIONS Intake of fructose increases serum uric acid. The fructose intake via a blueberry drink induced lowest increase and thus may be protective.
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Affiliation(s)
- Camilla Olofsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Björn Anderstam
- Division of Renal Medicine M99, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | | | - Monica Eriksson
- Division of Renal Medicine M99, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Abdul R Qureshi
- Division of Renal Medicine M99, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Division of Renal Medicine M99, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Agneta Hilding
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Wieslaw Wiczkowski
- Institute of Animal Reproduction and Food Research of the Polish Academy of Sciences, Olsztyn, Poland
| | - Nicola Orsini
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Peter Stenvinkel
- Division of Renal Medicine M99, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Neda Rajamand Ekberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Donderski R, Miśkowiec-Wiśniewska I, Kretowicz M, Grajewska M, Manitius J, Kamińska A, Junik R, Siódmiak J, Stefańska A, Odrowąż-Sypniewska G, Pluta A, Lanaspa M, Johnson RJ. The fructose tolerance test in patients with chronic kidney disease and metabolic syndrome in comparison to healthy controls. BMC Nephrol 2015; 16:68. [PMID: 25935771 PMCID: PMC4450852 DOI: 10.1186/s12882-015-0048-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 04/01/2015] [Indexed: 01/08/2023] Open
Abstract
Background Fructose acutely raises serum uric acid in normal subjects, but the effect in subjects with metabolic syndrome or subjects with chronic kidney disease is unknown. The aim of the study was to evaluate changes in serum uric acid during the fructose tolerance test in patients with chronic kidney disease, metabolic syndrome with comparison to healthy controls. Methods Studies were performed in 36 subjects with obesity (body mass index >30) and metabolic syndrome, 14 patients with stage 3 chronic kidney disease, and 25 healthy volunteers. The fructose tolerance test was performed in each patient. The change in serum uric acid during the fructose challenge was correlated with baseline ambulatory blood pressure, serum uric acid, metabolic, and inflammatory markers, and target organ injury including carotid intima media thickness and renal resistive index (determined by Doppler). Results Absolute serum uric acid values were highest in the chronic kidney disease group, followed by the metabolic syndrome and then healthy controls. Similar increases in serum uric acid in response to the fructose tolerance test was observed in all three groups, but the greatest percent rise was observed in healthy controls compared to the other two groups. No significant association was shown between the relative rise in uric acid and clinical or inflammatory parameters associated with kidney disease (albuminuria, eGFR) or metabolic syndrome. Conclusions Subjects with chronic kidney disease and metabolic syndrome have higher absolute uric acid values following a fructose tolerance test, but show a relatively smaller percent increase in serum uric acid. Changes in serum uric acid during the fructose tolerance test did not correlate with changes in metabolic parameters, inflammatory mediators or with target organ injury. These studies suggest that acute changes in serum uric acid in response to fructose do not predict the metabolic phenotype or presence of inflammatory mediators in subjects with obesity, metabolic syndrome or chronic kidney disease. Trial registration The study was registered in ClinicalTrials.gov. Identifier : NCT01332526. www.register.clinicaltrials.gov/01332526 Electronic supplementary material The online version of this article (doi:10.1186/s12882-015-0048-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rafał Donderski
- Department of Nephrology, Hypertension and Internal Medicine, Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland.
| | - Ilona Miśkowiec-Wiśniewska
- Department of Nephrology, Hypertension and Internal Medicine, Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland.
| | - Marek Kretowicz
- Department of Nephrology, Hypertension and Internal Medicine, Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland.
| | - Magdalena Grajewska
- Department of Nephrology, Hypertension and Internal Medicine, Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland.
| | - Jacek Manitius
- Department of Nephrology, Hypertension and Internal Medicine, Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland.
| | - Anna Kamińska
- Department of Diabetology and Endocrinology, Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland.
| | - Roman Junik
- Department of Diabetology and Endocrinology, Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland.
| | - Joanna Siódmiak
- Department of Laboratory Medicine, Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland.
| | - Anna Stefańska
- Department of Laboratory Medicine, Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland.
| | - Grażyna Odrowąż-Sypniewska
- Department of Laboratory Medicine, Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland.
| | - Agnieszka Pluta
- Institute of Public Nursing, Collegium Medicum, Bydgoszcz, Nicolaus Copernicus University, Toruń, Poland.
| | - Miguel Lanaspa
- Division of Renal Diseases and Hypertension, University of Colorado Denver, Denver, CO, USA.
| | - Richard J Johnson
- Division of Renal Diseases and Hypertension, University of Colorado Denver, Denver, CO, USA.
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Koppe L, Pelletier CC, Alix PM, Kalbacher E, Fouque D, Soulage CO, Guebre-Egziabher F. Insulin resistance in chronic kidney disease: new lessons from experimental models. Nephrol Dial Transplant 2013; 29:1666-74. [PMID: 24286973 DOI: 10.1093/ndt/gft435] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Insulin resistance (IR) is a common feature of chronic kidney disease (CKD), but the underlying mechanisms still remain unclear. A growing body of evidence suggests that IR and its associated metabolic disorders are important contributors for the cardiovascular burden of these patients. In recent years, the modification of the intestinal flora and activation of inflammation pathways have been implicated in the pathogenesis of IR in obese and diabetic patients. All these pathways ultimately lead to lipid accumulation in ectopic sites and impair insulin signalling. These important discoveries have led to major advances in understanding the mechanisms of uraemia-induced IR. Indeed, recent studies show impairment of the intestinal barrier function and changes in the composition of the gut microbiome during CKD that can contribute to the prevailing inflammation, and the production and absorption of toxins generated from bacterial metabolism. The specific role of individual uraemic toxins in the pathogenesis of IR has been highlighted in rodents. Moreover, correcting some uraemia-associated factors by modulating the intestinal flora improves insulin sensitivity. This review outlines potential mechanisms by which important modifications of body homeostasis induced by the decline in kidney function can affect insulin sensitivity, and the relevance of recent advances in the field to provide novel therapeutic approaches to reduce IR associated cardiovascular mortality.
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Affiliation(s)
- Laetitia Koppe
- Université de Lyon, INSERM U1060, CarMeN, INSA de Lyon, Univ Lyon-1, Villeurbanne, France Department of Nephrology, Hospices Civils de Lyon, Hôpital E Herriot, Lyon, France
| | - Caroline C Pelletier
- Université de Lyon, INSERM U1060, CarMeN, INSA de Lyon, Univ Lyon-1, Villeurbanne, France Department of Nephrology, Hospices Civils de Lyon, Hôpital E Herriot, Lyon, France
| | - Pascaline M Alix
- Université de Lyon, INSERM U1060, CarMeN, INSA de Lyon, Univ Lyon-1, Villeurbanne, France Department of Nephrology, Hospices Civils de Lyon, Hôpital E Herriot, Lyon, France
| | - Emilie Kalbacher
- Université de Lyon, INSERM U1060, CarMeN, INSA de Lyon, Univ Lyon-1, Villeurbanne, France Department of Nephrology, Hospices Civils de Lyon, Hôpital E Herriot, Lyon, France
| | - Denis Fouque
- Université de Lyon, INSERM U1060, CarMeN, INSA de Lyon, Univ Lyon-1, Villeurbanne, France Department of Nephrology, Hospices Civils de Lyon, Hôpital E Herriot, Lyon, France
| | - Christophe O Soulage
- Department of Nephrology, Hospices Civils de Lyon, Hôpital E Herriot, Lyon, France
| | - Fitsum Guebre-Egziabher
- Université de Lyon, INSERM U1060, CarMeN, INSA de Lyon, Univ Lyon-1, Villeurbanne, France Department of Nephrology, Hospices Civils de Lyon, Hôpital E Herriot, Lyon, France
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Zawiasa A, Nowicki M. Acute effects of fructose consumption on uric acid and plasma lipids in patients with impaired renal function. Metabolism 2013; 62:1462-9. [PMID: 23866980 DOI: 10.1016/j.metabol.2013.05.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 05/26/2013] [Accepted: 05/29/2013] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Metabolic disturbances are common in patients with renal function impairment and are related to high rates of cardiovascular incidents and mortality. Kidney transplantation leads to improved survival but may lead to additional metabolic alterations caused by immunosuppressive drugs and improved nutrition. MATERIALS AND METHODS The short-term effect of oral fructose load on serum uric acid (UA), plasma lipids, and blood pressure (BP) was studied in 85 patients with chronic kidney disease (CKD) and impairment of renal function (glomerular filtration rate 50-65 ml/min per 1.73 m(2)), comprising 55 renal transplant recipients (RTR) treated with standard triple immunosuppressive therapy including a calcineurin inhibitor (CNI) cyclosporine A (CsA) or tacrolimus (Tac) and 30 non-transplanted patients with CKD. Both non-transplanted CKD patients and RTR had stable renal function and a comparable degree of kidney dysfunction. All subjects received orally 70 g of fructose dissolved in 200 ml of water. Serum UA, lipids, and blood pressure were measured at baseline and 60, 120, 180, and 240 minutes after fructose administration. RESULTS There was a significant increase of serum UA concentration (p<0.001) in both CKD patients and RTR--CsA- or Tac-treated patients comparable in the latter. Total cholesterol (TC), LDL, and HDL cholesterol significantly decreased and serum triglycerides (TG) markedly increased in RTR, whereas in CKD patients all serum lipid fractions increased. Blood pressure was unaffected by fructose intake. CONCLUSION Both non-transplanted and transplanted patients with mild renal function impairment show similar acute purine metabolic disturbances following oral administration of fructose but in the latter dietary fructose may induce a smaller hyperlipidemic response.
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Affiliation(s)
- Anna Zawiasa
- Department of Nephrology, Hypertension and Kidney Transplantation, Medical University of Łódź, Poland
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Stenvinkel P, Fröbert O, Anderstam B, Palm F, Eriksson M, Bragfors-Helin AC, Qureshi AR, Larsson T, Friebe A, Zedrosser A, Josefsson J, Svensson M, Sahdo B, Bankir L, Johnson RJ. Metabolic changes in summer active and anuric hibernating free-ranging brown bears (Ursus arctos). PLoS One 2013; 8:e72934. [PMID: 24039826 PMCID: PMC3767665 DOI: 10.1371/journal.pone.0072934] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 07/12/2013] [Indexed: 12/31/2022] Open
Abstract
The brown bear (Ursus arctos) hibernates for 5 to 6 months each winter and during this time ingests no food or water and remains anuric and inactive. Despite these extreme conditions, bears do not develop azotemia and preserve their muscle and bone strength. To date most renal studies have been limited to small numbers of bears, often in captive environments. Sixteen free-ranging bears were darted and had blood drawn both during hibernation in winter and summer. Samples were collected for measurement of creatinine and urea, markers of inflammation, the calcium-phosphate axis, and nutritional parameters including amino acids. In winter the bear serum creatinine increased 2.5 fold despite a 2-fold decrease in urea, indicating a remarkable ability to recycle urea nitrogen during hibernation. During hibernation serum calcium remained constant despite a decrease in serum phosphate and a rise in FGF23 levels. Despite prolonged inactivity and reduced renal function, inflammation does not ensue and bears seem to have enhanced antioxidant defense mechanisms during hibernation. Nutrition parameters showed high fat stores, preserved amino acids and mild hyperglycemia during hibernation. While total, essential, non-essential and branched chain amino acids concentrations do not change during hibernation anorexia, changes in individual amino acids ornithine, citrulline and arginine indicate an active, although reduced urea cycle and nitrogen recycling to proteins. Serum uric acid and serum fructose levels were elevated in summer and changes between seasons were positively correlated. Further studies to understand how bears can prevent the development of uremia despite minimal renal function during hibernation could provide new therapeutic avenues for the treatment of human kidney disease.
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Affiliation(s)
- Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Ole Fröbert
- Department of Cardiology, University Hospital of Örebro, Örebro, Sweden
| | - Björn Anderstam
- Division of Renal Medicine, Department of Clinical Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Fredrik Palm
- Department of Medical & Health Sciences, Experimental Renal Medicine, Linköping University, Linköping, Sweden
| | - Monica Eriksson
- Division of Renal Medicine, Department of Clinical Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Ann-Christin Bragfors-Helin
- Division of Renal Medicine, Department of Clinical Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Abdul Rashid Qureshi
- Division of Renal Medicine, Department of Clinical Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Tobias Larsson
- Division of Renal Medicine, Department of Clinical Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Andrea Friebe
- Zoologisches Institut, Goethe-Universität, Frankfurt am Main, Germany
| | - Andreas Zedrosser
- Faculty of Arts & Sciences, Department of Environmental & Health Studies, Telemark University College, Porsgrunn, Norway
- Institute for Wildlife Biology & Game Management, University for Natural Research & Life Sciences, Vienna, Austria
| | - Johan Josefsson
- Department of Cardiology, University Hospital of Örebro, Örebro, Sweden
| | - My Svensson
- Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark
| | - Berolla Sahdo
- Department of Clinical Medicine, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Lise Bankir
- INSERM Unit 872-E2, Centre de Recherche des Cordeliers, Paris, France
| | - Richard J. Johnson
- Division of Renal Diseases and Hypertension, University of Colorado Denver, Denver, Colorado, United States of America
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