1
|
Orlacchio A, Guastoni C, Beretta GD, Cosmai L, Galluzzo M, Gori S, Grassedonio E, Incorvaia L, Marcantoni C, Netti GS, Passamonti M, Porta C, Procopio G, Rizzo M, Roma S, Romanini L, Stacul F, Casinelli A. SIRM-SIN-AIOM: appropriateness criteria for evaluation and prevention of renal damage in the patient undergoing contrast medium examinations-consensus statements from Italian College of Radiology (SIRM), Italian College of Nephrology (SIN) and Italian Association of Medical Oncology (AIOM). Radiol Med 2022; 127:534-542. [PMID: 35303246 PMCID: PMC9098565 DOI: 10.1007/s11547-022-01483-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/08/2022] [Indexed: 11/04/2022]
Abstract
The increasing number of examinations and interventional radiological procedures that require the administration of contrast medium (CM) in patients at risk for advanced age and/or comorbidities highlights the problem of CM-induced renal toxicity. A multidisciplinary group consisting of specialists of different disciplines—radiologists, nephrologists and oncologists, members of the respective Italian Scientific Societies—agreed to draw up this position paper, to assist clinicians increasingly facing the challenges posed by CM-related renal dysfunction in their daily clinical practice. The major risk factor for acute renal failure following CM administration (post-CM AKI) is the preexistence of renal failure, particularly when associated with diabetes, heart failure or cancer. In accordance with the recent guidelines ESUR, the present document reaffirms the importance of renal risk assessment through the evaluation of the renal function (eGFR) measured on serum creatinine and defines the renal risk cutoff when the eGFR is < 30 ml/min/1.73 m2 for procedures with intravenous (i.v.) or intra-arterial (i.a.) administration of CM with renal contact at the second passage (i.e., after CM dilution with the passage into the pulmonary circulation). The cutoff of renal risk is considered an eGFR < 45 ml/min/1.73 m2 in patients undergoing i.a. administration with first-pass renal contact (CM injected directly into the renal arteries or in the arterial district upstream of the renal circulation) or in particularly unstable patients such as those admitted to the ICU. Intravenous hydration using either saline or Na bicarbonate solution before and after CM administration represents the most effective preventive measure in patients at risk of post-CM AKI. In the case of urgency, the infusion of 1.4% sodium bicarbonate pre- and post-CM may be more appropriate than the administration of saline. In cancer patients undergoing computed tomography, pre- and post-CM hydration should be performed when the eGFR is < 30 ml/min/1.73 m2 and it is also advisable to maintain a 5 to 7 days interval with respect to the administration of cisplatin and to wait 14 days before administering zoledronic acid. In patients with more severe renal risk (i.e., with eGFR < 20 ml/min/1.73 m2), particularly if undergoing cardiological interventional procedures, the prevention of post-CM AKI should be implemented through an internal protocol shared between the specialists who treat the patient. In magnetic resonance imaging (MRI) using gadolinium CM, there is a lower risk of AKI than with iodinated CM, particularly if doses < 0.1 mmol/kg body weight are used and in patients with eGFR > 30 ml/min/1.73 m2. Dialysis after MRI is indicated only in patients already undergoing chronic dialysis treatment to reduce the potential risk of systemic nephrogenic fibrosis.
Collapse
Affiliation(s)
- Antonio Orlacchio
- Radiology Unit, Department of Surgical Science, University of Rome "Tor Vergata", Rome, Italy. .,Emergency Radiology, Policlinico Tor Vergata, Viale Oxford, 81, 00133, Rome, Italy.
| | | | | | - Laura Cosmai
- Nephology Unit, Azienda Ospedaliera San Carlo Borromeo di Milano, Milan, Italy
| | - Michele Galluzzo
- Emergency Radiology, Azienda Ospedaliera San Camillo-Forlanini, Rome, Italy
| | - Stefania Gori
- Department of Oncology, IRCC Ospedale Sacro Cuore Don Calabria, Negrar Valpolicella, Italy
| | | | | | - Carmelita Marcantoni
- Nephology UnitSan Marco Hospital, Azienda Ospedaliero Universitaria, Catania, Italy
| | | | | | | | - Giuseppe Procopio
- Genito-Urinary Medical Oncology, Fondazione Istituto Nazionale Tumori, Milano, Italy
| | - Mimma Rizzo
- Oncology Unit, Hospital Santa Chiara, Trento, Italy
| | - Silvia Roma
- Radiology Unit, Hospital F. Spaziani, Frosinone, Italy
| | - Laura Romanini
- Radiology Unit, Ospedale di Cremona, ASST Cremona, Cremona, Italy
| | - Fulvio Stacul
- Department of Radiology, Maggiore Hospital, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Alice Casinelli
- Emergency Radiology, Policlinico Tor Vergata, Viale Oxford, 81, 00133, Rome, Italy
| |
Collapse
|
2
|
Ward DB, Brown KC, Valentovic MA. Radiocontrast Agent Diatrizoic Acid Induces Mitophagy and Oxidative Stress via Calcium Dysregulation. Int J Mol Sci 2019; 20:ijms20174074. [PMID: 31438500 PMCID: PMC6747199 DOI: 10.3390/ijms20174074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/17/2019] [Accepted: 08/18/2019] [Indexed: 01/15/2023] Open
Abstract
Contrast-induced acute kidney injury (CI-AKI) is the third most common cause of hospital associated kidney damage. Potential mechanisms of CI-AKI may involve diminished renal hemodynamics, inflammatory responses, and direct cytotoxicity. The hypothesis for this study is that diatrizoic acid (DA) induces direct cytotoxicity to human proximal tubule (HK-2) cells via calcium dysregulation, mitochondrial dysfunction, and oxidative stress. HK-2 cells were exposed to 0–30 mg I/mL DA or vehicle for 2–24 h. Conversion of 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and trypan blue exclusion indicated a decrease in mitochondrial and cell viability within 2 and 24 h, respectively. Mitochondrial dysfunction was apparent within 8 h post exposure to 15 mg I/mL DA as shown by Seahorse XF cell mito and Glycolysis Stress tests. Mitophagy was increased at 8 h by 15 mg I/mL DA as confirmed by elevated LC3BII/I expression ratio. HK-2 cells pretreated with calcium level modulators BAPTA-AM, EGTA, or 2-aminophenyl borinate abrogated DA-induced mitochondrial damage. DA increased oxidative stress biomarkers of protein carbonylation and 4-hydroxynonenol (4HNE) adduct formation. Caspase 3 and 12 activation was induced by DA compared to vehicle at 24 h. These studies indicate that clinically relevant concentrations of DA impair HK-2 cells by dysregulating calcium, inducing mitochondrial turnover and oxidative stress, and activating apoptosis.
Collapse
Affiliation(s)
- Dakota B Ward
- Department of Biomedical Sciences, Toxicology Research Cluster, Joan C. Edwards School of Medicine, Marshall University, 1 Marshall Drive, Huntington, WV 25755, USA
| | - Kathleen C Brown
- Department of Biomedical Sciences, Toxicology Research Cluster, Joan C. Edwards School of Medicine, Marshall University, 1 Marshall Drive, Huntington, WV 25755, USA
| | - Monica A Valentovic
- Department of Biomedical Sciences, Toxicology Research Cluster, Joan C. Edwards School of Medicine, Marshall University, 1 Marshall Drive, Huntington, WV 25755, USA.
| |
Collapse
|
3
|
Ward DB, Valentovic MA. Contrast Induced Acute Kidney Injury and Direct Cytotoxicity of Iodinated Radiocontrast Media on Renal Proximal Tubule Cells. J Pharmacol Exp Ther 2019; 370:160-171. [PMID: 31101680 DOI: 10.1124/jpet.119.257337] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 05/16/2019] [Indexed: 12/12/2022] Open
Abstract
The administration of intravenous iodinated radiocontrast media (RCM) to visualize internal structures during diagnostic procedures has increased exponentially since their first use in 1928. A serious side effect of RCM exposure is contrast-induced acute kidney injury (CI-AKI), which is defined as an abrupt and prolonged decline in renal function occurring 48-72 hours after injection. Multiple attempts have been made to decrease the toxicity of RCM by altering ionic strength and osmolarity, yet there is little evidence to substantiate that a specific RCM is superior in avoiding CI-AKI. RCM-associated kidney dysfunction is largely attributed to alterations in renal hemodynamics, specifically renal vasoconstriction; however, numerous studies indicate direct cytotoxicity as a source of epithelial damage. Exposure of in vitro renal proximal tubule cells to RCM has been shown to affect proximal tubule epithelium in the following manner: 1) changes to cellular morphology in the form of vacuolization; 2) increased production of reactive oxygen species, resulting in oxidative stress; 3) mitochondrial dysfunction, resulting in decreased efficiency of the electron transport chain and ATP production; 4) perturbation of the protein folding capacity of the endoplasmic reticulum (ER) (activating the unfolded protein response and inducing ER stress); and 5) decreased activity of cell survival kinases. The present review focuses on the direct cytotoxicity of RCM on proximal tubule cells in the absence of in vivo complications, such as alterations in renal hemodynamics or cytokine influence.
Collapse
Affiliation(s)
- Dakota B Ward
- Department of Biomedical Sciences, Toxicology Research Cluster, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Monica A Valentovic
- Department of Biomedical Sciences, Toxicology Research Cluster, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
| |
Collapse
|
4
|
Diercks DB, Owen KP, Kline JA, Sutter ME. Urine metabolomic analysis to detect metabolites associated with the development of contrast induced nephropathy. Clin Exp Emerg Med 2016; 3:204-212. [PMID: 28168227 PMCID: PMC5292299 DOI: 10.15441/ceem.15.110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/08/2016] [Accepted: 02/01/2016] [Indexed: 11/23/2022] Open
Abstract
Objective Contrast induced nephropathy (CIN) is a result of injury to the proximal tubules. The incidence of CIN is around 11% for imaging done in the acute care setting. We aim to analyze the metabolic patterns in the urine, before and after dosing with intravenous contrast for computed tomography (CT) imaging of the chest, to determine if metabolomic changes exist in patients who develop CIN. Methods A convenience sample of high risk patients undergoing a chest CT with intravenous contrast were eligible for enrollment. Urine samples were collected prior to imaging and 4 to 6 hours post imaging. Samples underwent gas chromatography/mass spectrometry profiling. Peak metabolite values were measured and data was log transformed. Significance analysis of microarrays and partial least squares was used to determine the most significant metabolites prior to CT imaging and within subject. Analysis of variance was used to rank metabolites associated with temporal change and CIN. CIN was defined as an increase in serum creatinine level of ≥ 0.5 mg/dL or ≥ 25% above baseline within 48 hours after contrast administration. Results We sampled paired urine samples from 63 subjects. The incidence of CIN was 6/63 (9.5%). Patients without CIN had elevated urinary citric acid and taurine concentrations in the pre-CT urine. Xylulose increased in the post CT sample in patients who developed CIN. Conclusion Differences in metabolomics patterns in patients who do and do not develop CIN exist. Metabolites may be potential early identifiers of CIN and identify patients at high-risk for developing this condition prior to imaging.
Collapse
Affiliation(s)
- Deborah B Diercks
- Department of Emergency Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Kelly P Owen
- Department of Emergency Medicine, Davis Medical Center, University of California, Sacramento, CA, USA
| | | | - Mark E Sutter
- Department of Emergency Medicine, Davis Medical Center, University of California, Sacramento, CA, USA
| |
Collapse
|
5
|
Diercks DB, Owen KP, Tolstikov V, Sutter ME, Kline JA. Urinary metabolomic analysis to detect changes after intravenous, non-ionic, low osmolar iodinated radiocontrast for computerized tomographic imaging. West J Emerg Med 2015; 15:152-7. [PMID: 24672603 PMCID: PMC3966458 DOI: 10.5811/westjem.2013.11.15343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Revised: 04/24/2013] [Accepted: 11/12/2013] [Indexed: 11/26/2022] Open
Abstract
Introduction Contrast-induced nephropathy is a result of injury to the proximal tubules caused by oxidative stress and ischemia. Metabolomics is a novel technique that has been used to identify renal damage from drug toxicities. The objective of this study is to analyze the metabolic changes in the urine after dosing with intravenous (IV) contrast for computed tomograph (CT) of the chest Methods A convenience sample of patients undergoing a chest CT with IV contrast who had at least one of the following: age ≥50 years, diabetes, heart failure, chronic kidney disease, coronary artery disease, or diastolic blood pressure >90 mmHg -- were eligible for enrollment. Urine samples were collected prior to imaging and 4–6 hours post imaging. Samples underwent gas chromography/mass spectrometry profiling. We measured peak metabolite values and log transformed data. Paired T tests were calculated. We used significance analysis of microarrays (SAM) to determine the most significant metabolites. Results The cohort comprised 14 patients with matched samples; 9/14 (64.3) were males, and the median age was 61 years (IQR 50–68). A total of 158 metabolites were identified. Using SAM we identified 9 metabolites that were identified as significant using a delta of 1.6. Conclusion Changes in urinary metabolites are present soon after contrast administration. This change in urinary metabolites may be potential early identifiers of contrast-induced nephropathy and could identify patients at high-risk for developing this condition.
Collapse
Affiliation(s)
- Deborah B Diercks
- University of California Davis, Department of Emergency Medicine, Sacramento, California
| | - Kelly P Owen
- University of California Davis, Department of Emergency Medicine, Sacramento, California
| | - Vladimir Tolstikov
- University of California Davis, Department of Emergency Medicine, Sacramento, California
| | - Mark E Sutter
- University of California Davis, Department of Emergency Medicine, Sacramento, California
| | - Jeffrey A Kline
- Carolinas Medical Center, Department of Emergency Medicine, Charlotte, North Carolina
| |
Collapse
|
6
|
Caixeta A, Dogan O, Weisz G. Contrast-induced nephropathy: Protective role of fenoldopam. Clin Exp Pharmacol Physiol 2012; 39:497-505. [DOI: 10.1111/j.1440-1681.2012.05707.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Adriano Caixeta
- Center for Interventional Vascular Therapy; New York Presbyterian Hospital; Columbia University Medical Center; New York; NY; USA
| | - Ozgen Dogan
- Center for Interventional Vascular Therapy; New York Presbyterian Hospital; Columbia University Medical Center; New York; NY; USA
| | - Giora Weisz
- Center for Interventional Vascular Therapy; New York Presbyterian Hospital; Columbia University Medical Center; New York; NY; USA
| |
Collapse
|
7
|
Seeliger E, Sendeski M, Rihal CS, Persson PB. Contrast-induced kidney injury: mechanisms, risk factors, and prevention. Eur Heart J 2012; 33:2007-15. [PMID: 22267241 DOI: 10.1093/eurheartj/ehr494] [Citation(s) in RCA: 347] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
In general, iodinated contrast media (CM) are tolerated well, and CM use is steadily increasing. Acute kidney injury is the leading life-threatening side effect of CM. Here, we highlight endpoints used to assess CM-induced acute kidney injury (CIAKI), CM types, risk factors, and CIAKI prevention. Moreover, we put forward a unifying theory as to how CIAKI comes about; the kidney medulla's unique hyperosmolar environment concentrates CM in the tubules and vasculature. Highly concentrated CM in the tubules and vessels increases fluid viscosity. Thus, flow through medullary tubules and vessels decreases. Reducing the flow rate will increase the contact time of cytotoxic CM with the tubular epithelial cells and vascular endothelium, and thereby damage cells and generate oxygen radicals. As a result, medullary vasoconstriction takes place, causing hypoxia. Moreover, the glomerular filtration rate declines due to congestion of highly viscous tubular fluid. Effective prevention aims at reducing the medullary concentration of CM, thereby diminishing fluid viscosity. This is achieved by generous hydration using isotonic electrolyte solutions. Even forced diuresis may prove efficient if accompanied by adequate volume supplementation. Limiting the CM dose is the most effective measure to diminish fluid viscosity and to reduce cytotoxic effects.
Collapse
Affiliation(s)
- Erdmann Seeliger
- Institute of Physiology, Center for Cardiovascular Research, Charité-Universitätsmedizin Berlin, CCM, Hessische Str. 3-4, Berlin D-10115, Germany.
| | | | | | | |
Collapse
|
8
|
Abstract
Contrast-induced nephropathy (CIN) affects in-hospital, short- and long-term morbidity and mortality. It also leads to prolonged hospital stay and increased medical cost. Given the potential clinical severity of CIN, there has been considerable interest in the development of preventative strategies to reduce the risk of contrast-induced renal deterioration in at-risk populations. A number of pharmacologic and mechanical preventive measures have been attempted, but no method other than adequate periprocedural hydration has been conclusively successful. Since its introduction in 2000, N-acetylcysteine (NAC) has been widely investigated, albeit with conflicting findings for its nephroprotection capability in patients receiving contrast media procedures. However, there is still virtually no definitive evidence of effectiveness of NAC. Although the exact mechanism responsible for the protective action of NAC from renal function deterioration remains unclear, the antioxidant and vasodilatory properties of NAC have been suggested as the main mechanisms. This review summarizes the current status of NAC as a potential agent to prevent renal functional deterioration and its limitations.
Collapse
Affiliation(s)
- Sang-Ho Jo
- Division of Cardiology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| |
Collapse
|
9
|
Abstract
1. The present review focuses on the cytotoxic effects of iodinated contrast media (CM) that are shared by all types of CM. 2. Although the clinical nephrotoxicity of CM has been progressively improved, all currently available CM still possess a level of cytotoxicity, which is probably caused by iodine. 3. The toxicity caused by specific CM properties, such as osmolarity, viscosity and ionic strength, can be differentiated from the cytotoxicity common to all CM in studies using cell culture, isolated blood vessels and isolated tubules. 4. The cytotoxicity induced by CM leads to apoptosis and cell death of endothelial and tubular cells and may be initiated by cell membrane damage, together with oxidative stress. 5. Cell damage may be aggravated by factors such as tissue hypoperfusion and hypoxia, properties of individual CM, such as ionic strength, high osmolarity and/or viscosity, and clinically unfavourable conditions. 6. Clinically detectable renal failure may result from the summation of all these factors.
Collapse
Affiliation(s)
- Mauricio M Sendeski
- Institute of Vegetative Physiology, Charité Medical University, Berlin, Germany.
| |
Collapse
|
10
|
Abstract
Contrast induced nephropathy (CIN) is an iatrogenic disorder, resulting from exposure to contrast media. Contrast-induced hemodynamic and direct cytotoxic effects on renal structures are highly evident in its pathogenesis, whereas other mechanisms are still poorly understood. CIN is typically defined as an increase in serum creatinine by either > or =0.5 mg/dl or by > or =25% from baseline within the first 2-3 days after contrast administration. Although rare in the general population, CIN has a high incidence in patients with an underlying renal disorder, in diabetics, and the elderly. The risk factors are synergistic in their ability to produce CIN. The best way to prevent CIN is to identify the patients at risk and to provide adequate peri-procedural hydration. The role of various drugs in prevention of CIN is still controversial and warrants future studies. Despite remaining uncertainty regarding the degree of nephrotoxicity produced by various contrast agents, in current practice non-ionic low-osmolar contrast media are preferred over the high-osmolar contrast media in patients with renal impairment.
Collapse
Affiliation(s)
- Tereza Pucelikova
- Cardiovascular Research Foundation, 55 East 59th Street, 6th Floor, New York, New York 10022, USA
| | | | | |
Collapse
|
11
|
Affiliation(s)
- Brendan J Barrett
- Division of Nephrology, Memorial University of Newfoundland, St. John's, Newf., Canada.
| | | |
Collapse
|
12
|
Abstract
The normal milieu of the kidney includes hypoxia, large osmotic fluxes, and an enormous amount of fluid/solute reabsorption. Renal adaptation to these conditions requires a host of molecular chaperones that stabilize protein conformation, target nascent proteins to their final intracellular destination, and prevent protein aggregation. Under physiologic or pharmacologic stress, inducible molecular chaperones provide additional mechanisms for repairing or degrading non-native proteins and for inhibiting stress-induced apoptosis. In contrast to intracellular chaperones, chaperones present on the cell surface regulate the immune system and have cytokine-like effects. A diverse range of chaperones and chaperone functions provide the renal cell with an armamentarium of responses to improve the chances of survival.
Collapse
Affiliation(s)
- Steven C Borkan
- Evans Biomedical Research Center, Boston Medical Center, Renal Section, 650 Albany Street, Boston, Massachusetts 02118-2518, USA.
| | | |
Collapse
|
13
|
Morgunov NS, Foster GS, Hirsch DJ. Contrast media induced changes in tubular electrophysiology and glomerular filtration rate in the mouse kidney. Can J Physiol Pharmacol 1997. [DOI: 10.1139/y97-118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
14
|
Andersen KJ, Vik H, Eikesdal HP, Christensen EI. Effects of contrast media on renal epithelial cells in culture. ACTA RADIOLOGICA. SUPPLEMENTUM 1995; 399:213-8. [PMID: 8610519 DOI: 10.1177/0284185195036s39926] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Proximal and distal tubular cells in culture have been exposed to various roentgen contrast media (CM) at concentrations of 0 to 100 mg I/ml for 22 hours to study cellular mechanisms that may be involved in CM-induced nephropathy. The effects on cell morphology were assessed by electron microscopy and cell viability was evaluated. Levels of brush border and lysosomal marker enzymes in the culture medium were assayed biochemically. Morphological examination showed that CM induced a concentration-dependent formation of large cytoplasmic vacuoles in both cell lines. Cellular damage was observed more frequently after exposure to low-osmolal rather than the iso-osmolal CM iodixanol; the low-osmolal CM causing more cell death and inhibiting cellular growth to a greater degree than did iodixanol. In cultures of both cell lines the CM produced a concentration-dependent increase in brush border marker enzyme activity. While an increase in lysosomal enzyme activity was seen at low concentrations, a decrease in activity occurred at high concentrations. Earlier investigations have demonstrated that the nonionic CM have less pronounced effects on the cell lines studied than ionic CM. The results presented here indicate that the effects of the iso-osmolal nonionic CM (iodixanol) on both the investigated cell lines are less marked than those of the low-osmolal nonionic CM investigated.
Collapse
Affiliation(s)
- K J Andersen
- Division of Clinical Cell Biology, Medical Department A, University of Bergen, Haukeland Hospital, Norway
| | | | | | | |
Collapse
|