1
|
Macias SL, Palmer O, Simonovich JA, Clark RA, Hudalla GA, Keselowsky BG. Immunometabolic Approaches Mitigating Foreign Body Response and Transcriptome Characterization of the Foreign Body Capsule. Adv Healthc Mater 2024:e2400602. [PMID: 39148172 DOI: 10.1002/adhm.202400602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 07/08/2024] [Indexed: 08/17/2024]
Abstract
Directing immunometabolism presents new opportunities to modulate key cell types associated with the formation of foreign body response (FBR) capsule. Contrasting approaches directing immunometabolism are investigated to mitigate FBR: a broadly suppressive metabolic inhibitor (MI) cocktail comprised of 2-deoxyglucose (2-DG), metformin, and 6-diazo-5-oxo-l-norleucine (DON) with daily systemic dosing regimen, and local weekly injection of the more narrowly focused tryptophan catabolizing IDO-Gal3 fusion protein. Treatments significantly decrease FBR capsule formed around subcutaneously implanted cellulose disks. MI cocktail results in a substantially thinner FBR capsule (40% of control), while weekly local injection of IDO-Gal3 also results in a thinner FBR capsule (69% of control). RNA-sequencing capsule transcripts reveal MI cocktail promotes quiescence, with decreased antigen processing and presentation, T helper subset differentiation, and cytokine-cytokine receptor pathway. IDO-Gal3 promotes pro-regenerative, alternatively activated M2-like macrophages and T helper 2 cells, with increased expression of type 2 response-associated genes (Il4, Il13, Arg1, Mrc1, Chil3, Gata3). IDO-Gal3 decreases pro-inflammatory innate sensing pathways, and C-type lectin receptor, NOD-like receptor, RIG-I-like receptor, and Toll-like receptor signaling. This work helps define key gene targets and pathways concomitantly regulated in the FBR capsule during immunometabolic modulation compared to control FBR capsule.
Collapse
Affiliation(s)
- Sabrina L Macias
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32611, USA
| | - Olivia Palmer
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32611, USA
| | - Jennifer A Simonovich
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32611, USA
| | - Ryan A Clark
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32611, USA
| | - Gregory A Hudalla
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32611, USA
| | - Benjamin G Keselowsky
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, 32611, USA
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, 32610, USA
| |
Collapse
|
2
|
Noble J, Cabezas L, Truffot A, Dumolard L, Jouve T, Malvezzi P, Rostaing L, Dard C, Saas P, Cravedi P, Macek-Jilkova Z. Glycolysis Changes in Alloreactive Memory B Cells in Highly Sensitized Kidney Transplant Recipients Undergonig Desensitization Therapy. Transpl Int 2024; 37:13029. [PMID: 39081904 PMCID: PMC11287219 DOI: 10.3389/ti.2024.13029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 06/25/2024] [Indexed: 08/02/2024]
Abstract
Despite the growing use of desensitization strategies, hyperimmune patients remain at high risk of antibody-mediated rejection suggesting that, even when donor-specific antibodies (DSA) are effectively depleted, anti-donor specific B cells persist. We included 10 highly sensitized recipients that underwent desensitization with plasmapheresis and B cell depletion prior to kidney transplantation. We quantified changes in DSA (luminex), total B-cell subsets (flow cytometry), anti-donor HLA B cells (fluorospot), and single-cell metabolism in serially collected samples before desensitization, at the time of transplant, and at 6 and 12 months thereafter. Desensitization was associated with a decrease in DSA and total memory B cell and naive B cell percentage, while plasma cells and memory anti-donor HLA circulating B cells persisted up to 12 months after transplant. At 12-month post-transplantation, memory B cells increased their glycolytic capacity, while proliferative KI67+ plasma cells modified their metabolism by increasing fatty acid and amino acid oxidation capacity and decreasing their glucose dependence. Despite effective DSA depletion, anti-donor B cells persist in kidney transplant recipients. Due to the reliance of these cells on glycolysis, glycolysis-targeting therapies might represent a valuable treatment strategy.
Collapse
Affiliation(s)
- Johan Noble
- Nephrology, Hemodialysis Apheresis and Kidney Transplantation, Department, CHU Grenoble Alpes, Grenoble, France
- University Grenoble Alpes, CNRS, Inserm, CHU Grenoble Alpes, Institute for Advanced Biosciences, Grenoble, France
- Department of Medicine, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Lara Cabezas
- Nephrology, Hemodialysis Apheresis and Kidney Transplantation, Department, CHU Grenoble Alpes, Grenoble, France
- University Grenoble Alpes, CNRS, Inserm, CHU Grenoble Alpes, Institute for Advanced Biosciences, Grenoble, France
| | - Aurelie Truffot
- Department of Medicine, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Virology Department, University Hospital Grenoble, Grenoble, France
| | - Lucile Dumolard
- University Grenoble Alpes, CNRS, Inserm, CHU Grenoble Alpes, Institute for Advanced Biosciences, Grenoble, France
| | - Thomas Jouve
- Nephrology, Hemodialysis Apheresis and Kidney Transplantation, Department, CHU Grenoble Alpes, Grenoble, France
- University Grenoble Alpes, CNRS, Inserm, CHU Grenoble Alpes, Institute for Advanced Biosciences, Grenoble, France
| | - Paolo Malvezzi
- Nephrology, Hemodialysis Apheresis and Kidney Transplantation, Department, CHU Grenoble Alpes, Grenoble, France
| | - Lionel Rostaing
- Nephrology, Hemodialysis Apheresis and Kidney Transplantation, Department, CHU Grenoble Alpes, Grenoble, France
- University Grenoble Alpes, CNRS, Inserm, CHU Grenoble Alpes, Institute for Advanced Biosciences, Grenoble, France
| | - Céline Dard
- EFS, Recherche et Développement, Grenoble, France
| | - Philippe Saas
- University Grenoble Alpes, CNRS, Inserm, CHU Grenoble Alpes, Institute for Advanced Biosciences, Grenoble, France
- EFS, Recherche et Développement, Grenoble, France
| | - Paolo Cravedi
- Department of Medicine, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Zuzana Macek-Jilkova
- University Grenoble Alpes, CNRS, Inserm, CHU Grenoble Alpes, Institute for Advanced Biosciences, Grenoble, France
- Hepato-Gastroenterology and Digestive Oncology Department, CHU Grenoble Alpes, Grenoble, France
| |
Collapse
|
3
|
Noble J, Macek Jilkova Z, Aspord C, Malvezzi P, Fribourg M, Riella LV, Cravedi P. Harnessing Immune Cell Metabolism to Modulate Alloresponse in Transplantation. Transpl Int 2024; 37:12330. [PMID: 38567143 PMCID: PMC10985621 DOI: 10.3389/ti.2024.12330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 03/06/2024] [Indexed: 04/04/2024]
Abstract
Immune cell metabolism plays a pivotal role in shaping and modulating immune responses. The metabolic state of immune cells influences their development, activation, differentiation, and overall function, impacting both innate and adaptive immunity. While glycolysis is crucial for activation and effector function of CD8 T cells, regulatory T cells mainly use oxidative phosphorylation and fatty acid oxidation, highlighting how different metabolic programs shape immune cells. Modification of cell metabolism may provide new therapeutic approaches to prevent rejection and avoid immunosuppressive toxicities. In particular, the distinct metabolic patterns of effector and suppressive cell subsets offer promising opportunities to target metabolic pathways that influence immune responses and graft outcomes. Herein, we review the main metabolic pathways used by immune cells, the techniques available to assay immune metabolism, and evidence supporting the possibility of shifting the immune response towards a tolerogenic profile by modifying energetic metabolism.
Collapse
Affiliation(s)
- Johan Noble
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
- Inserm U 1209, CNRS UMR 5309, Team Epigenetics, Immunity, Metabolism, Cell Signaling and Cancer, Institute for Advanced Biosciences Grenoble, University Grenoble Alpes, La Tronche, France
| | - Zuzana Macek Jilkova
- Inserm U 1209, CNRS UMR 5309, Team Epigenetics, Immunity, Metabolism, Cell Signaling and Cancer, Institute for Advanced Biosciences Grenoble, University Grenoble Alpes, La Tronche, France
- Hepato-Gastroenterology and Digestive Oncology Department, University Hospital Grenoble, Grenoble, France
| | - Caroline Aspord
- Inserm U 1209, CNRS UMR 5309, Team Epigenetics, Immunity, Metabolism, Cell Signaling and Cancer, Institute for Advanced Biosciences Grenoble, University Grenoble Alpes, La Tronche, France
- Établissement Français du Sang Auvergne-Rhône-Alpes, R&D-Laboratory, Grenoble, France
| | - Paolo Malvezzi
- Nephrology, Hemodialysis, Apheresis and Kidney Transplantation Department, University Hospital Grenoble, Grenoble, France
| | - Miguel Fribourg
- Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai New York, New York, NY, United States
| | - Leonardo V. Riella
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Paolo Cravedi
- Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai New York, New York, NY, United States
| |
Collapse
|
4
|
Iske J, Cao Y, Roesel MJ, Shen Z, Nian Y. Metabolic reprogramming of myeloid-derived suppressor cells in the context of organ transplantation. Cytotherapy 2023; 25:789-797. [PMID: 37204374 DOI: 10.1016/j.jcyt.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 04/08/2023] [Accepted: 04/10/2023] [Indexed: 05/20/2023]
Abstract
Myeloid-derived suppressor cells (MDSCs) are naturally occurring leukocytes that develop from immature myeloid cells under inflammatory conditions that were discovered initially in the context of tumor immunity. Because of their robust immune inhibitory activities, there has been growing interest in MDSC-based cellular therapies for transplant tolerance induction. Indeed, various pre-clinical studies have introduced in vivo expansion or adoptive transfer of MDSC as a promising therapeutic strategy leading to a profound extension of allograft survival due to suppression of alloreactive T cells. However, several limitations of cellular therapies using MDSCs remain to be addressed, including their heterogeneous nature and limited expansion capacity. Metabolic reprogramming plays a crucial role for differentiation, proliferation and effector function of immune cells. Notably, recent reports have focused on a distinct metabolic phenotype underlying the differentiation of MDSCs in an inflammatory microenvironment representing a regulatory target. A better understanding of the metabolic reprogramming of MDSCs may thus provide novel insights for MDSC-based treatment approaches in transplantation. In this review, we will summarize recent, interdisciplinary findings on MDSCs metabolic reprogramming, dissect the underlying molecular mechanisms and discuss the relevance for potential treatment approaches in solid-organ transplantation.
Collapse
Affiliation(s)
- Jasper Iske
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Yu Cao
- Research Institute of Transplant Medicine, Tianjin First Central Hospital, Nankai University, Tianjin, China
| | - Maximilian J Roesel
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Zhongyang Shen
- Research Institute of Transplant Medicine, Tianjin First Central Hospital, Nankai University, Tianjin, China
| | - Yeqi Nian
- Research Institute of Transplant Medicine, Tianjin First Central Hospital, Nankai University, Tianjin, China.
| |
Collapse
|
5
|
Shi ZY, Yang C, Lu LY, Lin CX, Liang S, Li G, Zhou HM, Zheng JM. Inhibition of hexokinase 2 with 3-BrPA promotes MDSCs differentiation and immunosuppressive function. Cell Immunol 2023; 385:104688. [PMID: 36774675 DOI: 10.1016/j.cellimm.2023.104688] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 12/08/2022] [Accepted: 02/03/2023] [Indexed: 02/08/2023]
Abstract
The adoptive transfer of ex vivo generated myeloid-derived suppressor cells (MDSCs) may be a promising therapeutic strategy for preventing allograft rejection after solid organ transplantation. Currently, the precise role of immune-metabolic pathways in the differentiation and function of MDSCs is not fully understood. Hexokinase 2 (HK2) is an isoform of hexokinase and is a key enzyme involved in the increased aerobic glycolysis of different immune cells during their activation and function. Here, we demonstrate that the addition of HK2 inhibitor 3-Bromopyruvic acid (3-BrPA) into traditional MDSCs induction system in vitro significantly promoted MDSCs production and enhanced their immunosuppressive function. Treatment with 3-BrPA increased the expression of MDSC-related immunosuppressive molecules, such as iNOS, Arg1, and CXCR2. Moreover, the adoptive transfer of 3-BrPA-treated MDSCs significantly prolonged the survival time of mouse heart allografts. This study provides a novel strategy to solve the problems of harvesting enough autologous cells for MDSC production from sick patients, and producing functionally enhanced MDSCs for preventing graft rejection and inducing tolerance.
Collapse
Affiliation(s)
- Zhan-Yue Shi
- Department of Cardiothoracic Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Chao Yang
- Department of Organ Transplantation, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510000, China
| | - Liu-Yi Lu
- Department of Cardiothoracic Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China; Research Center of Medicine, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Can-Xiang Lin
- Department of Plastic Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shi Liang
- Department of Cardiothoracic Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Gen Li
- Department of Cardiothoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong-Min Zhou
- Department of Cardiothoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Jun-Meng Zheng
- Department of Cardiothoracic Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China.
| |
Collapse
|
6
|
Iglesias M, Brennan DC, Larsen CP, Raimondi G. Targeting inflammation and immune activation to improve CTLA4-Ig-based modulation of transplant rejection. Front Immunol 2022; 13:926648. [PMID: 36119093 PMCID: PMC9478663 DOI: 10.3389/fimmu.2022.926648] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022] Open
Abstract
For the last few decades, Calcineurin inhibitors (CNI)-based therapy has been the pillar of immunosuppression for prevention of organ transplant rejection. However, despite exerting effective control of acute rejection in the first year post-transplant, prolonged CNI use is associated with significant side effects and is not well suited for long term allograft survival. The implementation of Costimulation Blockade (CoB) therapies, based on the interruption of T cell costimulatory signals as strategy to control allo-responses, has proven potential for better management of transplant recipients compared to CNI-based therapies. The use of the biologic cytotoxic T-lymphocyte associated protein 4 (CTLA4)-Ig is the most successful approach to date in this arena. Following evaluation of the BENEFIT trials, Belatacept, a high-affinity version of CTLA4-Ig, has been FDA approved for use in kidney transplant recipients. Despite its benefits, the use of CTLA4-Ig as a monotherapy has proved to be insufficient to induce long-term allograft acceptance in several settings. Multiple studies have demonstrated that events that induce an acute inflammatory response with the consequent release of proinflammatory cytokines, and an abundance of allograft-reactive memory cells in the recipient, can prevent the induction of or break established immunomodulation induced with CoB regimens. This review highlights advances in our understanding of the factors and mechanisms that limit CoB regimens efficacy. We also discuss recent successes in experimentally designing complementary therapies that favor CTLA4-Ig effect, affording a better control of transplant rejection and supporting their clinical applicability.
Collapse
Affiliation(s)
- Marcos Iglesias
- Vascularized and Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- *Correspondence: Giorgio Raimondi, ; Marcos Iglesias,
| | - Daniel C. Brennan
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Christian P. Larsen
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Giorgio Raimondi
- Vascularized and Composite Allotransplantation (VCA) Laboratory, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- *Correspondence: Giorgio Raimondi, ; Marcos Iglesias,
| |
Collapse
|
7
|
Lee CF, Cheng CH, Hung HC, Lee JC, Wang YC, Wu TH, Wu TJ, Chou HS, Chan KM, Lee WC. Sedative and Immunosuppressive Effects of Dexmedetomidine in Transplantation. Pharmaceuticals (Basel) 2021; 14:825. [PMID: 34451922 PMCID: PMC8400267 DOI: 10.3390/ph14080825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/19/2021] [Accepted: 08/19/2021] [Indexed: 11/17/2022] Open
Abstract
Dexmedetomidine, an α2-adrenergic receptor agonist, is used as an anti-anxiety medication. It exerts a cholinergic effect, thereby reducing the release of tumor necrosis factor alpha (TNF-α). We hypothesized that the use of dexmedetomidine as a sedative agent in transplantation would also protect allografts. We examined our patients who underwent living donor liver transplantation. Subsequently, we generated a series of mouse models to investigate the effect of dexmedetomidine on sedation-based tolerance post transplantation. A total of 49 liver recipients were enrolled in this study, of which 23 (47%) were administered dexmedetomidine through 24 h infusion on postoperative day 1. A trend toward the improvement of hepatocyte injury along with better liver function was observed in the dexmedetomidine-treated group during the first postoperative week. In animal models, dexmedetomidine inhibited the proliferation of CD4+ and CD8+ T cells and TNF-α production in a dose-dependent manner. We used dexmedetomidine to treat skin-transplanted mice and observed a significantly prolonged graft survival in mice that were administered a higher dose of dexmedetomidine. Our results revealed that dexmedetomidine exerts a dual effect of sedation and immunosuppression. This light-sedation approach will not only make patients calmer in the intensive care unit but also protect allografts from injury.
Collapse
Affiliation(s)
- Chen-Fang Lee
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (C.-H.C.); (H.-C.H.); (J.-C.L.); (Y.-C.W.); (T.-H.W.); (T.-J.W.); (H.-S.C.); (K.-M.C.); (W.-C.L.)
- College of Medicine, Chang-Gung University, Taoyuan City 333, Taiwan
| | - Chih-Hsien Cheng
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (C.-H.C.); (H.-C.H.); (J.-C.L.); (Y.-C.W.); (T.-H.W.); (T.-J.W.); (H.-S.C.); (K.-M.C.); (W.-C.L.)
| | - Hao-Chien Hung
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (C.-H.C.); (H.-C.H.); (J.-C.L.); (Y.-C.W.); (T.-H.W.); (T.-J.W.); (H.-S.C.); (K.-M.C.); (W.-C.L.)
| | - Jin-Chiao Lee
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (C.-H.C.); (H.-C.H.); (J.-C.L.); (Y.-C.W.); (T.-H.W.); (T.-J.W.); (H.-S.C.); (K.-M.C.); (W.-C.L.)
| | - Yu-Chiao Wang
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (C.-H.C.); (H.-C.H.); (J.-C.L.); (Y.-C.W.); (T.-H.W.); (T.-J.W.); (H.-S.C.); (K.-M.C.); (W.-C.L.)
| | - Tsung-Han Wu
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (C.-H.C.); (H.-C.H.); (J.-C.L.); (Y.-C.W.); (T.-H.W.); (T.-J.W.); (H.-S.C.); (K.-M.C.); (W.-C.L.)
| | - Ting-Jung Wu
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (C.-H.C.); (H.-C.H.); (J.-C.L.); (Y.-C.W.); (T.-H.W.); (T.-J.W.); (H.-S.C.); (K.-M.C.); (W.-C.L.)
| | - Hong-Shiue Chou
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (C.-H.C.); (H.-C.H.); (J.-C.L.); (Y.-C.W.); (T.-H.W.); (T.-J.W.); (H.-S.C.); (K.-M.C.); (W.-C.L.)
| | - Kun-Ming Chan
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (C.-H.C.); (H.-C.H.); (J.-C.L.); (Y.-C.W.); (T.-H.W.); (T.-J.W.); (H.-S.C.); (K.-M.C.); (W.-C.L.)
| | - Wei-Chen Lee
- Department of Liver and Transplantation Surgery, Chang-Gung Memorial Hospital at Linkou, Taoyuan City 333, Taiwan; (C.-H.C.); (H.-C.H.); (J.-C.L.); (Y.-C.W.); (T.-H.W.); (T.-J.W.); (H.-S.C.); (K.-M.C.); (W.-C.L.)
| |
Collapse
|