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Liu B, Zhang Y, Wang Y, Meng Q, Zhang D, Yang H, Li G, Wang Y, Zhou H. Pharmacological targeting of AMPK to restore glucose and fatty acid metabolism homeostasis attenuates transplanted kidney fibrosis. Biochim Biophys Acta Mol Basis Dis 2024; 1871:167510. [PMID: 39278511 DOI: 10.1016/j.bbadis.2024.167510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 08/10/2024] [Accepted: 09/07/2024] [Indexed: 09/18/2024]
Abstract
Chronic fibrosis often occurs in transplanted kidneys, leading to progressive functional decline. The underlying mechanisms may involve disruption in the metabolism of renal tubular epithelial cells. The liver kinase B1 (LKB1)-AMPK pathway is a pivotal regulatory hub for glucose and fatty acid metabolism and may play a role in transplanted kidney fibrosis, but it has not been reported. In this study we administered fenofibrate, 2-deoxyglucose, or metformin to modulate metabolism in Brown Norway rat kidney transplants and investigated pathways involved in fibrosis using various assays. We identified an impaired LKB1-AMPK pathway within epithelial cells, resulting in perturbed glucose and fatty acid metabolism, collagen secretion, extracellular matrix remodeling, and epithelial-mesenchymal transition. ACOX1, a pivotal enzyme in the fatty acid peroxisomal β-oxidation pathway, played an important role in transplanted renal fibrosis. Furthermore, several metabolism-targeting drugs, particularly metformin, emerged as potent fibrosis inhibitors. Metformin attenuated fibrosis, improved renal function, and reduced inflammation and macrophage infiltration in the transplanted kidneys. These results provide new perspectives for understanding the complex molecular basis underlying transplanted renal fibrosis and developing novel therapeutic strategies.
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Affiliation(s)
- Bin Liu
- Department of Urology II, The First Hospital of Jilin University, Changchun 130021, Jilin, China
| | - Yanghe Zhang
- Department of Urology II, The First Hospital of Jilin University, Changchun 130021, Jilin, China
| | - Yuxiong Wang
- Department of Urology II, The First Hospital of Jilin University, Changchun 130021, Jilin, China
| | - Qingfei Meng
- Key Laboratory of Pathobiology, Ministry of Education, Jilin University, Changchun 130021, Jilin, China
| | - Dan Zhang
- Key Laboratory of Pathobiology, Ministry of Education, Jilin University, Changchun 130021, Jilin, China
| | - Hongxia Yang
- Key Laboratory of Pathobiology, Ministry of Education, Jilin University, Changchun 130021, Jilin, China
| | - Guangtao Li
- Key Laboratory of Pathobiology, Ministry of Education, Jilin University, Changchun 130021, Jilin, China
| | - Yishu Wang
- Key Laboratory of Pathobiology, Ministry of Education, Jilin University, Changchun 130021, Jilin, China
| | - Honglan Zhou
- Department of Urology II, The First Hospital of Jilin University, Changchun 130021, Jilin, China
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Lichner Z, Ding M, Khare T, Dan Q, Benitez R, Praszner M, Song X, Saleeb R, Hinz B, Pei Y, Szászi K, Kapus A. Myocardin-Related Transcription Factor Mediates Epithelial Fibrogenesis in Polycystic Kidney Disease. Cells 2024; 13:984. [PMID: 38891116 PMCID: PMC11172104 DOI: 10.3390/cells13110984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 05/21/2024] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
Polycystic kidney disease (PKD) is characterized by extensive cyst formation and progressive fibrosis. However, the molecular mechanisms whereby the loss/loss-of-function of Polycystin 1 or 2 (PC1/2) provokes fibrosis are largely unknown. The small GTPase RhoA has been recently implicated in cystogenesis, and we identified the RhoA/cytoskeleton/myocardin-related transcription factor (MRTF) pathway as an emerging mediator of epithelium-induced fibrogenesis. Therefore, we hypothesized that MRTF is activated by PC1/2 loss and plays a critical role in the fibrogenic reprogramming of the epithelium. The loss of PC1 or PC2, induced by siRNA in vitro, activated RhoA and caused cytoskeletal remodeling and robust nuclear MRTF translocation and overexpression. These phenomena were also manifested in PKD1 (RC/RC) and PKD2 (WS25/-) mice, with MRTF translocation and overexpression occurring predominantly in dilated tubules and the cyst-lining epithelium, respectively. In epithelial cells, a large cohort of PC1/PC2 downregulation-induced genes was MRTF-dependent, including cytoskeletal, integrin-related, and matricellular/fibrogenic proteins. Epithelial MRTF was necessary for the paracrine priming of the fibroblast-myofibroblast transition. Thus, MRTF acts as a prime inducer of epithelial fibrogenesis in PKD. We propose that RhoA is a common upstream inducer of both histological hallmarks of PKD: cystogenesis and fibrosis.
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Affiliation(s)
- Zsuzsanna Lichner
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada; (Z.L.); (T.K.); (R.S.); (K.S.)
| | - Mei Ding
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada; (Z.L.); (T.K.); (R.S.); (K.S.)
| | - Tarang Khare
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada; (Z.L.); (T.K.); (R.S.); (K.S.)
- Enrich Bioscience, Toronto, ON M5B 1T8, Canada
| | - Qinghong Dan
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada; (Z.L.); (T.K.); (R.S.); (K.S.)
| | - Raquel Benitez
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada; (Z.L.); (T.K.); (R.S.); (K.S.)
| | - Mercédesz Praszner
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada; (Z.L.); (T.K.); (R.S.); (K.S.)
| | - Xuewen Song
- Division of Nephrology, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Rola Saleeb
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada; (Z.L.); (T.K.); (R.S.); (K.S.)
- Department of Laboratory Medicine and Pathobiology, Temerty School of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Boris Hinz
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada; (Z.L.); (T.K.); (R.S.); (K.S.)
- Faculty of Dentistry, University of Toronto, Toronto, ON M5G 1G6, Canada
| | - York Pei
- Division of Nephrology, University Health Network, Toronto, ON M5G 2C4, Canada
| | - Katalin Szászi
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada; (Z.L.); (T.K.); (R.S.); (K.S.)
- Department of Laboratory Medicine and Pathobiology, Temerty School of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - András Kapus
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Toronto, ON M5B 1T8, Canada; (Z.L.); (T.K.); (R.S.); (K.S.)
- Department of Surgery, University of Toronto, Toronto, ON M5T 1P5, Canada
- Department of Biochemistry, University of Toronto, Toronto, ON M5S 1A8, Canada
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Capelli I, Lerario S, Ciurli F, Berti GM, Aiello V, Provenzano M, La Manna G. Investigational agents for autosomal dominant polycystic kidney disease: preclinical and early phase study insights. Expert Opin Investig Drugs 2024; 33:469-484. [PMID: 38618918 DOI: 10.1080/13543784.2024.2342327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/08/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most common inherited kidney condition caused by a single-gene mutation. It leads patients to kidney failure in more than 50% of cases by the age of 60, and, given the dominant inheritance, this disease is present in the family history in more than 90% of cases. AREAS COVERED This review aims to analyze the set of preclinical and early-phase studies to provide a general view of the current progress on ADPKD therapeutic options. Articles from PubMed and the current status of the trials listed in clinicaltrials.gov were examined for the review. EXPERT OPINION Many potential therapeutic targets are currently under study for the treatment of ADPKD. A few drugs have reached the clinical phase, while many are currently still in the preclinical phase. Organoids could be a novel approach to the study of drugs in this phase. Other than pharmacological options, very important developing approaches are represented by gene therapy and the use of MiRNA inhibitors.
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Affiliation(s)
- Irene Capelli
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Sarah Lerario
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Francesca Ciurli
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Gian Marco Berti
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Valeria Aiello
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Michele Provenzano
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Rende, Italy
| | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum University of Bologna, Bologna, Italy
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Olaniyi KS, Areloegbe SE, Fiemotongha FE. Cardiac energy depletion in a rat model of polycystic ovarian syndrome is reversed by acetate and associated with inhibitory effect of HDAC2/mTOR. Eur J Pharmacol 2024; 962:176243. [PMID: 38048978 DOI: 10.1016/j.ejphar.2023.176243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 12/06/2023]
Abstract
In addition to the clinical manifestation of polycystic ovarian syndrome (PCOS), life-threatening diseases, especially hypertension and cardiovascular disease (CVD) are emerging critical complications of PCOS. Changes in cardiac energy remains an independent risk factor of CVD. Histone deacetylase (HDAC) inhibitors, including acetate has received attention for its beneficial role in energy regulation. Herein we hypothesized that acetate improves cardiac energy homeostasis in experimentally induced PCOS. Female Wistar rats (8-week-old) were divided into groups. To induce PCOS, 1 mg/kg of letrozole was given for 21 days. After confirmation of PCOS, acetate (200 mg/kg) was administered for 6 weeks. Rats with PCOS showed multiple ovarian cysts with androgen excess and decreased SHBG. The rats also manifested impaired glucose tolerance/hyperinsulinemia and hypertriglyceridemia. Increased systemic oxidative stress (malondialdehyde)/inflammatory (NF-kB/SDF-1) markers and nitric oxide deficiency (NO/eNOS) were observed. Though, the body weight was increased without affecting the cardiac mass index of PCOS rats. Nevertheless, there was an increase in cardiac triglyceride and oxidative stress/inflammatory markers with consequent cardiac injury, revealed by decreased levels of SIRT-1/HIF-1α and increased levels of CTGF/TGFβ-1 and plasma troponin T. These led to cardiac ATP depletion with increased AMP and AMP/ATP ratio. These alterations were accompanied by elevated levels of mTOR and HDAC2, which were reversed when treated with acetate. The present results interestingly suggest that HDAC2 inhibition by acetate reversed cardiac energy depletion and attendant cardiomorbidities in experimental PCOS model. A beneficial effect that is accompanied by suppressed expression of mTOR.
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Affiliation(s)
- Kehinde S Olaniyi
- Cardio/Endo-metabolic and Microbiome Research Unit, Department of Physiology, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, 360101, Nigeria.
| | - Stephanie E Areloegbe
- Cardio/Endo-metabolic and Microbiome Research Unit, Department of Physiology, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, 360101, Nigeria
| | - Faustina E Fiemotongha
- Cardio/Endo-metabolic and Microbiome Research Unit, Department of Physiology, College of Medicine and Health Sciences, Afe Babalola University, Ado-Ekiti, 360101, Nigeria
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Pana C, Stanigut AM, Cimpineanu B, Alexandru A, Salim C, Nicoara AD, Resit P, Tuta LA. Urinary Biomarkers in Monitoring the Progression and Treatment of Autosomal Dominant Polycystic Kidney Disease-The Promised Land? MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050915. [PMID: 37241147 DOI: 10.3390/medicina59050915] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023]
Abstract
Autosomal dominant polycystic kidney disease (ADPKD) is the most common genetic kidney disease, and it leads to end-stage renal disease (ESRD). The clinical manifestations of ADPKD are variable, with extreme differences observable in its progression, even among members of the same family with the same genetic mutation. In an age of new therapeutic options, it is important to identify patients with rapidly progressive evolution and the risk factors involved in the disease's poor prognosis. As the pathophysiological mechanisms of the formation and growth of renal cysts have been clarified, new treatment options have been proposed to slow the progression to end-stage renal disease. Furthermore, in addition to the conventional factors (PKD1 mutation, hypertension, proteinuria, total kidney volume), increasing numbers of studies have recently identified new serum and urinary biomarkers of the disease's progression, which are cheaper and more easily to dosing from the early stages of the disease. The present review discusses the utility of new biomarkers in the monitoring of the progress of ADPKD and their roles in new therapeutic approaches.
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Affiliation(s)
- Camelia Pana
- Nephrology Department, Faculty of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
| | - Alina Mihaela Stanigut
- Nephrology Department, Faculty of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
| | - Bogdan Cimpineanu
- Medical Semiology Department, Faculty of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
| | - Andreea Alexandru
- Nephrology Department, Constanta County Emergency Hospital, 900601 Constanta, Romania
| | - Camer Salim
- Emergency Department, Constanta County Emergency Hospital, 900601 Constanta, Romania
| | - Alina Doina Nicoara
- Medical Semiology Department, Faculty of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
| | - Periha Resit
- Faculty of Medicine, "Ovidius" University of Constanta, 900601 Constanta, Romania
| | - Liliana Ana Tuta
- Nephrology Department, Faculty of Medicine, "Ovidius" University of Constanta, 900470 Constanta, Romania
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Shillingford JM, Shayman JA. Functional TFEB activation characterizes multiple models of renal cystic disease and loss of polycystin-1. Am J Physiol Renal Physiol 2023; 324:F404-F422. [PMID: 36794754 PMCID: PMC10069964 DOI: 10.1152/ajprenal.00237.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 02/07/2023] [Accepted: 02/07/2023] [Indexed: 02/17/2023] Open
Abstract
Polycystic kidney disease is a disorder of renal epithelial growth and differentiation. Transcription factor EB (TFEB), a master regulator of lysosome biogenesis and function, was studied for a potential role in this disorder. Nuclear translocation and functional responses to TFEB activation were studied in three murine models of renal cystic disease, including knockouts of folliculin, folliculin interacting proteins 1 and 2, and polycystin-1 (Pkd1) as well as in mouse embryonic fibroblasts lacking Pkd1 and three-dimensional cultures of Madin-Darby canine kidney cells. Nuclear translocation of Tfeb characterized cystic but not noncystic renal tubular epithelia in all three murine models as both an early and sustained response to cyst formation. Epithelia expressed elevated levels of Tfeb-dependent gene products, including cathepsin B and glycoprotein nonmetastatic melanoma protein B. Nuclear Tfeb translocation was observed in mouse embryonic fibroblasts lacking Pkd1 but not wild-type fibroblasts. Pkd1 knockout fibroblasts were characterized by increased Tfeb-dependent transcripts, lysosomal biogenesis and repositioning, and increased autophagy. The growth of Madin-Darby canine kidney cell cysts was markedly increased following exposure to the TFEB agonist compound C1, and nuclear Tfeb translocation was observed in response to both forskolin and compound C1 treatment. Nuclear TFEB also characterized cystic epithelia but not noncystic tubular epithelia in human patients with autosomal dominant polycystic kidney disease. Noncanonical activation of TFEB is characteristic of cystic epithelia in multiple models of renal cystic disease including those associated with loss of Pkd1. Nuclear TFEB translocation is functionally active in these models and may be a component of a general pathway contributing to cystogenesis and growth.NEW & NOTEWORTHY Changes in epithelial cell metabolism are important in renal cyst development. The role of TFEB, a transcriptional regulator of lysosomal function, was explored in several models of renal cystic disease and human ADPKD tissue sections. Nuclear TFEB translocation was uniformly observed in cystic epithelia in each model of renal cystic disease examined. TFEB translocation was functionally active and associated with lysosomal biogenesis and perinuclear repositioning, increased TFEB-associated protein expression, and activation of autophagic flux. Compound C1, a TFEB agonist, promoted cyst growth in 3-D cultures of MDCK cells. Nuclear TFEB translocation is an underappreciated signaling pathway for cystogenesis that may represent a new paradigm for cystic kidney disease.
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Affiliation(s)
- Jonathan M Shillingford
- Department of Internal Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, United States
| | - James A Shayman
- Department of Internal Medicine, University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan, United States
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Bakaj I, Pocai A. Metabolism-based approaches for autosomal dominant polycystic kidney disease. Front Mol Biosci 2023; 10:1126055. [PMID: 36876046 PMCID: PMC9980902 DOI: 10.3389/fmolb.2023.1126055] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 02/06/2023] [Indexed: 02/18/2023] Open
Abstract
Autosomal Dominant Polycystic Kidney Disease (ADPKD) leads to end stage kidney disease (ESKD) through the development and expansion of multiple cysts throughout the kidney parenchyma. An increase in cyclic adenosine monophosphate (cAMP) plays an important role in generating and maintaining fluid-filled cysts because cAMP activates protein kinase A (PKA) and stimulates epithelial chloride secretion through the cystic fibrosis transmembrane conductance regulator (CFTR). A vasopressin V2 receptor antagonist, Tolvaptan, was recently approved for the treatment of ADPKD patients at high risk of progression. However additional treatments are urgently needed due to the poor tolerability, the unfavorable safety profile, and the high cost of Tolvaptan. In ADPKD kidneys, alterations of multiple metabolic pathways termed metabolic reprogramming has been consistently reported to support the growth of rapidly proliferating cystic cells. Published data suggest that upregulated mTOR and c-Myc repress oxidative metabolism while enhancing glycolytic flux and lactic acid production. mTOR and c-Myc are activated by PKA/MEK/ERK signaling so it is possible that cAMPK/PKA signaling will be upstream regulators of metabolic reprogramming. Novel therapeutics opportunities targeting metabolic reprogramming may avoid or minimize the side effects that are dose limiting in the clinic and improve on the efficacy observed in human ADPKD with Tolvaptan.
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Affiliation(s)
- Ivona Bakaj
- Cardiovascular and Metabolism, Janssen Research and Development, Spring House, PA, United States
| | - Alessandro Pocai
- Cardiovascular and Metabolism, Janssen Research and Development, Spring House, PA, United States
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Raina R, Houry A, Rath P, Mangat G, Pandher D, Islam M, Khattab AG, Kalout JK, Bagga S. Clinical Utility and Tolerability of Tolvaptan in the Treatment of Autosomal Dominant Polycystic Kidney Disease (ADPKD). Drug Healthc Patient Saf 2022; 14:147-159. [PMID: 36105663 PMCID: PMC9467294 DOI: 10.2147/dhps.s338050] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 08/22/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Rupesh Raina
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
- Department of Nephrology, Akron Children’s Hospital, Akron, OH, USA
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
- Correspondence: Rupesh Raina, Consultant Nephrologist, Adult-Pediatric Kidney Disease/Hypertension, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA, Tel +1 330-543-8950, Fax +1 330-543-3980, Email ;
| | - Ahmad Houry
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Pratik Rath
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Guneive Mangat
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Davinder Pandher
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
- Mount Sinai South Nassau, Oceanside, NY, 11570, USA
| | - Muhammad Islam
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | | | - Joseph K Kalout
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Sumedha Bagga
- Questrom School of Business, Boston University, Boston, MA, USA
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