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Qi Y, Yang H, Wang S, Zou L, Zhao F, Zhang Q, Hong Y, Luo Q, Zhou Q, Geng P, Chen H, Ji F, Cai J, Dai D. Identification and Functional Assessment of Eight CYP3A4 Allelic Variants *39-*46 Detected in the Chinese Han Population. Drug Metab Dispos 2024; 52:218-227. [PMID: 38195522 DOI: 10.1124/dmd.123.001542] [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: 09/20/2023] [Revised: 12/10/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024] Open
Abstract
Cytochrome P450 3A4 (CYP3A4), a key enzyme, is pivotal in metabolizing approximately half of the drugs used clinically. The genetic polymorphism of the CYP3A4 gene significantly influences individual variations in drug metabolism, potentially leading to severe adverse drug reactions (ADRs). In this study, we conducted a genetic analysis on CYP3A4 gene in 1163 Chinese Han individuals to identify the genetic variations that might affect their drug metabolism capabilities. For this purpose, a multiplex polymerase chain reaction (PCR) amplicon sequencing technique was developed, enabling us to perform the genotyping of CYP3A4 gene efficiently and economically on a large scale. As a result, a total of 14 CYP3A4 allelic variants were identified, comprising six previously reported alleles and eight new nonsynonymous variants that were nominated as new allelic variants *39-*46 by the PharmVar Association. Further, functional assessments of these novel CYP3A4 variants were undertaken by coexpressing them with cytochromes P450 oxidoreductase (CYPOR) in Saccharomyces cerevisiae microsomes. Immunoblot analysis indicated that with the exception of CYP3A4.40 and CYP3A4.45, the protein expression levels of most new variants were similar to that of the wild-type CYP3A4.1 in yeast cells. To evaluate their catalytic activities, midazolam was used as a probe drug. The results showed that variant CYP3A4.45 had almost no catalytic activity, whereas the other variants exhibited significantly reduced drug metabolism abilities. This suggests that the majority of the CYP3A4 variants identified in the Chinese population possess markedly altered capacities for drug metabolism. SIGNIFICANCE STATEMENT: In this study, we established a multiplex polymerase chain reaction (PCR) amplicon sequencing method and detected the maximum number of new CYP3A4 variants in a single ethnic population. Additionally, we performed the functional characterizations of these eight novel CYP3A4 allele variants in vitro. This study not only contributes to the understanding of CYP3A4 genetic polymorphism in the Chinese Han population but also holds substantial reference value for their potential clinical applications in personalized medicine.
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Affiliation(s)
- Yuying Qi
- Peking University Fifth School of Clinical Medicine, Beijing, China (Y.Q., H.Y., D.D.); The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China (H.Y., F.Z., J.C.); Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, China (S.W., Q.Z., P.G.); and Department of Cardiology (L.Z., Q.Z., H.C., F.J.) and Department of Gastroenterology (Y.H., Q.L.), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Hang Yang
- Peking University Fifth School of Clinical Medicine, Beijing, China (Y.Q., H.Y., D.D.); The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China (H.Y., F.Z., J.C.); Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, China (S.W., Q.Z., P.G.); and Department of Cardiology (L.Z., Q.Z., H.C., F.J.) and Department of Gastroenterology (Y.H., Q.L.), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Shuanghu Wang
- Peking University Fifth School of Clinical Medicine, Beijing, China (Y.Q., H.Y., D.D.); The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China (H.Y., F.Z., J.C.); Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, China (S.W., Q.Z., P.G.); and Department of Cardiology (L.Z., Q.Z., H.C., F.J.) and Department of Gastroenterology (Y.H., Q.L.), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Lili Zou
- Peking University Fifth School of Clinical Medicine, Beijing, China (Y.Q., H.Y., D.D.); The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China (H.Y., F.Z., J.C.); Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, China (S.W., Q.Z., P.G.); and Department of Cardiology (L.Z., Q.Z., H.C., F.J.) and Department of Gastroenterology (Y.H., Q.L.), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Fangling Zhao
- Peking University Fifth School of Clinical Medicine, Beijing, China (Y.Q., H.Y., D.D.); The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China (H.Y., F.Z., J.C.); Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, China (S.W., Q.Z., P.G.); and Department of Cardiology (L.Z., Q.Z., H.C., F.J.) and Department of Gastroenterology (Y.H., Q.L.), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Qing Zhang
- Peking University Fifth School of Clinical Medicine, Beijing, China (Y.Q., H.Y., D.D.); The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China (H.Y., F.Z., J.C.); Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, China (S.W., Q.Z., P.G.); and Department of Cardiology (L.Z., Q.Z., H.C., F.J.) and Department of Gastroenterology (Y.H., Q.L.), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yun Hong
- Peking University Fifth School of Clinical Medicine, Beijing, China (Y.Q., H.Y., D.D.); The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China (H.Y., F.Z., J.C.); Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, China (S.W., Q.Z., P.G.); and Department of Cardiology (L.Z., Q.Z., H.C., F.J.) and Department of Gastroenterology (Y.H., Q.L.), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Qingfeng Luo
- Peking University Fifth School of Clinical Medicine, Beijing, China (Y.Q., H.Y., D.D.); The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China (H.Y., F.Z., J.C.); Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, China (S.W., Q.Z., P.G.); and Department of Cardiology (L.Z., Q.Z., H.C., F.J.) and Department of Gastroenterology (Y.H., Q.L.), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Quan Zhou
- Peking University Fifth School of Clinical Medicine, Beijing, China (Y.Q., H.Y., D.D.); The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China (H.Y., F.Z., J.C.); Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, China (S.W., Q.Z., P.G.); and Department of Cardiology (L.Z., Q.Z., H.C., F.J.) and Department of Gastroenterology (Y.H., Q.L.), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Peiwu Geng
- Peking University Fifth School of Clinical Medicine, Beijing, China (Y.Q., H.Y., D.D.); The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China (H.Y., F.Z., J.C.); Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, China (S.W., Q.Z., P.G.); and Department of Cardiology (L.Z., Q.Z., H.C., F.J.) and Department of Gastroenterology (Y.H., Q.L.), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Hao Chen
- Peking University Fifth School of Clinical Medicine, Beijing, China (Y.Q., H.Y., D.D.); The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China (H.Y., F.Z., J.C.); Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, China (S.W., Q.Z., P.G.); and Department of Cardiology (L.Z., Q.Z., H.C., F.J.) and Department of Gastroenterology (Y.H., Q.L.), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Fusui Ji
- Peking University Fifth School of Clinical Medicine, Beijing, China (Y.Q., H.Y., D.D.); The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China (H.Y., F.Z., J.C.); Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, China (S.W., Q.Z., P.G.); and Department of Cardiology (L.Z., Q.Z., H.C., F.J.) and Department of Gastroenterology (Y.H., Q.L.), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Jianping Cai
- Peking University Fifth School of Clinical Medicine, Beijing, China (Y.Q., H.Y., D.D.); The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China (H.Y., F.Z., J.C.); Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, China (S.W., Q.Z., P.G.); and Department of Cardiology (L.Z., Q.Z., H.C., F.J.) and Department of Gastroenterology (Y.H., Q.L.), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Dapeng Dai
- Peking University Fifth School of Clinical Medicine, Beijing, China (Y.Q., H.Y., D.D.); The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China (H.Y., F.Z., J.C.); Laboratory of Clinical Pharmacy, The Sixth Affiliated Hospital of Wenzhou Medical University, The People's Hospital of Lishui, Lishui, China (S.W., Q.Z., P.G.); and Department of Cardiology (L.Z., Q.Z., H.C., F.J.) and Department of Gastroenterology (Y.H., Q.L.), Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
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Williams ML, Kannankeril PJ, Breeyear JH, Edwards TL, Van Driest SL, Choi L. Effect of CYP3A5 and CYP3A4 Genetic Variants on Fentanyl Pharmacokinetics in a Pediatric Population. Clin Pharmacol Ther 2021; 111:896-908. [PMID: 34877660 DOI: 10.1002/cpt.2506] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/03/2021] [Indexed: 12/30/2022]
Abstract
Fentanyl is an anesthetic/analgesic commonly used in surgical and recovery settings. CYP3A4 and CYP3A5 encode enzymes, which metabolize fentanyl; genetic variants in these genes impact fentanyl pharmacokinetics in adults. Pharmacokinetic (PK) studies are difficult to replicate in children due to the burden of additional blood taken solely for research purposes. The aim of this study is to test the effect of CYP3A5 and CYP3A4 genetic variants on fentanyl PKs in children using opportunistically collected samples. Fentanyl concentrations were measured from remnant blood specimens and dosing data were extracted from electronic health records. Variant data defining CYP3A4*1G and CYP3A5*3 and *6 alleles were available from prior genotyping; alleles with no variant were defined as *1. The study cohort included 434 individuals (median age 9 months, 52% male subjects) and 1,937 fentanyl concentrations were available. A two-compartment model was selected as the base model, and the final covariate model included age, weight, and surgical severity score. Clearance was significantly associated with either CYP3A5*3 or CYP3A5*6 alleles, but not the CYP3A4*1G allele. A genotype of CYP3A5*1/*3 or CYP3A5*1/*6 (i.e., intermediate metabolizer status) was associated with a 0.84-fold (95% confidence interval (CI): 0.71-1.00) reduction in clearance vs. CYP3A5*1/*1 (i.e., normal metabolizer status). CYP3A5*3/*3, CYP3A5*3/*6, or CYP3A5*6/*6 (i.e., poor metabolizer status) was associated with a 0.76-fold (95% CI: 0.58-0.99) reduction in clearance. In the final model, expected clearance was 8.9 and 6.8 L/hour for a normal and poor metabolizer, respectively, with median population covariates (9 months old, 7.7 kg, low surgical severity).
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Affiliation(s)
- Michael L Williams
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Prince J Kannankeril
- Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joseph H Breeyear
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Todd L Edwards
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sara L Van Driest
- Center for Pediatric Precision Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leena Choi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Magarbeh L, Gorbovskaya I, Le Foll B, Jhirad R, Müller DJ. Reviewing pharmacogenetics to advance precision medicine for opioids. Biomed Pharmacother 2021; 142:112060. [PMID: 34523422 DOI: 10.1016/j.biopha.2021.112060] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/14/2021] [Accepted: 08/16/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Adequate opioid prescribing is critical for therapeutic success of pain management. Despite the widespread use of opioids, optimized opioid therapy remains unresolved with risk of accidental lethal overdosing. With the emergence of accumulating evidence linking genetic variation to opioid response, pharmacogenetic based treatment recommendations have been proposed. OBJECTIVE The aim of this review is to evaluate pharmacogenetic evidence and provide an overview on genes involved in the pharmacokinetics and pharmacodynamics of opioids. METHODS For this review, a systematic literature search of published articles was used in PubMed®, with no language restriction and between the time period of January 2000 to December 2020. We reviewed randomized clinical studies, study cohorts and case reports that investigated the influence of genetic variants on selected opioid pharmacokinetics and pharmacodynamics. In addition, we reviewed current CPIC clinical recommendations for pharmacogenetic testing. RESULTS Results of this review indicate consistent evidence supporting the association between selected genetic variants of CYP2D6 for opioid metabolism. CPIC guidelines include recommendations that indicate the avoidance of tramadol use, in addition to codeine, in CYP2D6 poor metabolizers and ultrarapid metabolizers, and to monitor intermediate metabolizers for less-than-optimal response. While there is consistent evidence for OPRM1 suggesting increased postoperative morphine dosing requirements in A118G G-allele carriers, the clinical relevance remains limited. CONCLUSION There is emerging evidence of clinical relevance of CYP2D6 and, to a lesser extent, OPRM1 polymorphism in personalized opioid drug dosing. As a result, first clinics have started to implement pharmacogenetic guidelines for CYP2D6 and codeine.
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Affiliation(s)
- Leen Magarbeh
- Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Ilona Gorbovskaya
- Institute of Medical Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Bernard Le Foll
- Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada; Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada; Acute Care Program, Centre for Addiction and Mental Health, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Reuven Jhirad
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Office of the Chief Coroner and Ontario Forensic Pathology Service, Toronto, ON, Canada
| | - Daniel J Müller
- Department of Pharmacology and Toxicology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada.
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Zusman BE, Kochanek PM, Jha RM. Cerebral Edema in Traumatic Brain Injury: a Historical Framework for Current Therapy. Curr Treat Options Neurol 2020; 22:9. [PMID: 34177248 PMCID: PMC8223756 DOI: 10.1007/s11940-020-0614-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW The purposes of this narrative review are to (1) summarize a contemporary view of cerebral edema pathophysiology, (2) present a synopsis of current management strategies in the context of their historical roots (many of which date back multiple centuries), and (3) discuss contributions of key molecular pathways to overlapping edema endophenotypes. This may facilitate identification of important therapeutic targets. RECENT FINDINGS Cerebral edema and resultant intracranial hypertension are major contributors to morbidity and mortality following traumatic brain injury. Although Starling forces are physical drivers of edema based on differences in intravascular vs extracellular hydrostatic and oncotic pressures, the molecular pathophysiology underlying cerebral edema is complex and remains incompletely understood. Current management protocols are guided by intracranial pressure measurements, an imperfect proxy for cerebral edema. These include decompressive craniectomy, external ventricular drainage, hyperosmolar therapy, hypothermia, and sedation. Results of contemporary clinical trials assessing these treatments are summarized, with an emphasis on the gap between intermediate measures of edema and meaningful clinical outcomes. This is followed by a brief statement summarizing the most recent guidelines from the Brain Trauma Foundation (4th edition). While many molecular mechanisms and networks contributing to cerebral edema after TBI are still being elucidated, we highlight some promising molecular mechanism-based targets based on recent research including SUR1-TRPM4, NKCC1, AQP4, and AVP1. SUMMARY This review outlines the origins of our understanding of cerebral edema, chronicles the history behind many current treatment approaches, and discusses promising molecular mechanism-based targeted treatments.
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Affiliation(s)
- Benjamin E. Zusman
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Institute for Clinical Research Education, University of Pittsburgh, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick M. Kochanek
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Children’s Hospital of Pittsburgh, UPMC, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, PA, USA
| | - Ruchira M. Jha
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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