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Suvakov S, Vaughan L, Parashuram S, Mielke M, Bielinski SJ, Chamberlain AM, Kantarci K, Garovic VD. Abstract P102: A History Of Preeclampsia Is Associated With Accelerated Aging And Multimorbidity Later In Life. Hypertension 2022. [DOI: 10.1161/hyp.79.suppl_1.p102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Preeclampsia (PE) is a pregnancy-specific hypertensive disorder which affects up to 7% of all pregnancies. It is associated with increased risk for cardiovascular disease later in life. We have recently reported increased senescence and accelerated aging in women with PE. We hypothesize that senescence burden remains after PE. The aim of this study was to compare senescence profiles, and history of individual chronic conditions and multimorbidity, a marker of accelerated aging, in women with and without a history of PE.
Methods:
Forty women with histories of PE and 40 with histories of normotensive pregnancy confirmed by manual chart review were age- and parity-matched. None of the women had a history of CVD at the time of recruitment. Markers of senescence (p16, p21 and Klotho) and metabolic syndrome (leptin, adiponectin) were measured and compared between women with and without histories of preeclampsia using conditional logistic regression. The rates of chronic conditions and multimorbidity between the groups were also compared.
Results:
Urinary Klotho/creatinine levels were significantly lower (median [IQR]: 117 [87.4, 224] vs. 205 [101, 359], respectively, p=0.042), while leptin/adiponectin ratio was significantly higher (median [IQR]: 0.25 [0.13, 0.45] vs. 0.05 [0.02, 0.12], p=0.027) among women with histories of PE compared to controls. There were no significant differences observed in plasma p21 or p16 concentrations. Women with histories of PE experienced a higher prevalence of two or more co-morbidities compared to women with normotensive pregnancies [67.5% (27/40) vs. 22.5% (9/40), p<0.05]. Results were similar after removing hypertension as a comorbidity [45% (18/40) vs. 20.0% (8/40), p<0.05].
Conclusion:
Women with a history of PE had altered markers of senescence, metabolic syndrome and multimorbidity decades after PE.
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Vaughan L, White WM, Tobah YSB, Kattah A, Parashuram S, Gunaratne MD, Vermunt JV, Mielke M, Milic NM, Suvakov S, Bielinski S, Chamberlain AM, Garovic VD. Cohort profile: the Olmsted County hypertensive disorders of pregnancy (HDP) cohort using the Rochester Epidemiology Project. BMJ Open 2022; 12:e055057. [PMID: 35473734 PMCID: PMC9045052 DOI: 10.1136/bmjopen-2021-055057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 03/29/2022] [Indexed: 11/17/2022] Open
Abstract
PURPOSE The Olmsted County hypertensive disorders of pregnancy (HDP) cohort is a population-based retrospective study designed to compare the incidence of HDP on a per-pregnancy and per-woman basis and to identify associations between HDP with ageing-related diseases, as well as accumulation of multimorbidity. PARTICIPANTS Using the Rochester Epidemiology Project (REP) medical records-linkage system, a cohort was collected consisting of women who gave birth in Olmsted County between 1976 and 1982. After exclusions, a per-pregnancy cohort of 7544 women with 9862 pregnancies between 1976 and 1982 was identified, and their delivery information was manually reviewed. A subset of these women comprised the per-woman cohort of 4322 pregnancies from 1839 women with delivery information available throughout the entirety of their childbearing years, along with decades of follow-up data available for research via the REP. FINDINGS TO DATE By constructing both per-pregnancy and per-woman cohorts, we reported a doubling of HDP incidence rates when assessed on a per-woman basis compared with rates observed on a per-pregnancy basis. Moreover, in addition to finding that women with a history of HDP developed specific diseases at higher rates and at early ages, we also discovered that a history of HDP is associated with accelerated ageing, through accumulation of multimorbidity. FUTURE PLANS In addition to these outcomes described above, many other potential outcomes of interest for studies of HDP can be ascertained from accessing the electronic health records (EHR) and billing systems available through the REP. These data can include all International Classification of Diseases (ICD)-9 and ICD-10 and Current Procedural Terminology coded diagnoses and procedures, healthcare utilisation, including office visits, hospitalisations and emergency room visits, and full text of the EHR that is available for chart abstraction or for natural language processing of the clinical notes.
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Affiliation(s)
- Lisa Vaughan
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Wendy M White
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Andrea Kattah
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Santosh Parashuram
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jane V Vermunt
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Michelle Mielke
- Division of Epidemiology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Natasa M Milic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
- Department of Medical Statistics and Informatics, University of Belgrade Faculty of Medicine, Beograd, Beograd, Serbia
| | - Sonja Suvakov
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Alanna M Chamberlain
- Division of Epidemiology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vesna D Garovic
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
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Kattah AG, Albadri S, Alexander MP, Smith B, Parashuram S, Mai ML, Khamash HA, Cosio FG, Garovic VD. Impact of Pregnancy on GFR Decline and Kidney Histology in Kidney Transplant Recipients. Kidney Int Rep 2022; 7:28-35. [PMID: 35005311 PMCID: PMC8720805 DOI: 10.1016/j.ekir.2021.10.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction Women with advanced kidney disease are advised to wait until after transplant to pursue pregnancy, but the impact of pregnancy on estimated glomerular filtration rate (eGFR) decline and kidney histology is unclear. Methods We identified a cohort of women aged 18 to 44 years at transplant from 1996 to 2014 at our 3-site program (N = 816) and determined whether they had a pregnancy >20 weeks gestation post-transplant by chart review. Outcomes included rate of change in eGFR after pregnancy, changes in kidney histology before and after pregnancy, graft failure, and 50% reduction in eGFR. Results There were 37 women with one or more pregnancies lasting longer than 20 weeks gestation post-transplant. Comparing women with and without pregnancy post-transplant, there was a significant increase in the rate of eGFR decline after pregnancy (−2.4 ml/min per 1.73 m2 per year vs. −1.9 ml/min per 1.73 m2 per year in women with no pregnancy, P < 0.001). Pregnancy did not affect the risk of graft failure, death-censored graft failure, or 50% reduction in eGFR. Conclusion Pregnancy affects the rate of eGFR decline in the allograft. Postpregnancy biopsy findings revealed an increase in vascular injury, which could be a potential mechanism. We did not find a significant increase in risk of graft failure or reduction in eGFR by 50% owing to pregnancy.
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Affiliation(s)
- Andrea G Kattah
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Sam Albadri
- Department of Laboratory Medicine and Pathology, Hennepin HealthCare, Minneapolis, Minnesota, USA
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Byron Smith
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Santosh Parashuram
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Marin L Mai
- Division of Nephrology, Mayo Clinic, Jacksonville, Florida, USA
| | - Hasan A Khamash
- Division of Nephrology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Fernando G Cosio
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
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Dines VA, Garovic VD, Parashuram S, Cosio FG, Kattah AG. Pregnancy, Contraception, and Menopause in Advanced Chronic Kidney Disease and Kidney Transplant. Women's Health Reports 2021; 2:488-496. [PMID: 34841395 PMCID: PMC8617582 DOI: 10.1089/whr.2021.0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 09/23/2021] [Indexed: 12/05/2022]
Abstract
Background: Reproductive health is an essential part of the care of women with kidney disease. However, the self-reported patient experience of reproductive issues has been underexplored. Materials and Methods: We identified a cohort of women ages 18 to 44 at the time of kidney transplant from 1996 to 2014 at our 3-site program (n = 816). We sent each woman a survey on her reproductive lifespan, characterizing features from menarche to menopause. Results: We received survey responses from 190 patients (27%). One third of respondents reported amenorrhea before transplant, and 61.5% of these women reported resumption of menses post-transplant. The average age of menopause was 45.5 years, earlier than the general population (51.3 years). There were 204 pregnancies pretransplant and 52 pregnancies post-transplant. Pregnancies post-transplant were more likely to be complicated by preeclampsia, preterm delivery, and small for gestational age babies than pregnancies that occurred >5 years before transplant. Pregnancies <5 years before transplant were similar to post-transplant pregnancies with respect to complications. Forty-two percent of women were advised to avoid pregnancy after transplant, most often by a nephrology provider. Conclusions: In our cohort of kidney transplant recipients, women report increased pregnancy-related complications post-transplant and in the 5 years before transplant, compared with pregnancies that occurred greater than 5 years before transplant. They were often counseled to avoid pregnancy altogether. Women reported a younger age of menopause relative to the general population. This should be considered when counseling patients with chronic kidney disease regarding optimal pregnancy timing.
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Affiliation(s)
- Virginia A. Dines
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Vesna D. Garovic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Santosh Parashuram
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Fernando G. Cosio
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea G. Kattah
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
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Garovic VD, White WM, Vaughan L, Saiki M, Parashuram S, Garcia-Valencia O, Weissgerber TL, Milic N, Weaver A, Mielke MM. Incidence and Long-Term Outcomes of Hypertensive Disorders of Pregnancy. J Am Coll Cardiol 2020; 75:2323-2334. [PMID: 32381164 DOI: 10.1016/j.jacc.2020.03.028] [Citation(s) in RCA: 167] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 02/28/2020] [Accepted: 03/05/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) are associated with increased risks for cardiovascular disease later in life. The HDP incidence is commonly assessed using diagnostic codes, which are not reliable; and typically are expressed per-pregnancy, which may underestimate the number of women with an HDP history after their reproductive years. OBJECTIVES This study sought to determine the incidence of HDP expressed as both per-pregnancy and per-woman, and to establish their associations with future chronic conditions and multimorbidity, a measure of accelerated aging, in a population-based cohort study. METHODS Using the Rochester Epidemiology Project medical record-linkage system, the authors identified residents of Olmsted County, Minnesota, who delivered between 1976 and 1982. The authors classified pregnancies into normotensive, gestational hypertension, pre-eclampsia, eclampsia, pre-eclampsia superimposed on chronic hypertension, and chronic hypertension using a validated electronic algorithm, and calculated the incidence of HDP both per-pregnancy and per-woman. The risk of chronic conditions between women with versus those without a history of HDP (age and parity 1:2 matched) was quantified using the hazard ratio and corresponding 95% confidence interval estimated from a Cox model. RESULTS Among 9,862 pregnancies, we identified 719 (7.3%) with HDP and 324 (3.3%) with pre-eclampsia. The incidence of HDP and pre-eclampsia doubled when assessed on a per-woman basis: 15.3% (281 of 1,839) and 7.5% (138 of 1,839), respectively. Women with a history of HDP were at increased risk for subsequent diagnoses of stroke (hazard ratio [HR]: 2.27; 95% confidence interval [CI]: 1.37 to 3.76), coronary artery disease (HR: 1.89; 95% CI: 1.26 to 2.82), cardiac arrhythmias (HR: 1.62; 95% CI: 1.28 to 2.05), chronic kidney disease (HR: 2.41; 95% CI: 1.54 to 3.78), and multimorbidity (HR: 1.25; 95% CI: 1.15 to 1.35). CONCLUSIONS The HDP population-based incidence expressed per-pregnancy underestimates the number of women affected by this condition during their reproductive years. A history of HDP confers significant increase in risks for future chronic conditions and multimorbidity.
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Affiliation(s)
- Vesna D Garovic
- Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Rochester, Minnesota; Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota.
| | - Wendy M White
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Lisa Vaughan
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Mie Saiki
- Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Santosh Parashuram
- Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Oscar Garcia-Valencia
- Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Tracey L Weissgerber
- Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Natasa Milic
- Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Rochester, Minnesota; Department of Medical Statistics & Informatics, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Amy Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Michelle M Mielke
- Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, Minnesota; Department of Neurology, Mayo Clinic College of Medicine, Rochester, Minnesota
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Haitao T, Vermunt JV, Abeykoon J, Ghamrawi R, Gunaratne M, Jayachandran M, Narang K, Parashuram S, Suvakov S, Garovic VD. COVID-19 and Sex Differences: Mechanisms and Biomarkers. Mayo Clin Proc 2020; 95:2189-2203. [PMID: 33012349 PMCID: PMC7402208 DOI: 10.1016/j.mayocp.2020.07.024] [Citation(s) in RCA: 166] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 07/02/2020] [Indexed: 01/08/2023]
Abstract
Men are consistently overrepresented in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and coronavirus disease 2019 (COVID-19) severe outcomes, including higher fatality rates. These differences are likely due to gender-specific behaviors, genetic and hormonal factors, and sex differences in biological pathways related to SARS-CoV-2 infection. Several social, behavioral, and comorbid factors are implicated in the generally worse outcomes in men compared with women. Underlying biological sex differences and their effects on COVID-19 outcomes, however, have received less attention. The present review summarizes the available literature regarding proposed molecular and cellular markers of COVID-19 infection, their associations with health outcomes, and any reported modification by sex. Biological sex differences characterized by such biomarkers exist within healthy populations and also differ with age- and sex-specific conditions, such as pregnancy and menopause. In the context of COVID-19, descriptive biomarker levels are often reported by sex, but data pertaining to the effect of patient sex on the relationship between biomarkers and COVID-19 disease severity/outcomes are scarce. Such biomarkers may offer plausible explanations for the worse COVID-19 outcomes seen in men. There is the need for larger studies with sex-specific reporting and robust analyses to elucidate how sex modifies cellular and molecular pathways associated with SARS-CoV-2. This will improve interpretation of biomarkers and clinical management of COVID-19 patients by facilitating a personalized medical approach to risk stratification, prevention, and treatment.
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Affiliation(s)
- Tu Haitao
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Department of Nephrology, The First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, Guangdong, PR China
| | - Jane V Vermunt
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Jithma Abeykoon
- Division of Hematology and Oncology, Mayo Clinic, Rochester, MN
| | - Ranine Ghamrawi
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - Muthuvel Jayachandran
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Division of Hematology and Oncology, Mayo Clinic, Rochester, MN; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN
| | - Kavita Narang
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN; Division of Maternal Fetal Medicine, Mayo Clinic, Rochester, MN
| | | | - Sonja Suvakov
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN.
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Milic NM, Codsi E, Butler Tobah YS, White WM, Kattah AG, Weissgerber TL, Saiki M, Parashuram S, Vaughan LE, Weaver AL, Savic M, Mielke MM, Garovic VD. Electronic Algorithm Is Superior to Hospital Discharge Codes for Diagnoses of Hypertensive Disorders of Pregnancy in Historical Cohorts. Mayo Clin Proc 2018; 93:1707-1719. [PMID: 30522591 PMCID: PMC6353636 DOI: 10.1016/j.mayocp.2018.08.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 07/02/2018] [Accepted: 08/13/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To develop and validate criteria for the retrospective diagnoses of hypertensive disorders of pregnancy that would be amenable to the development of an electronic algorithm, and to compare the accuracy of diagnoses based on both the algorithm and diagnostic codes with the gold standard, of physician-made diagnoses based on a detailed review of medical records using accepted clinical criteria. PATIENTS AND METHODS An algorithm for hypertensive disorders of pregnancy was developed by first defining a set of criteria for retrospective diagnoses, which included relevant clinical variables and diagnosis of hypertension that required blood pressure elevations in greater than 50% of readings ("the 50% rule"). The algorithm was validated using the Rochester Epidemiology Project (Rochester, Minnesota). A stratified random sample of pregnancies and deliveries between January 1, 1976, and December 31, 1982, with the algorithm-based diagnoses was generated for review and physician-made diagnoses (normotensive, gestational hypertension, and preeclampsia), which served as the gold standard; the targeted cohort size for analysis was 25 per diagnosis category according to the gold standard. Agreements between (1) algorithm-based diagnoses and (2) diagnostic codes and the gold standard were analyzed. RESULTS Sensitivities of the algorithm for 25 normotensive pregnancies, 25 with gestational hypertension, and 25 with preeclampsia were 100%, 88%, and 100%, respectively, and specificities were 94%, 100%, and 100%, respectively. Diagnostic code sensitivities were 96% for normotensive pregnancies, 32% for gestational hypertension, and 96% for preeclampsia, and specificities were 78%, 96%, and 88%, respectively. CONCLUSION The electronic diagnostic algorithm was highly sensitive and specific in identifying and classifying hypertensive disorders of pregnancy and was superior to diagnostic codes.
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Affiliation(s)
- Natasa M Milic
- Division of Nephrology and Hypertension, University of Belgrade, Belgrade, Serbia; Department of Biostatistics, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Elisabeth Codsi
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Yvonne S Butler Tobah
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Wendy M White
- Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Andrea G Kattah
- Division of Nephrology and Hypertension, University of Belgrade, Belgrade, Serbia
| | - Tracey L Weissgerber
- Division of Nephrology and Hypertension, University of Belgrade, Belgrade, Serbia
| | - Mie Saiki
- Division of Nephrology and Hypertension, University of Belgrade, Belgrade, Serbia
| | - Santosh Parashuram
- Division of Nephrology and Hypertension, University of Belgrade, Belgrade, Serbia
| | - Lisa E Vaughan
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Amy L Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Marko Savic
- Department of Biostatistics, Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Michelle M Mielke
- Department of Health Sciences Research and Department of Neurology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, University of Belgrade, Belgrade, Serbia; Department of Obstetrics and Gynecology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN.
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