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Truong HL, Barreto JN, Mara KC, Hampel PJ, Micallef IN, Nowakowski GS, Thanarajasingam G, Thompson CA, Wang Y, Witzig TE, Herrmann SM, Leung N. Rechallenge With High-Dose Methotrexate After Treatment With Glucarpidase in Adult Patients With Lymphoma. JCO Oncol Pract 2024; 20:797-807. [PMID: 38408299 DOI: 10.1200/op.23.00628] [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: 09/26/2023] [Revised: 11/09/2023] [Accepted: 12/15/2023] [Indexed: 02/28/2024] Open
Abstract
PURPOSE Limited evidence exists regarding methotrexate (MTX) resumption after patients with lymphoma receive glucarpidase for toxic MTX levels and acute kidney injury (AKI). METHODS This retrospective review included adults with lymphoma treated with glucarpidase after MTX at Mayo Clinic between January 31, 2020, and October 10, 2022. Descriptive statistics summarize patient characteristics and clinical outcomes. RESULTS Of 11 patients treated with glucarpidase after MTX, seven (64%) were rechallenged with MTX. Indications for MTX rechallenge included confirmed CNS disease (n = 6, 86%) and intravascular lymphoma (n = 1, 14%). Compared with the nonrechallenged subgroup, before receiving MTX that required glucarpidase rescue, the rechallenged patients had lower median pretreatment serum creatinine (Scr; 0.7 v 1.2 mg/dL), and none had AKI with previous MTX doses, n = 0 (0%) versus n = 2 (50%). During the MTX dose requiring glucarpidase rescue, the rechallenged group had lower median peak Scr (1.26 v 3.32 mg/dL) and lower incidence of AKI stage III (n = 1 [14%] v n = 3 [75%]), and none of the rechallenged patients required renal replacement therapy (RRT; n = 0 [0%] v n = 1 [25%]). At the first rechallenge after glucarpidase administration, the median MTX dose reduction was 56% (range, 46%-75%), and the lowest used dose when prescribed according to each treatment protocol schedule was 1.5 g/m2. Two (29%) patients experienced AKI (n = 1 stage I, n = 1 stage II) after MTX rechallenge. Zero patients required RRT, and zero required another glucarpidase administration. Six (86%) patients completed all recommended MTX doses. CONCLUSION In selected adults with lymphoma who required glucarpidase for toxic MTX levels after administration of high-dose MTX, resumption of MTX therapy at lower doses is safe. Patients selected for MTX resumption had experienced less severe AKI during the previous cycle compared with those not selected for MTX resumption.
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Affiliation(s)
- Huong L Truong
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Loxo@Lilly, Lilly Corporate Center, Indianapolis, IN
| | | | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Paul J Hampel
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Ivana N Micallef
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Gita Thanarajasingam
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Carrie A Thompson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Yucai Wang
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Thomas E Witzig
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Sandra M Herrmann
- Division of Nephrology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Nelson Leung
- Division of Nephrology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
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Rice ML, Barreto EF, Rule AD, Martin CE, Truong HL, Mara KC, Kashani KB, Thompson CA, Witzig TE, Barreto JN. Development and validation of a model to predict acute kidney injury following high-dose methotrexate in patients with lymphoma. Pharmacotherapy 2024; 44:4-12. [PMID: 37926860 DOI: 10.1002/phar.2889] [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: 06/21/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 11/07/2023]
Abstract
STUDY OBJECTIVE To develop and validate a model for predicting acute kidney injury (AKI) after high-dose methotrexate (HDMTX) exposure. DESIGN Retrospective analysis. SETTING Multisite integrated health system throughout Minnesota and Wisconsin. PATIENTS Adult patients with lymphoma who received HDMTX as a 4-h infusion. MEASUREMENTS AND MAIN RESULTS LASSO methodology was used to identify factors available at the outset of therapy that predicted incident AKI within 7 days following HDMTX. The model was then validated in an independent cohort. The incidence of AKI within 7 days following HDMTX was 21.6% (95% confidence interval (CI) 18.4%-24.8%) in the derivation cohort (435 unique patients who received a total of 1642 doses of HDMTX) and 15.6% (95% CI 5.3%-24.8%) in the validation cohort (55 unique patients who received a total of 247 doses of HDMTX). Factors significantly associated with AKI after HDMTX in the multivariable model included age ≥ 55 years, male sex, and lower HDMTX dose number. Other factors that were not found to be significantly associated with AKI on multivariable analysis, but were included in the final model, were body surface area, Charlson Comorbidity Index, and estimated glomerular filtration rate. The c-statistic of the model was 0.72 (95% CI 0.69-0.75) in the derivation cohort and 0.72 (95% CI 0.60-0.84) in the validation cohort. CONCLUSION This model utilizing identified sociodemographic and clinical factors is predictive of AKI following HDMTX administration in adult patients with lymphoma.
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Affiliation(s)
- Mikhaila L Rice
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
- Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA
| | - Erin F Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew D Rule
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Huong L Truong
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Carrie A Thompson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas E Witzig
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason N Barreto
- Department of Pharmacy, Mayo Clinic, Rochester, Minnesota, USA
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Cao J, Li S, Li D, Hua W, Guo L, Xia Z. Development and Validation of Pretreatment Serum Total Bilirubin as a Biomarker to Predict the Clinical Outcomes in Primary Central Nervous System Lymphoma: A Multicenter Cohort Study. Cancers (Basel) 2023; 15:4584. [PMID: 37760555 PMCID: PMC10526312 DOI: 10.3390/cancers15184584] [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: 08/04/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Primary central nervous system lymphoma (PCNSL) is a predominantly aggressive neoplasm isolated to the central nervous system or vitreoretinal space. Bilirubin is an important biomarker reflecting hepatic function and oxidative stress status that is associated with the occurrence and development of various tumors. However, its prognostic role in PCNSL has yet to be evaluated. Therefore, we conducted a prospective-retrospective study to analyze the predictive value of serum total bilirubin (STB) in PCNSL patients. The association between the pretreatment STB and clinical outcomes in PCNSL was developed in the discovery cohort (retrospective [n = 44] and prospective [n = 45]) and validated in an independent retrospective cohort (n = 69). A generalized additive model, Kaplan-Meier curve, and Cox analysis were applied. In the discovery cohort, the STB showed a linear relationship with overall survival (OS, p = 0.011) and progression-free survival (PFS, p = 0.0476). The median STB level of 12.0 µmol/L was determined as the cutoff value to predict the clinical outcomes with area under the receiver operating characteristic curve (AUROC) values of 0.9205 and 0.8464 for OS and PFS, respectively. The median STB level resulted in similar accuracy for predicting the clinical outcomes in the validation cohort with AUROC values of 0.8857 and 0.8589 for OS and PFS, respectively. In both the discovery and validation cohorts, the Kaplan-Meier survival curve and Cox regression analysis showed that the upper median STB groups showed significantly worse OS than the lower median STB groups. In conclusion, the pretreatment STB could be considered a novel biomarker to predict the clinical outcomes in patients with PCNSL receiving high-dose methotrexate-based combination immunochemotherapy.
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Affiliation(s)
- Jiazhen Cao
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, Shanghai 200032, China;
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Shengjie Li
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China; (S.L.); (W.H.)
- Institute of Neurosurgery, Fudan University, Shanghai 200040, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai 200040, China
- Department of Clinical Laboratory, Eye & ENT Hospital, Shanghai Medical College, Fudan University, Shanghai 200031, China
| | - Danhui Li
- Department of Pathology, RenJi Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200127, China;
| | - Wei Hua
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai 200040, China; (S.L.); (W.H.)
- Institute of Neurosurgery, Fudan University, Shanghai 200040, China
- Shanghai Key Laboratory of Brain Function Restoration and Neural Regeneration, Shanghai 200040, China
| | - Lin Guo
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, Shanghai 200032, China;
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Zuguang Xia
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
- Department of lymphoma, Fudan University Shanghai Cancer Center, Fudan University, Shanghai 200032, China
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Jafari F, Arasteh O, Hosseinjani H, Allahyari A, Ataei Azimi S, Askari VR. A critical review of methotrexate clinical interactions: role of transporters. Expert Opin Drug Metab Toxicol 2023; 19:91-107. [PMID: 36946211 DOI: 10.1080/17425255.2023.2193325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION Methotrexate (MTX) is an anti-folate and immunosuppressive drug prescribed for various malignancies and immune diseases. However, delayed elimination of MTX associated with concomitant use of some medications can lead to severe and life-threatening adverse effects. AREAS COVERED This paper investigated drug-MTX interactions that lead to elevated MTX levels and related adverse effects due to the role of transporters. Methotrexate toxicity occurs at both low and high doses administrations. According to the studies we reviewed in this paper, most interaction records with methotrexate occurred with co-administration of indomethacin, ketoprofen, omeprazole, piperacillin/tazobactam, ciprofloxacin, co-trimoxazole, probenecid, and imatinib, mainly due to the role of transporters. However, most studies were performed as case reports or series, and confirming the exact drug-methotrexate interaction still needs further clinical investigations. EXPERT OPINION Our findings showed no firm evidence of interactions of proton pump inhibitors (PPIs), levetiracetam, and NSAIDS with MTX. Moreover, patients' risk factors, hypoalbuminemia, renal failure, third space fluid retention, the elderly, polypharmacy, and transport inhibition are the most critical factors for MTX toxicity. If substitution or temporary discontinuation is not possible, healthcare providers should be aware of interactions, especially in patients with risk factors for MTX toxicity.
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Affiliation(s)
- Fatemeh Jafari
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Omid Arasteh
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hesamoddin Hosseinjani
- Department of Clinical Pharmacy, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Abolghasem Allahyari
- Division of Hematology and Oncology, Department of Internal medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sajad Ataei Azimi
- Division of Hematology and Oncology, Department of Internal medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Vahid Reza Askari
- International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran
- Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
- Department of Pharmaceutical Sciences in Persian Medicine, School of Persian and Complementary Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Ibarra M, Combs R, Taylor ZL, Ramsey LB, Mikkelsen T, Buddington RK, Heldrup J, Barreto JN, Guscott M, Lowe J, Hurmiz C, Marada S, Howard SC, Schaiquevich P. Insights from a pharmacometric analysis of HDMTX in adults with cancer: Clinically relevant covariates for application in precision dosing. Br J Clin Pharmacol 2023; 89:660-671. [PMID: 35998099 DOI: 10.1111/bcp.15506] [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: 04/28/2022] [Revised: 07/25/2022] [Accepted: 08/08/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS High-dose methotrexate (HDMTX) is an essential part of the treatment of several adult and paediatric malignancies. Despite meticulous supportive care during HDMTX administration, severe toxicities, including acute kidney injury (AKI), may occur contributing to patient morbidity. Population pharmacokinetics provide a powerful tool to predict time to clear HDMTX and adjust subsequent doses. We sought to develop and validate pharmacokinetic models for HDMTX in adults with diverse malignancies and to relate systemic exposure with the occurrence of severe toxicity. METHODS Anonymized, de-identified data were provided from 101 US oncology practices that participate in the Guardian Research Network, a non-profit clinical research consortium. Modelled variables included clinical, laboratory, demographic and pharmacological data. Population pharmacokinetic analysis was performed by means of nonlinear mixed effects modelling using MonolixSuite. RESULTS A total of 693 HDMTX courses from 243 adults were analysed, of which 62 courses (8.8%) were associated with stage 2/3 acute kidney injury (43 stage 2, 19 stage 3). A three-compartment model adequately fitted the data. Time-dependent serum creatinine, baseline serum albumin and allometrically scaled bodyweight were clinically significant covariates related to methotrexate clearance. External evaluation confirmed a satisfactory predictive performance of the model in adults receiving HDMTX. Dose-normalized methotrexate concentration at 24 and 48 hours correlated with AKI incidence. CONCLUSION We developed a population pharmacometric model that considers weight, albumin and time-dependent creatinine that can be used to guide supportive care in adult patients with delayed HDMTX elimination.
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Affiliation(s)
- Manuel Ibarra
- Department of Pharmaceutical Sciences, Faculty of Chemistry. Universidad de la República, Montevideo, Uruguay
| | | | - Zachary L Taylor
- Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Laura B Ramsey
- Division of Research in Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Division of Clinical Pharmacology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Torben Mikkelsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Randal K Buddington
- Department of Molecular and Cellular Physiology, LSU Health Sciences, Shreveport, LA, USA
| | - Jesper Heldrup
- Childhood Cancer and Research Unit, University Children's Hospital, Lund, Sweden
| | | | | | | | | | | | - Scott C Howard
- Resonance, Inc., Arlington, TN, USA.,College of Nursing, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Paula Schaiquevich
- Unit of Innovative Treatments, Hospital de Pediatria JP Garrahan, Buenos Aires, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, CONICET, Buenos Aires, Argentina
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D'Onofrio G, Riva A, Amadori E, Lattanzi S, Rose K, Verrotti A, Striano P. Pharmacokinetic considerations surrounding the use of levetiracetam for seizure prophylaxis in neurocritical care - an overview. Expert Opin Drug Metab Toxicol 2022; 18:575-585. [PMID: 36006892 DOI: 10.1080/17425255.2022.2117606] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Levetiracetam (LEV) is one of the most widely used anti-seizure medications (ASMs) in clinical practice. This is due both to a different mechanism of action when compared to other ASMs and its easy handling. Indeed, because of its interesting pharmacokinetic properties, it is often used outside of the labelled indications, notably in the neurocritical setting as prophylaxis of epileptic seizures. AREAS COVERED A literature search was conducted and the most relevant studies on the pharmacokinetic properties of LEV were selected by two independent investigators. Current evidence on the use of ASM prophylaxis in the neurocritical setting was also reviewed, highlighting and discussing the strengths and limits of LEV as drug of choice for anti-epileptic prophylaxis in this scenario. EXPERT OPINION LEV has a "near-ideal" pharmacokinetic profile, which makes it an attractive drug for ASM prophylaxis in neurocritical care. However, current recommendations restrict ASMs prophylaxis to very selected circumstances and the role of LEV is marginal. Moreover, studies are generally designed to compare LEV versus phenytoin, whereas studies comparing LEV versus placebo are lacking. Further randomized trials will be needed to better elucidate LEV utility and its neuroprotective role in the neurocritical setting.
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Affiliation(s)
- Gianluca D'Onofrio
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy.,Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto "Giannina Gaslini", Via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Antonella Riva
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy.,Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto "Giannina Gaslini", Via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Elisabetta Amadori
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy.,Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto "Giannina Gaslini", Via Gerolamo Gaslini 5, 16147 Genoa, Italy
| | - Simona Lattanzi
- Department of Experimental and Clinical Medicine, Neurological Clinic, Marche Polytechnic University, Via Conca 71, 60020, Ancona, Italy
| | - Klaus Rose
- klausrose Consulting, Riehen, Switzerland
| | - Alberto Verrotti
- Pediatric Unit, Department of Medicine and Surgery, University of Perugia, 06156 Perugia, Italy
| | - Pasquale Striano
- Department of Neurosciences Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Via Gerolamo Gaslini 5, 16147 Genoa, Italy.,Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto "Giannina Gaslini", Via Gerolamo Gaslini 5, 16147 Genoa, Italy
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Barreto JN, Reid JM, Thompson CA, Mara KC, Rule AD, Kashani KB, Leung N, Larson T, McGovern RM, Witzig TE, Barreto EF. Prospective evaluation of high-dose methotrexate pharmacokinetics in adult patients with lymphoma using novel determinants of kidney function. Clin Transl Sci 2022; 15:105-117. [PMID: 34378331 PMCID: PMC8742646 DOI: 10.1111/cts.13125] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/06/2021] [Accepted: 07/10/2021] [Indexed: 12/14/2022] Open
Abstract
High-dose methotrexate (HDMTX) pharmacokinetics (PKs), including the best estimated glomerular filtration rate (eGFR) equation that reflects methotrexate (MTX) clearance, requires investigation. This prospective, observational, single-center study evaluated adult patients with lymphoma treated with HDMTX. Samples were collected at predefined time points up to 96 h postinfusion. MTX and 7-hydroxy-MTX PKs were estimated by standard noncompartmental analysis. Linear regression determined which serum creatinine- or cystatin C-based eGFR equation best predicted MTX clearance. The 80 included patients had a median (interquartile range [IQR]) age of 68.6 years (IQR 59.2-75.6), 54 (67.5%) were men, and 74 (92.5%) were White. The median (IQR) dose of MTX was 7.6 (IQR 4.8-11.3) grams. Median clearance was similar across three dosing levels at 4.5-5.6 L/h and was consistent with linear PKs. Liver function, weight, age, sex, concomitant chemotherapy, and number of previous MTX doses did not impact clearance. MTX area under the curve (AUC) values varied over a fourfold range and appeared to increase in proportion to the dose. The eGFRcys (ml/min) equation most closely correlated with MTX clearance in both the entire cohort and after excluding outlier MTX clearance values (r = 0.31 and 0.51, respectively). HDMTX as a 4-h infusion displays high interpatient pharmacokinetic variability. Population PK modeling to optimize MTX AUC attainment requires further evaluation. The cystatin C-based eGFR equation most closely estimated MTX clearance and should be investigated for dosing and monitoring in adults requiring MTX as part of lymphoma management.
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Affiliation(s)
| | - Joel M. Reid
- Department of Molecular Pharmacology and Experimental TherapeuticsMayo ClinicRochesterMinnesotaUSA,Department of OncologyMayo ClinicRochesterMinnesotaUSA
| | - Carrie A. Thompson
- Division of HematologyDepartment of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Kristin C. Mara
- Division of Biomedical Statistics and InformaticsDepartment of Health Sciences ResearchMayo ClinicRochesterMinnesotaUSA
| | - Andrew D. Rule
- Division of Nephrology and HypertensionDepartment of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Kianoush B. Kashani
- Division of Nephrology and HypertensionDepartment of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Nelson Leung
- Division of Nephrology and HypertensionDepartment of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Thomas R. Larson
- Department of Molecular Pharmacology and Experimental TherapeuticsMayo ClinicRochesterMinnesotaUSA
| | | | - Thomas E. Witzig
- Division of HematologyDepartment of Internal MedicineMayo ClinicRochesterMinnesotaUSA
| | - Erin F. Barreto
- Department of PharmacyMayo ClinicRochesterMinnesotaUSA,Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMinnesotaUSA
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