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Chen X, Shu X, He L, Yang H, Lu X, Wang G, Ge Y. High prevalence and mortality of Pneumocystis jirovecii pneumonia in anti-MDA5 antibody-positive dermatomyositis. Rheumatology (Oxford) 2023; 62:3302-3309. [PMID: 36734589 DOI: 10.1093/rheumatology/kead063] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/15/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES To identify potential risk factors and prognostic factors of Pneumocystis jirovecii pneumonia (PJP) infection in anti-melanoma differentiation-associated gene 5 antibody-positive DM (anti-MDA5+ DM) patients, and to evaluate the diagnostic performance of metagenomic next-generation sequencing (mNGS). METHODS Anti-MDA5+ DM patients who underwent mNGS or real-time PCR for PJP detection were recruited. The potential risk factors for PJP occurrence and death were analysed via Logistic regression and Cox proportional hazards regression, respectively. The diagnostic efficacy of mNGS was compared with the conventional methods. RESULTS 91 patients were enrolled and 44 were assigned to PJP+ group. The PJP detection rate was 48.4%. PJP often occurred in the first 3 months (68.2%) of the disease; this period also showed the highest mortality rate (20.5%). Fever and increased lactate dehydrogenase (LDH) were independent risk factors for PJP occurrence, while trimethoprim-sulfamethoxazole (TMP/SMZ) prophylaxis was an independent protective factor (all P < 0.05). Older age and increased LDH were predictors for mortality in patients with anti-MDA5+ DM and PJP (all P < 0.05). In addition, we found that mNGS had a sensitivity of 100.0% and specificity of 90.0% in diagnosing PJP, with the highest area under the curve of 0.95 (P < 0.001). CONCLUSION PJP has high prevalence and mortality in anti-MDA5+ DM. It is crucial for clinicians to identify high-risk patients and promptly institute TMP/SMZ to prevent PJP. mNGS is the preferred approach for pathogen detection in anti-MDA5+ DM when PJP is suspected.
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Affiliation(s)
- Xixia Chen
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Xiaoming Shu
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, China
| | - Linrong He
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, China
| | - Hanbo Yang
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, China
| | - Xin Lu
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, China
| | - Guochun Wang
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, China
| | - Yongpeng Ge
- Department of Rheumatology, Key Myositis Laboratories, China-Japan Friendship Hospital, Beijing, China
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Clemente Garulo D, Núñez-Cuadros E, Camacho Lovillo M, Calzada-Hernández J, Guillén Martín S, Fernández Silveira L, Lirola Cruz MJ, Tagarro A, Alcobendas Rueda RM, López López A, Satrustegi Aritziturri M, Calvo C. Position statement on infection screening, prophylaxis, and vaccination in pediatric patients with rheumatic diseases and immunosuppressive therapies, part 2: infection prophylaxis. Eur J Pediatr 2023; 182:4271-4284. [PMID: 37439850 PMCID: PMC10570166 DOI: 10.1007/s00431-023-05080-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/18/2023] [Accepted: 06/21/2023] [Indexed: 07/14/2023]
Abstract
This study aims to provide practical recommendations on prophylaxis for infection in pediatric patients with immune-mediated rheumatic diseases receiving/scheduled to receive immunosuppressive therapy. A qualitative approach was applied. A narrative literature review was performed via Medline. Primary searches were conducted using MeSH terms and free text to identify articles that analyzed data on infections and vaccinations in pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapy. The results were presented and discussed in a nominal group meeting comprising a committee of 12 pediatric rheumatologists from the Prevention and Treatment of Infections Working Group of the Spanish Society of Pediatric Rheumatology. Several recommendations were generated. A consensus procedure was implemented via a Delphi process that was extended to members of the Spanish Society of Pediatric Rheumatology and the Vaccine Advisory Committee of the Spanish Association of Pediatrics. Participants produced a score ranging from 0 (completely disagree) to 10 (completely agree). Agreement was considered to have been reached if at least 70% of participants voted ≥ 7. The literature review included more than 400 articles. Overall, 63 recommendations were generated (23 on infection prophylaxis) and voted by 59 pediatric rheumatologists and other pediatric specialists, all of whom achieved the pre-established level of agreement. The recommendations on prophylaxis of infection cover vaccination and prophylaxis against varicella zoster virus, tuberculosis, Pneumocystis jiroveccii, and invasive fungal infections in pediatric patients with immune-mediated rheumatic diseases receiving/scheduled to receive immunosuppressive therapy. Conclusion: Based on current evidence and a Delphi process, we provided consensus and updated recommendations on prophylaxis and treatment of infections to guide those caring for pediatric rheumatology patients. What is Known: •Data largely derived from adults find that infectious diseases and related complications are a major cause of morbidity and mortality in patients with immune-mediated rheumatic diseases. •It is crucial to be aware of the preventive measures that should be implemented to prevent these infections in children, although most guidelines are often extrapolated from adult cases. What is New: •In the absence of evidence, a literature review and a Delphi survey were conducted to establish a series of expert recommendations that could prove useful in clinical practice, providing a practical and simple day-to-day approach to be used by pediatric rheumatologists. •The recommendations focus on tuberculosis, herpes zoster virus, fungal infections, and Pneumocystis jirovecii.
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Affiliation(s)
| | - Esmeralda Núñez-Cuadros
- Pediatric Rheumatology Unit, UGC Pediatría, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Av. del Arroyo de los Ángeles, S/N, 29011, Málaga, Spain.
| | - Marisol Camacho Lovillo
- Servicio de Inmunología, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBIS), Reumatología E Infectología Pediátricas, Seville, Spain
| | - Joan Calzada-Hernández
- Unitat de Reumatologia Pediàtrica, Servei de Pediatria, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, Spain
| | - Sara Guillén Martín
- Department of Paediatrics, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - Laura Fernández Silveira
- Servicio de Inmunología, Hospital Universitario Virgen del Rocío/Instituto de Biomedicina de Sevilla (IBIS), Reumatología E Infectología Pediátricas, Seville, Spain
| | - María José Lirola Cruz
- Department of Paediatric Rheumatology, Instituto Hispalense de Pediatría, Seville, Spain
| | - Alfredo Tagarro
- Pediatrics Department, Instituto de Investigación 12 de Octubre (imas12), Hospital Universitario Infanta Sofía, Universidad Europea, Hospital 12 de Octubre, Madrid, Spain
| | | | - Agustín López López
- Department of Paediatrics, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | | | - Cristina Calvo
- Department of Pediatrics, Infectious and Tropical Diseases, Hospital Universitario La Paz, and La Paz Research Institute (IdiPaz), Madrid, Spain
- Translational Research Network of Pediatric Infectious Diseases (RITIP). Madrid, Madrid, Spain
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Zalmanovich A, Ben-Ami R, Rahav G, Alon D, Moses A, Olshtain-Pops K, Weinberger M, Shitrit P, Katzir M, Gottesman BS, Chowers M. Rituximab identified as an independent risk factor for severe PJP: A case-control study. PLoS One 2020; 15:e0239042. [PMID: 32915907 PMCID: PMC7485893 DOI: 10.1371/journal.pone.0239042] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 08/28/2020] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE Pneumocystis jirovecii pneumonia (PJP) was reported among immunosuppressed patients with deficits in cell-mediated immunity and in patients treated with immunomodulatory drugs. The aim of this study was to identify risk-factors for PJP in noninfected HIV patients. METHODS This retrospective, test negative, case-control study was conducted in six hospitals in Israel, 2006-2016. Cases were hospitalized HIV-negative patients with pneumonia diagnosed as PJP by bronchoalveolar lavage. Controls were similar patients negative for PJP. RESULTS Seventy-six cases and 159 controls were identified. Median age was 63.7 years, 65% males, 34% had hematological malignancies, 11% inflammatory diseases, 47% used steroids and 9% received antilymphocyte monoclonal antibodies. PJP was independently associated with antilymphocyte monoclonal antibodies (OR 11.47, CI 1.50-87.74), high-dose steroid treatment (OR 4.39, CI 1.52-12.63), lymphopenia (OR 8.13, CI 2.48-26.60), low albumin (OR 0.15, CI 0.40-0.54) and low BMI (OR 0.80, CI 0.68-0.93). CONCLUSION In conclusion, rituximab, which is prescribed for a wide variety of malignant and inflammatory disorders, was found to be significant risk-factor for PJP. Increased awareness of possible PJP infection in this patient population is warranted.
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Affiliation(s)
- Anat Zalmanovich
- Department of Internal Medicine A, Meir Medical Center, Kfar Saba, Israel
| | - Ronen Ben-Ami
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Disease Unit, Tel Aviv Medical Center, Tel Aviv, Israel
| | - Galia Rahav
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Disease Unit, Sheba Medical Center, Ramat Gan, Israel
| | - Danny Alon
- Department of Internal Medicine A, Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Allon Moses
- Infectious Disease Unit, Hadassah Medical Center, Jerusalem, Israel
- Hebrew University of Jerusalem, Jerusalem, Israel
| | - Karen Olshtain-Pops
- Infectious Disease Unit, Hadassah Medical Center, Jerusalem, Israel
- Hebrew University of Jerusalem, Jerusalem, Israel
| | - Miriam Weinberger
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Disease Unit, Assaf Harofeh Medical Center, Be’er Yaakov, Israel
| | - Pnina Shitrit
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Diseases Unit, Meir Medical Center, Kfar Saba, Israel
| | - Michal Katzir
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Diseases Unit, Meir Medical Center, Kfar Saba, Israel
| | - Bat-Sheva Gottesman
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Diseases Unit, Meir Medical Center, Kfar Saba, Israel
| | - Michal Chowers
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Infectious Diseases Unit, Meir Medical Center, Kfar Saba, Israel
- * E-mail:
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Verhaert M, Blockmans D, De Langhe E, Henckaerts L. Pneumocystis jirovecii pneumonia in patients treated for systemic autoimmune disorders: a retrospective analysis of patient characteristics and outcome. Scand J Rheumatol 2020; 49:345-352. [DOI: 10.1080/03009742.2020.1762921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- M Verhaert
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - D Blockmans
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - E De Langhe
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - L Henckaerts
- Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Barroil M, Girard C, Lerisson M, Negroni V, Bertrand AS, Pallure V, Bessis D, Guillot B, Dereure O. [Use of rituximab in maintenance treatment of pemphigus: A retrospective series]. Ann Dermatol Venereol 2020; 147:173-178. [PMID: 31955970 DOI: 10.1016/j.annder.2019.08.020] [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: 12/20/2018] [Revised: 03/31/2019] [Accepted: 08/05/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Rituximab (RTX), currently recommended as first-line treatment in moderate to severe pemphigus vulgaris (PV) and superficial pemphigus (PS) along with initial systemic steroids, may also be used as second-line or subsequent treatment, and this therapeutic strategy was investigated in a real-life monocentre retrospective survey. MATERIAL AND METHODS All patients treated between January 2010 and March 2018 with RTX as second-line or subsequent treatment for moderate to severe PV or PS and followed for at least one year were included. The main objective was to evaluate rates and times of complete clinical remission (CCR) after a first course of RTX. The secondary objectives consisted mainly of treatment safety, and frequency and time to relapse after the initial CCR. RESULTS The 24 patients selected received on average 2 cycles of RTX (i.e. 24 initial cycles and 24 additional cycles in all) over a mean follow-up period of 45 months. 18/24 (75%) patients achieved initial CCR within a mean 7.7 months. Despite at least one relapse in 13/18 initially responding patients regardless of relapse time, 59% (14/24) and 33% (8/24) were either in CCR and off treatment, or in partial remission, whether treated or untreated, according to the latest patient news, with an overall response rate of 92%. Safety was fair in these fragile patients. DISCUSSION AND CONCLUSION This survey of the practical use of RTX confirms its interest in moderate to severe pemphigus as a second-line or subsequent treatment, a situation that probably remains relevant even if this molecule is increasingly used as first-line therapy.
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Affiliation(s)
- M Barroil
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France
| | - C Girard
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France
| | - M Lerisson
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France
| | - V Negroni
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France
| | - A-S Bertrand
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France
| | - V Pallure
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France
| | - D Bessis
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France
| | - B Guillot
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France
| | - O Dereure
- Département de Dermatologie et INSERM U1058 « pathogénèse et contrôle des infections chroniques », université de Montpellier, hôpital Saint-Éloi, 80, avenue Augustin-Fliche, Montpellier cedex 5, France.
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Binet Q, Mairesse J, Vanthuyne M, Marot JC, Wieers G. Hypercalcemia Heralding Pneumocystis jirovecii Pneumonia in an HIV-Seronegative Patient with Diffuse Cutaneous Systemic Sclerosis. Mycopathologia 2019; 184:787-793. [PMID: 31729682 DOI: 10.1007/s11046-019-00397-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 10/09/2019] [Indexed: 11/30/2022]
Abstract
Pneumocystis pneumonia (PCP) is a life-threatening fungal infection occurring in immunocompromised patients such as HIV-positive patients with low CD4 cell count or patients under heavy immunosuppressive therapy. We report the case of a 59-year-old male with severe diffuse cutaneous systemic sclerosis presenting with asthenia, dry cough and worsening shortness of breath for the last 15 days. Biological studies were remarkable for PTH-independent severe hypercalcemia with low 25-hydroxyvitamin D and a paradoxically elevated 1,25-dihydroxyvitamin D. Early bronchoalveolar lavage allowed for PCP diagnosis and targeted treatment. We discuss the underlying physiopathology and difficulties regarding prophylaxis and treatment.
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Affiliation(s)
- Quentin Binet
- Division of General Internal Medicine and Infectiology, Clinique St-Pierre Ottignies, Avenue Reine Fabiola, 9, 1340, Ottignies, Belgium.
| | - Jacques Mairesse
- Division of Clinical Biology and Cytology, Clinique St-Pierre Ottignies, Ottignies, Belgium
| | - Marie Vanthuyne
- Division of Rheumatology, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium.,Division of Rheumatology, Grand Hôpital de Charleroi, Gilly, Belgium
| | - Jean-Christophe Marot
- Division of General Internal Medicine and Infectiology, Clinique St-Pierre Ottignies, Avenue Reine Fabiola, 9, 1340, Ottignies, Belgium
| | - Grégoire Wieers
- Division of General Internal Medicine and Infectiology, Clinique St-Pierre Ottignies, Avenue Reine Fabiola, 9, 1340, Ottignies, Belgium
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White PL, Price JS, Backx M. Pneumocystis jirovecii Pneumonia: Epidemiology, Clinical Manifestation and Diagnosis. CURRENT FUNGAL INFECTION REPORTS 2019. [DOI: 10.1007/s12281-019-00349-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Grossin D, Broner J, Arnaud E, Goulabchand R, Gris JC. [Acquired autoimmune haemophilia: Where is the place of rituximab in the treatment strategy? Reflection from a monocentric series of 8 patients and literature review]. Rev Med Interne 2019; 40:574-580. [PMID: 30904179 DOI: 10.1016/j.revmed.2019.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/14/2019] [Accepted: 02/24/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Autoimmune acquired haemophilia is a rare autoimmune disease. The purpose of immunosuppressive therapy is to stop the production of autoantibodies that inhibit clotting factors VIII or IX. A corticosteroids-cyclophosphamide combination is recommanded as first-line therapy. From our experience at the University Hospital of Nîmes, we discuss the place of rituximab in the therapeutic arsenal. METHODS We report a monocentric observational retrospective study. Our data are discussed in light of literature data, in particular cohorts EACH2 and SACHA. RESULTS Eight patients (7 with FVIII anibodies) were consecutively included from 2005. The average age was 68.5 years with a male predominance (62.5%). Bleeding manifestations were usually spontaneous and superficial. A pathology, mostly autoimmune or neoplastic, was associated in 5/8 patients. A "by-pass" haemostatic treatment was prescribed for 3/8 patients. Rituximab was prescribed for 5/8 patients, three times as first-line therapy, and always associated with corticosteroids. Three patients received a cyclophosphamid/cortisone combination, two were treated exclusively with oral corticosteroids. Remission was obtained in all patients, without subsequent relapse. The average time to obtain remission under rituximab (after the first injection) was 32.5 days (10-143). The results observed in our series of patients are consistent with the data from the literature. CONCLUSIONS Rituximab appears to be an effective and well-tolerated treatment for autoimmune acquired haemophilia. However, its place remains to be specified.
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Affiliation(s)
- D Grossin
- Service de médecine interne, CHU Nîmes, 30029 Nîmes, France.
| | - J Broner
- Service de médecine interne, CHU Nîmes, 30029 Nîmes, France
| | - E Arnaud
- Service de médecine interne, CHU Nîmes, 30029 Nîmes, France
| | - R Goulabchand
- Département de médecine interne maladies multi-organiques, CHU Saint-Éloi, Montpellier, France
| | - J C Gris
- Service d'hématologie, CHU Nîmes, 30029 Nîmes, France
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Lee H, Han A, Choi C, Ahn S, Min SI, Min SK, Lee H, Kim YS, Yang J, Ha J. Proposal of a Selective Prophylaxis Strategy Based on Risk Factors to Prevent Early and Late Pneumocystis jirovecii Pneumonia after Renal Transplantation. KOREAN JOURNAL OF TRANSPLANTATION 2018. [DOI: 10.4285/jkstn.2018.32.4.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ho Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Ahram Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Chanjoong Choi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sanghyun Ahn
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-il Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Kee Min
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jaeseok Yang
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Transplantation Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Jongwon Ha
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- Department of Transplantation Research Institute, Seoul National University College of Medicine, Seoul, Korea
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