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Cho H, Yoo KY, Shin JY, Lee EK, Choi B. Comparison of thrombotic adverse events in patients treated with factor VIII products and emicizumab using the 2018-2022 US Food and Drug Administration Adverse Event Reporting System data. J Thromb Haemost 2024; 22:1640-1648. [PMID: 38395359 DOI: 10.1016/j.jtha.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 02/08/2024] [Accepted: 02/13/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Relatively little is known about thrombotic adverse events (AEs) of emicizumab in postmarketing real-world settings, particularly in comparison with factor VIII (FVIII) products. A recent European study reported a potentially greater thrombotic risk of emicizumab compared with FVIII products. OBJECTIVES This drug safety study aims to investigate whether thrombotic AEs are more frequently reported for emicizumab than for FVIII products and if so, whether it is independent of bypassing agents as coreporting drugs using the United States Food and Drug Administration Adverse Event Reporting System data. METHODS Disproportionality analyses for thrombotic AEs of emicizumab vs FVIII products were conducted. Three signal detection indicators were used: proportional reporting ratio (PRR), reporting odds ratio (ROR), and informational component (IC). RESULTS During 2018-2022, the proportions of thrombotic AEs among all AEs were 4.07% (97 out of 2383) and 1.44% (134 out of 9324) for emicizumab and FVIII products, respectively: PRR = 2.83 (2.19-3.66), ROR = 2.91 (2.23-3.79), and IC = 1.04 (0.70-1.28). Bypassing agents as coreporting drugs were identified in 36% and 15% of the total thrombotic AE reports associated with emicizumab and FVIII products, respectively. Even after thrombotic AE reports with bypassing agents were excluded, the reporting proportion of thrombotic AEs was still greater for emicizumab than for FVIII products: PRR = 2.19 (1.60-2.99). CONCLUSION Thrombotic AEs in the United States Food and Drug Administration Adverse Event Reporting System data were about 3 times more frequently reported for emicizumab than for FVIII products. More research and efforts in the future are warranted for monitoring, elucidating, and preventing the potential risk of thrombotic AEs in hemophilia therapy, including emicizumab.
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Affiliation(s)
- Hyunjeong Cho
- Department of Research and Development, GC Biopharma, Yongin, South Korea; Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | | | - Ju-Young Shin
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea; School of Pharmacy, Sungkyunkwan University, Suwon, South Korea; Department of Clinical Research Design and Evaluation, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, South Korea
| | - Eun-Kyoung Lee
- Department of Research and Development, GC Biopharma, Yongin, South Korea
| | - BongKyoo Choi
- Department of Research and Development, GC Biopharma, Yongin, South Korea; Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea.
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2
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Fager AM, Ellsworth P, Key NS, Monroe DM, Hoffman M. Emicizumab promotes factor Xa generation on endothelial cells. J Thromb Haemost 2024; 22:1605-1615. [PMID: 38460838 DOI: 10.1016/j.jtha.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 01/31/2024] [Accepted: 02/26/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Until recently, the treatment of hemophilia A relied on factor (F)VIII replacement. However, up to one-third of patients with severe hemophilia A develop neutralizing alloantibodies that render replacement therapies ineffective. The development of emicizumab, a bispecific antibody that partially mimics FVIIIa, has revolutionized the treatment of these patients. However, the use of an activated prothrombin complex concentrate [FEIBA (Takeda)] to treat breakthrough bleeding in patients on emicizumab has been associated with thrombotic complications including a unique microangiopathy. OBJECTIVES We hypothesized that the thrombotic complications observed with the combination of emicizumab and FEIBA might be due to excessive expression of procoagulant activity on the surface of endothelial cells. METHODS We examined the ability of emicizumab to promote FX activation on endothelial cells using 2 cell culture models. RESULTS We found that endothelial cells readily support emicizumab-mediated activation of FX by FIXa. The level of FXa generation depends on the concentration of available FIXa. The addition of FEIBA to emicizumab increased FXa generation in a dose-dependent manner on endothelial cells in both models. The rate of FXa generation was further enhanced by endothelial cell activation. However, unlike emicizumab, we found limited FXa generation in the presence of FVIII(a), which followed a significant lag time and was not dependent on FIXa concentration under these conditions. CONCLUSION Emicizumab promotes FXa generation on the surface of endothelial cells, which is markedly enhanced in the presence of FEIBA. These findings demonstrate a potential mechanism for the thrombotic complications seen with the combined use of emicizumab and FEIBA.
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Affiliation(s)
- Ammon M Fager
- Hematology/Oncology Service, Department of Veterans Affairs Medical Center, Durham, North Carolina, USA; Division of Hematology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Patrick Ellsworth
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nigel S Key
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; Department of Laboratory Medicine and Pathology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Dougald M Monroe
- Blood Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Maureane Hoffman
- Pathology and Laboratory Medicine Service, Department of Veterans Affairs Medical Center, Durham, North Carolina, USA; Department of Pathology, Duke University School of Medicine, Durham, North Carolina, USA
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3
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Wall C, Xiang H, Palmer B, Chalmers E, Chowdary P, Collins PW, Fletcher S, Hall GW, Hart DP, Mathias M, Sartain P, Shapiro S, Stephensen D, Talks K, Hay CRM. Emicizumab prophylaxis in haemophilia A with inhibitors: Three years follow-up from the UK Haemophilia Centre Doctors' Organisation (UKHCDO). Haemophilia 2023; 29:743-752. [PMID: 36811304 DOI: 10.1111/hae.14762] [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: 11/07/2022] [Revised: 01/20/2023] [Accepted: 01/29/2023] [Indexed: 02/24/2023]
Abstract
INTRODUCTION The UK National Haemophilia Database (NHD) collects data from all UK persons with haemophilia A with inhibitors (PwHA-I). It is well-placed to investigate patient selection, clinical outcomes, drug safety and other issues not addressed in clinical trials of emicizumab. AIMS To determine safety, bleeding outcomes and early effects on joint health of emicizumab prophylaxis in a large, unselected cohort using national registry and patient reported Haemtrack (HT) data between 01 January 2018 and 30 September 2021. METHODS Prospectively collected bleeding outcomes were analysed in people with ≥6 months emicizumab HT data and compared with previous treatment if available. Change in paired Haemophilia Joint Health Scores (HJHS) were analysed in a subgroup. Adverse events (AEs) reports were collected and adjudicated centrally. RESULTS This analysis includes 117 PwHA-I. Mean annualised bleeding rate (ABR) was .32 (95% CI, .18; .39) over a median 42 months treatment with emicizumab. Within-person comparison (n = 74) demonstrated an 89% reduction in ABR after switching to emicizumab and an increase in zero treated bleed rate from 45 to 88% (p < .01). In a subgroup of 37 people, total HJHS improved in 36%, remained stable in 46% and deteriorated in 18%, with a median (IQR) within-person change of -2.0 (-9, 1.5) (p = .04). Three arterial thrombotic events were reported, two possibly drug related. Other AEs were generally non-severe and usually limited to early treatment, included cutaneous reactions (3.6%), headaches (1.4%), nausea (2.8%) and arthralgia (1.4%). CONCLUSIONS Emicizumab prophylaxis is associated with sustained low bleeding rates and was generally well-tolerated in people with haemophilia A and inhibitors.
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Affiliation(s)
| | - Hua Xiang
- National Haemophilia Database, Manchester, UK
| | - Ben Palmer
- National Haemophilia Database, Manchester, UK
| | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | | | | | | | - Daniel P Hart
- The Royal London Hospital, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Paul Sartain
- Patient Representative, The Haemophilia Society, UK
| | | | | | - Kate Talks
- Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Charles R M Hay
- Manchester Royal Infirmary, Manchester, UK.,National Haemophilia Database, Manchester, UK
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Mahlangu J, Iorio A, Kenet G. Emicizumab state-of-the-art update. Haemophilia 2022; 28 Suppl 4:103-110. [PMID: 35521723 PMCID: PMC9321850 DOI: 10.1111/hae.14524] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/15/2022] [Accepted: 02/15/2022] [Indexed: 12/20/2022]
Abstract
Introduction Emicizumab is a bispecific monoclonal antibody developed to address the unmet needs of clotting factor replacement therapy and has become the benchmark for optimal prophylaxis in managing patients with haemophilia A with inhibitors. We describe the emicizumab rollout and pharmacokinetic strategies and their use in paediatric patients. Methods The evolving real‐world experience in using emicizumab has confirmed its safety, efficacy and pharmacokinetic profile in paediatric, adolescent and adult patients receiving emicizumab at various prophylactic dosing regimens. The emicizumab current global rollout includes over 100 countries with 29 low to middle‐income countries accessing emicizumab through the World Federation of Haemophilia (WFH) Humanitarian Aid Program. The diversity of emicizumab dosing and pharmacokinetic tools such as the Calibra® and the WAPPS‐Hemo platforms make it possible to achieve prophylaxis goals in line with the WFH Haemophilia treatment guidelines recommendations, with minimal drug wastage. The emerging experience from long term clinical trials and long‐term real‐world follow‐up confirm the safety, efficacy, and pharmacokinetic profile of emicizumab in paediatric haemophilia A patients. A few questions, including inhibitor recurrence, concurrent use of emicizumab with various replacement therapies and inhibitor eradication, are being addressed through multiple ongoing clinical studies. Conclusion The current global rollout of emicizumab is remarkable, and versatile dosing regimens and evolving pharmacokinetic tools such as the Calibra® and WAPPS‐Hemo platforms make it a treatment choice available also for pharmacokinetic guided personalised treatment. Data from paediatric studies are consistent with those seen in adolescent and adult Haemophilia A.
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Affiliation(s)
- Johnny Mahlangu
- Haemophilia Comprehensive Care Centre, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa.,Faculty of Health Sciences, University of the Witwatersrand and NHLS, Johannesburg, South Africa
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence and Impact (HEI), Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Gili Kenet
- National Hemophilia, Center, Sheba Medical Center, Tel Hashomer, Israel.,Amalia Biron Research Institute of Thrombosis and Hemostasis, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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5
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Alam AU, Karkhaneh M, Attia T, Wu C, Sun HL. All-cause mortality and causes of death in persons with haemophilia: A systematic review and meta-analysis. Haemophilia 2021; 27:897-910. [PMID: 34592037 DOI: 10.1111/hae.14423] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/23/2021] [Accepted: 09/19/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Improvements in haemophilia treatment over the last decades resulted in increased life expectancy in persons with haemophilia (PWH). AIM We conducted a systematic review and meta-analysis to examine all-cause mortality and causes of death among PWH. METHODS We systematically searched EMBASE, MEDLINE, Web of Science, CINAHL and Cochrane central register of controlled trials from inception through March 15, 2021. Studies that reported a mortality estimate of PWH compared with the general population and/or reported causes of death were included. Random-effects meta-analysis with inverse variance method was used to obtain pooled estimates. We stratified the analysis by the year of cohort entry (before 2000 vs after 2000). RESULT Of the 4769 studies identified, 52 met the eligibility criteria. The pooled all-cause standardized mortality ratio (SMR) from 9 studies in PWH was 1.93 (95% CI 1.38-2.70; I2 = 97%). The pooled SMRs before and after the year 2000 were 2.40 (95% CI 1.92-3.00; I2 = 87%) and 1.20 (95% CI 1.03-1.40; I2 = 62%), respectively. Before the year 2000, 31.2% deaths occurred due to HIV followed by haemorrhage (26.0%), cardiovascular disease (18.2%), liver disease (9.0%), and cancer (8.9%). Fewer (13.9%) deaths were attributable to HIV after the year 2000 with the proportion of deaths due to haemorrhage remaining unchanged. CONCLUSION With treatment advances, mortality in PWH has declined over the last few decades approaching that of the general population. However, haemorrhage remains a leading cause of death requiring further attention.
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Affiliation(s)
- Arafat Ul Alam
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Mohammad Karkhaneh
- Department of Medicine, University of Alberta, Edmonton, Canada.,Institute of Health Economics, Edmonton, Canada
| | | | - Cynthia Wu
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Haowei Linda Sun
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, Canada
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6
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Makris M, Hermans C. Making treatment decisions in hemophilia based on available safety data. J Thromb Haemost 2021; 19:1138-1139. [PMID: 33792179 DOI: 10.1111/jth.15255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 01/16/2021] [Indexed: 12/12/2022]
Affiliation(s)
- Mike Makris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - Cedric Hermans
- Hemostasis and Thrombosis Unit, Division of Hematology, Cliniques Universitaires Saint-Luc, Université catholique de Louvain (UCLouvain, Brussels, Belgium
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Recht M. Safety first: Tracking adverse events associated with new therapies for people with hemophilia. J Thromb Haemost 2021; 19 Suppl 1:3-5. [PMID: 33331044 DOI: 10.1111/jth.15188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/19/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Michael Recht
- American Thrombosis and Hemostasis Network, Rochester, NY, USA
- The Hemophilia Center, Oregon Health & Science University, Portland, OR, USA
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Peyvandi F, Mahlangu JN, Pipe SW, Hay CRM, Pierce GF, Kuebler P, Kruse‐Jarres R, Shima M. Application of a hemophilia mortality framework to the Emicizumab Global Safety Database. J Thromb Haemost 2021; 19 Suppl 1:32-41. [PMID: 33331041 PMCID: PMC7756327 DOI: 10.1111/jth.15187] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND As the first non-factor replacement therapy for persons with congenital hemophilia A (PwcHA), emicizumab's safety profile is of particular interest to the community. OBJECTIVES We applied an algorithm for categorization of fatal events contemporaneous to emicizumab using reporter-assessed causality documented in the Roche Emicizumab Global Safety Database. PATIENTS/METHODS All fatalities in PwcHA reported to the database (from clinical trials, pre-market access, and spontaneous post-marketing reports) were categorized into: associated with hemophilia A-hemorrhagic, thrombotic, human immunodeficiency virus (HIV)/hepatitis C virus (HCV), hepatic (non-HCV); associated with general population-trauma/suicide, non-HA-associated conditions; or, unspecified. Reported cause of death was not reassessed. RESULTS As of cut-off May 15, 2020, 31 fatalities in PwcHA taking emicizumab were reported. Median age at death was 58 years; 51% had factor VIII inhibitors. Fifteen fatalities were considered associated with HA; overall, the most frequent category was hemorrhage (11/31). Of these, six had a history of life-threatening bleeds, and four had a history of intracranial hemorrhage. The remaining HA-associated fatalities were related to HIV/HCV (3/31) and other hepatic causes (1/31). No cases were categorized as thrombotic. Of 10 cases considered not associated with HA, two were categorized as cardiovascular (non-thrombotic), five as infection/sepsis, and one each of trauma/suicide, pulmonary, and malignancy. Six cases were unspecified. CONCLUSIONS No unique risk of death was associated with emicizumab prophylaxis in PwcHA. The data reveal that mortality in PwcHA receiving emicizumab was primarily associated with hemorrhage or non-HA-associated conditions, and was not reported by treaters to be related to emicizumab treatment.
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Affiliation(s)
- Flora Peyvandi
- IRCCS Fondazione Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis CenterMilanItaly
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
| | | | - Steven W. Pipe
- Departments of Pediatrics and PathologyUniversity of Michigan Medical SchoolAnn ArborMIUSA
| | | | | | | | - Rebecca Kruse‐Jarres
- University of WashingtonSeattleWAUSA
- Washington Center for Bleeding DisordersSeattleWAUSA
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Pipe SW, Kruse‐Jarres R, Mahlangu JN, Pierce GF, Peyvandi F, Kuebler P, De Ford C, Sanabria F, Ko RH, Chang T, Hay CRM. Establishment of a framework for assessing mortality in persons with congenital hemophilia A and its application to an adverse event reporting database. J Thromb Haemost 2021; 19 Suppl 1:21-31. [PMID: 33331042 PMCID: PMC7756842 DOI: 10.1111/jth.15186] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/15/2020] [Accepted: 10/28/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Despite recent therapeutic advances, life expectancy in persons with congenital hemophilia A (PwcHA) remains below that of the non-HA population. As new therapies are introduced, a uniform approach to the assessment of mortality is required for comprehensive evaluation of risk-benefit profiles, timely identification of emerging safety signals, and comparisons between treatments. OBJECTIVES Develop and test a framework for consistent reporting and analysis of mortality across past, current, and future therapies. PATIENTS/METHODS We identified known causes of mortality in PwcHA through literature review, analysis of the US Food and Drug Administration Adverse Event Reporting System (FAERS) database, and expert insights. Leading causes of death in general populations are those recognized by the Centers for Disease Control and Prevention and the World Health Organization. We developed an algorithm for assessing fatalities in PwcHA and used this to categorize FAERS data as a proof of concept. RESULTS PwcHA share mortality causes with the non-HA population including cardiovascular disease, malignancy, infections, pulmonary disease, dementias, and trauma/suicide. Causes associated with HA include hemorrhage, thrombosis, human immunodeficiency virus, hepatitis C virus, and liver dysfunction. We propose an algorithm employing these classes to categorize fatalities and use it to classify FAERS fatality data between 01/01/2000 and 03/31/2020; the most common causes were hemorrhage (22.2%) and thrombosis (10.4%). CONCLUSIONS A conceptual framework for examining mortality in PwcHA receiving any hemophilia therapy is proposed to analyze and interpret fatalities, enabling consistent and objective assessment. Application of the framework using FAERS data suggests a generally consistent pattern of reported mortality across HA treatments, supporting the utility of this unified approach.
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Affiliation(s)
- Steven W. Pipe
- Departments of Pediatrics and PathologyUniversity of Michigan Medical SchoolAnn ArborMIUSA
| | - Rebecca Kruse‐Jarres
- University of WashingtonSeattleWAUSA
- Washington Center for Bleeding DisordersSeattleWAUSA
| | | | | | - Flora Peyvandi
- IRCCS Fondazione Ca' Granda Ospedale Maggiore PoliclinicoAngelo Bianchi Bonomi Hemophilia and Thrombosis CenterMilanItaly
- Department of Pathophysiology and TransplantationUniversity of MilanMilanItaly
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