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Kohli A, Saluja A, Farooqi M, Arora S, Mittal N. Unmasking Sarcoidosis as the Culprit Behind Hypercalcemia-Induced Acute Pancreatitis: A Diagnostic Conundrum. Cureus 2023; 15:e47643. [PMID: 38021853 PMCID: PMC10667954 DOI: 10.7759/cureus.47643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Hypercalcemia-induced pancreatitis is a rare and challenging complication, particularly when secondary to sarcoidosis. This case report discusses the clinical presentation, diagnostic workup, and management of a 61-year-old patient diagnosed with hypercalcemia-induced pancreatitis secondary to sarcoidosis. The abstract highlights the complexities of diagnosing pancreatitis linked to elevated calcium levels and underscores the importance of recognizing underlying conditions such as sarcoidosis in these cases. Through this case, we aim to enhance awareness among clinicians regarding the association between sarcoidosis, hypercalcemia, and pancreatitis, ultimately contributing to improved diagnostic accuracy and patient care strategies.
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Affiliation(s)
- Aditya Kohli
- Internal Medicine, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Anshdeep Saluja
- Internal Medicine, Dayanand Medical College and Hospital, Ludhiana, IND
| | | | - Saurabh Arora
- Endocrinology, Dayanand Medical College and Hospital, Ludhiana, IND
| | - Naveen Mittal
- Endocrinology and Diabetes, Dayanand Medical College and Hospital, Ludhiana, IND
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Abstract
Sarcoidosis is a systemic inflammatory disease of unknown etiology. The pathogenesis rests on an aberrant T cell response to unidentified antigens in individuals predisposed by genetic and environmental factors. Increased expression of polarized macrophages and disequilibrium between effector and regulator T cells contribute to the formation of noncaseating granulomas, that are frequently found in affected organs. The main kidney abnormalities in sarcoidosis are granulomatous interstitial nephritis (GIN) and hypercalcemia-related disorders. The clinical diagnosis is difficult. The outcome is variable, ranging from spontaneous remission to end-stage kidney disease (ESKD). Early diagnosis and prompt treatment with corticosteroids can improve the prognosis. Hypercalcemia may be responsible for acute kidney injury (AKI) caused by vasoconstriction of afferent arterioles. Complications of persistent hypercalcemia include nephrocalcinosis and renal stones. In patients with ESKD, dialysis and transplantation can offer results comparable to those observed in patients with other causes of kidney failure. Based on a review of the literature, we present an overview of the etiopathogenesis, the renal manifestations of sarcoidosis and their complications, management and prognosis.
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DeCarli K, Masel R, Hsu A, Lopresti M. Treatment-induced sarcoidosis in a patient with metastatic clear cell ovarian cancer. BMJ Case Rep 2021; 14:e247278. [PMID: 34876449 PMCID: PMC8655527 DOI: 10.1136/bcr-2021-247278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 11/04/2022] Open
Abstract
Sarcoidosis is a granulomatous disease that commonly presents with lung or lymphatic system manifestations. Diagnosis is often delayed due to variable clinical presentation. This is a case of a patient with metastatic clear cell ovarian cancer who developed disease reoccurence after definitive treatment with surgery and adjuvant chemotherapy. She was treated with multiple lines of therapy, including investigational agents. During this time, she developed mediastinal lymphadenopathy and hypercalcaemia. Due to suspicion that her presentation was not a manifestation of her malignancy, she underwent two lymph node biopsies revealing granulomatous disease. She was initiated on prednisone for management of sarcoidosis, which led to radiologic, laboratory and symptomatic improvement. Although the precipitating factor for this patient's sarcoidosis cannot be definitively determined, nivolumab is a possible culprit. This case highlights the importance of a broad differential diagnosis when a patient undergoing antineoplastic treatment develops mediastinal lymphadenopathy or hypercalcaemia.
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Affiliation(s)
- Kathryn DeCarli
- Division of Hematology/Oncology, Lifespan Health System, Providence, Rhode Island, USA
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Rebecca Masel
- Division of Hematology/Oncology, Lifespan Health System, Providence, Rhode Island, USA
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Andrew Hsu
- Division of Hematology/Oncology, Lifespan Health System, Providence, Rhode Island, USA
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Mary Lopresti
- Division of Hematology/Oncology, Lifespan Health System, Providence, Rhode Island, USA
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
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Flowers RC, Ocampo J, Krautbauer J, Kupin WL. Hypercalcaemia in Mycobacterium kansasii pulmonary infection. BMJ Case Rep 2021; 14:e245800. [PMID: 34848413 PMCID: PMC8634358 DOI: 10.1136/bcr-2021-245800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2021] [Indexed: 12/25/2022] Open
Abstract
A gentleman in his 60s with end-stage kidney disease status post kidney transplantation on prednisone and tacrolimus presented with generalised weakness for 7 days, associated with altered mental status. Investigations revealed pancytopenia, acute kidney injury, hypercalcaemia, decreased parathyroid hormone (PTH) and normal calcitriol levels. CT of the chest showed multifocal lung opacities suspicious for malignancy. Bronchoscopy with biopsy yielded no malignant cells, and bronchoalveolar lavage specimens grew Mycobacterium kansasii The patient was treated with bisphosphonates, calcitonin and antibiotics for non-tuberculous mycobacteria pulmonary infection, with improvement in serum calcium levels, and was discharged after 5 weeks of hospitalisation.The work-up for hypercalcaemia begins with PTH measurement, and low PTH levels are consistent with malignancy, immobilisation and granulomatous diseases. Hypercalcaemia in the lattermost is classically caused by overproduction of calcitriol by activated macrophages. However, there are case reports of mycobacterial infections with hypercalcaemia despite normal calcitriol levels, supporting the existence of an additional mechanism of hypercalcaemia in granulomatous infections.
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Affiliation(s)
- Robert Costigan Flowers
- University of Miami Health System, Miami, Florida, USA
- Jackson Memorial Hospital, Miami, Florida, USA
| | - Javier Ocampo
- University of Miami Health System, Miami, Florida, USA
- Jackson Memorial Hospital, Miami, Florida, USA
| | - Justin Krautbauer
- University of Miami Health System, Miami, Florida, USA
- Jackson Memorial Hospital, Miami, Florida, USA
| | - Warren L Kupin
- Nephrology and Hypertension, Miami Transplant Institute, Miami, Florida, USA
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Motlaghzadeh Y, Bilezikian JP, Sellmeyer DE. Rare Causes of Hypercalcemia: 2021 Update. J Clin Endocrinol Metab 2021; 106:3113-3128. [PMID: 34240162 DOI: 10.1210/clinem/dgab504] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Primary hyperparathyroidism and malignancy are the etiologies in 90% of cases of hypercalcemia. When these entities are not the etiology of hypercalcemia, uncommon conditions need to be considered. In 2005, Jacobs and Bilezikian published a clinical review of rare causes of hypercalcemia, focusing on mechanisms and pathophysiology. This review is an updated synopsis of rare causes of hypercalcemia, extending the observations of the original article. EVIDENCE ACQUISITION Articles reporting rare associations between hypercalcemia and unusual conditions were identified through a comprehensive extensive PubMed-based search using the search terms "hypercalcemia" and "etiology," as well as examining the references in the identified case reports. We categorized the reports by adults vs pediatric and further categorized the adult reports based on etiology. Some included reports lacked definitive assessment of etiology and are reported as unknown mechanism with discussion of likely etiology. EVIDENCE SYNTHESIS There is a growing understanding of the breadth of unusual causes of hypercalcemia. When the cause of hypercalcemia is elusive, a focus on mechanism and review of prior reported cases is key to successful determination of the etiology. CONCLUSIONS The ever-expanding reports of patients with rare and even unknown mechanisms of hypercalcemia illustrate the need for continued investigation into the complexities of human calcium metabolism.
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Affiliation(s)
- Yasaman Motlaghzadeh
- Stanford University School of Medicine, Division of Endocrinology, Gerontology and Metabolism, Palo Alto, CA 94305, USA
| | - John P Bilezikian
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
| | - Deborah E Sellmeyer
- Stanford University School of Medicine, Division of Endocrinology, Gerontology and Metabolism, Palo Alto, CA 94305, USA
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Pislar N, Hocevar M. Intraoperative parathormone increase after focused parathyroidectomy in a patient with sarcoidosis - Case report. Ann Med Surg (Lond) 2021; 68:102577. [PMID: 34336200 PMCID: PMC8318857 DOI: 10.1016/j.amsu.2021.102577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/15/2021] [Accepted: 07/15/2021] [Indexed: 10/31/2022] Open
Abstract
Introduction Hypercalcaemia is most commonly a sign of primary hyperparathyroidism but can also be a sign of an active granulomatous disease. Standard treatment for primary hyperparathyroidism caused by a solitary parathyroid gland adenoma identified by localisation studies is minimally invasive focused parathyroidectomy. If unsuccessful, bilateral neck exploration is recommended. Case presentation We report the case of hypercalcaemia and ostheoporosis in a 63-year -old woman with a history of sarcoidosis and suspected primary hyperparathyroidism. Localisation studies for parathyroid adenoma were inconclusive due to active cervical and mediastinal granulomatous lymph nodes. Sarcoidosis was treated with corticosteroids but hypercalcaemia persisted. Focused parathyroidectomy was attempted with intraoperative parathyroid hormone measurement but an increase in parathyroid hormone levels was observed. However, with high clinical probability of a successfully removed adenoma and frozen section evaluation, we decided not to proceed with bilateral neck exploration. Serum parathyroid hormone and calcium levels dropped accordingly the following day. Clinical discussion We explored all possible underlying mechanisms for persistent elevated parathyroid hormone level described in literature. Conclusion We conclude that Wisconsin Criteria with intraoperative parathyroid hormone measured 20 minutes after adenoma removal should be applied in such cases.
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Affiliation(s)
- Nina Pislar
- Department of Surgical Oncology, Institute of Oncology Ljubljana, Zaloska Cesta 2, 1000, Ljubljana, Slovenia
| | - Marko Hocevar
- Department of Surgical Oncology, Institute of Oncology Ljubljana, Zaloska Cesta 2, 1000, Ljubljana, Slovenia
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Gunasekharan A, Thekekara J, Kwon Y, Irani F. Recurrent Pleural Effusions and Elevated PTHrP: An Unusual Case of Sarcoidosis. J Community Hosp Intern Med Perspect 2020; 10:594-596. [PMID: 33194137 PMCID: PMC7599017 DOI: 10.1080/20009666.2020.1816275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
A 63-year-old male with a past medical history of stage 3 chronic kidney disease, type 2 diabetes mellitus, hypertension, and coronary artery disease presented with recurrent symptomatic pleural effusions, low back pain and unintentional weight loss. Labs revealed elevated serum calcium and parathyroid hormone-related peptide, but normal parathyroid hormone, vitamin D, and angiotensin-converting enzyme levels. Malignancy workup was revealing for salt-and-pepper appearance of the bone marrow on MRI of the lumbar spine consistent with multiple myeloma. CT of chest, abdomen, and pelvis was negative for neoplastic process but showed a pleural effusion and calcified granulomas in hilar lymph nodes. Bone marrow biopsy of the lumbar region was subsequently conducted and revealed granulomas confirming the diagnosis of sarcoidosis. Treatment of sarcoidosis resulted in complete resolution of his symptoms and pleural effusion. This case highlights the variable presentation of sarcoidosis and its ability to mimic malignancy. Prompt recognition and treatment is essential in avoiding unnecessary costs and harm to the patient.
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Affiliation(s)
- Atchayaa Gunasekharan
- Department of Internal Medicine, Mercy Health - The Jewish Hospital, Cincinnati, OH, USA
| | - Joel Thekekara
- Department of Internal Medicine, Mercy Health - The Jewish Hospital, Cincinnati, OH, USA
| | - Younghwa Kwon
- Department of Internal Medicine, Mercy Health - The Jewish Hospital, Cincinnati, OH, USA
| | - Farzan Irani
- Department of Internal Medicine, Mercy Health - The Jewish Hospital, Cincinnati, OH, USA
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Mulkareddy V, Bhalla V, Upadhye S, Siddam P. The Diagnostic Dilemma of Sarcoidosis: A Case of Acute Hypercalcemia. Cureus 2020; 12:e10399. [PMID: 33062519 PMCID: PMC7549992 DOI: 10.7759/cureus.10399] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Hypercalcemia is a common clinical laboratory abnormality with a majority of cases attributed to malignancy or hyperparathyroidism. Although hypercalcemia is a common manifestation of sarcoidosis, it is rarely the initial presentation. Here we present a case of acute hypercalcemia in a 60-year-old gentleman, which was diagnosed as sarcoidosis following an elaborate workup, including radiological assessment and multiple organ biopsies. This case highlights the diagnostic dilemma of sarcoidosis due to varying clinical presentation that can mimic multiple conditions, including malignancy. Biopsy showing noncaseating granulomas is pathognomic of sarcoidosis. Due to its multisystemic and nonspecific presentation, selecting an appropriate biopsy site is key to diagnosis.
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Affiliation(s)
- Vani Mulkareddy
- Internal Medicine, Rochester Regional Health, Rochester General Hospital, Rochester, USA
| | - Varun Bhalla
- Internal Medicine, Rochester Regional Health, Rochester General Hospital, Rochester, USA
| | - Soham Upadhye
- Internal Medicine, Rochester Regional Health, Rochester General Hospital, Rochester, USA
| | - Preeti Siddam
- Internal Medicine, Rochester Regional Health, Rochester General Hospital, Rochester, USA
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Gwadera Ł, Białas AJ, Iwański MA, Górski P, Piotrowski WJ. Sarcoidosis and calcium homeostasis disturbances-Do we know where we stand? Chron Respir Dis 2020; 16:1479973119878713. [PMID: 31718265 PMCID: PMC6854763 DOI: 10.1177/1479973119878713] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The majority of cases involving hypercalcemia in the setting of sarcoidosis are explained by the overproduction of calcitriol by activated macrophages. Vitamin D takes part in the regulation of granuloma formation. However, using vitamin D metabolites to assess the activity of the disease is still problematic, and its usefulness is disputable. In some cases, though, a calcium metabolism disorder could be a valuable tool (i.e. as a marker of extrathoracic sarcoidosis). Although sarcoidosis does not cause a decrease in bone mineral density, increased incidence of vertebral deformities is noted. Despite increasing knowledge about calcium homeostasis disorders in patients with sarcoidosis, there is still a need for clear guidelines regarding calcium and vitamin D supplementation in these patients.
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Affiliation(s)
- Łukasz Gwadera
- Department of Pneumology and Allergy, Chair of Internal Medicine, Medical University of Lodz, Poland
| | - Adam Jerzy Białas
- Department of Pneumology and Allergy, Chair of Internal Medicine, Medical University of Lodz, Poland
| | | | - Paweł Górski
- Department of Pneumology and Allergy, Chair of Internal Medicine, Medical University of Lodz, Poland
| | - Wojciech Jerzy Piotrowski
- Department of Pneumology and Allergy, Chair of Internal Medicine, Medical University of Lodz, Poland
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Chronic Inflammatory Arthropathy Preceding Acute Systemic Manifestations of Sarcoidosis: A Possible Overlap of Idiopathic Juvenile Arthritis and Sarcoidosis. Case Rep Rheumatol 2019; 2019:6483245. [PMID: 31886005 PMCID: PMC6925795 DOI: 10.1155/2019/6483245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/14/2019] [Accepted: 11/18/2019] [Indexed: 12/17/2022] Open
Abstract
Sarcoidosis is a multisystem disease with unknown etiology, marked by T lymphocytes and macrophages agglomeration, which leads to the formation of noncaseating granulomas in the affected tissues. We describe a case of a 40-year-old black patient referred to our service for evaluation of nephrolithiasis and persistent elevation of plasma creatinine. He reported important weight loss, fever episodes, and abdominal and low back intermittent pain in the past 6 months. The investigation revealed elevated serum calcium level, hepatosplenomegaly, retroperitoneal lymphadenopathy, anemia, thrombocytopenia, and nephrolithiasis. The initial diagnostic hypothesis was lymphoproliferative disease, but the laparoscopic propaedeutic showed multiple white lesions on the liver surface, which biopsy identified as noncaseating granulomas with asteroid corpuscles, suggestive of sarcoidosis. He was treated with corticosteroids with significant improvement in symptoms and in calcium and creatinine levels. Besides, the patient presented a long-term large joints arthropathy, especially on the knees (with bilateral prosthesis), wrists, and ankles, of unknown etiology. We discuss the systemic manifestations of sarcoidosis related to the reported case, as well as the possible overlapping of idiopathic juvenile arthritis with sarcoidosis.
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Mageau A, Rigolet A, Benali K, Chauchard M, Ladjeroud S, Mahe I, Maisonobe T, Chauveheid MP, Papo T, Sacre K. Life-Threatening Hypercalcemia Revealing Diffuse and Isolated Acute Sarcoid-Like Myositis: A New Entity? (A Case-Series). Medicine (Baltimore) 2016; 95:e3089. [PMID: 26962842 PMCID: PMC4998923 DOI: 10.1097/md.0000000000003089] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Up to 50% patients with sarcoidosis display extra-pulmonary disease. However, initial and isolated (ie, without lung disease) acute muscular involvement associated with pseudo-malignant hypercalcemia is very uncommon. We report on 3 cases of life-threatening hypercalcemia revealing florid and isolated acute sarcoid-like myositis.All patients complained of fatigue, progressive general muscle weakness, and weight loss. Laboratory tests showed a severe life-threatening hypercalcemia (>3.4 mmol/L). Hypercalcemia was associated with increased serum level of 1,25-(OH)2 vitamin D and complicated with acute renal failure. One patient displayed acute pancreatitis due to hypercalcemia.In all cases, PET-scan, performed for malignancy screening, incidentally revealed an intense, diffuse, and isolated muscular fluorodeoxyglucose (FDG) uptake consistent with diffuse non-necrotizing giant cells granulomatous myositis demonstrated by muscle biopsy. Of note, creatine phosphokinase blood level was normal in all cases. No patients displayed the usual thoracic features of sarcoidosis.All patients were treated with high dose steroids and achieved rapid, complete, and sustained remission. A review of English and French publications in Medline revealed 5 similar published cases.Steroid-sensitive acute sarcoid-like myositis causing high calcitriol levels and life-threatening hypercalcemia should be recognized as a separate entity.
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Affiliation(s)
- Arthur Mageau
- From the Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris (AM, MPC, TP, KS); Département de Médecine Interne, Centre de référence de pathologie neuromusculaire, Hôpital Pitié-Salpêtrière, Université Pierre et Marie Curie, Assistance Publique Hôpitaux de Paris (AR); Département de Médecine Nucléaire (KB); Département de Médecine Interne, Hôpital Saint Antoine, Université Pierre et Marie Curie, Assistance Publique Hôpitaux de Paris (MC); Département de Radiologie (SL), Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris; Département de Médecine Interne, Hôpital Louis Mourier, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, EA REMES 7334 Recherche Clinique ville-hôpital, Méthodologies et Société (IM); Département de Neuropathologie et Neurophysiologie, Hôpital Pitié-Salpêtrière, Université Pierre et Marie Curie, Assistance Publique Hôpitaux de Paris (TM); Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodelling in Renal and Respiratory Diseases), Université Paris Diderot, PRES Sorbonne Paris Cité (TP, KS); and INSERM U1149, Université Paris Diderot, Laboratoire d'excellence INFLAMEX, PRES Sorbonne Paris Cité (TP, KS), Paris, France
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