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Magalhães de Castro B, Dos Santos Rosa T, de Araújo TB, de Luca Corrêa H, de Deus LA, Neves RVP, Reis AL, Dos Santos RL, da Silva Barbosa JM, de Sousa Honorato F, da Motta Vilalva Mestrinho VM, de Moraes MR, Tzanno-Martins C, Prestes J. Effects of cluster set resistance training on bone mineral density and markers of bone metabolism in older hemodialysis subjects: A pilot study. Bone 2024; 189:117240. [PMID: 39182595 DOI: 10.1016/j.bone.2024.117240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Revised: 08/20/2024] [Accepted: 08/22/2024] [Indexed: 08/27/2024]
Abstract
Chronic kidney disease (CKD) is associated with a series of mineral bone disturbances due to increased production of parathormone which increases the activity of osteoclasts, removing calcium and phosphorous from the bones. However, the literature lacks investigations on the feasibility of different resistance training (RT) methods, such as cluster-sets, in this population. Thus, the aim of the present study was to compare traditional versus cluster-set RT protocols on bone mineral density (BMD) T-score, BMD Total, femur BMD, L3-L4 BMD, femoral neck BMD, Klotho, FGF23, Klotho - FGF23 ratio, Sclerostin, vitamin D, phosphorous and calcium in older subjects with CKD. Seventy-eight older subjects (age: 57.55 ± 4.06 years, body mass: 72.26 ± 13.96 kg, body mass index: 26.73 ± 2.97 kg/m2) with CKD undergoing maintenance hemodialysis were randomly divided into control group (CG, n = 26), traditional RT (RT, n = 26) and cluster-set RT (RT-CS, n = 26) groups. Subjects completed 24 weeks of RT three times per week, 1 h and 30 min before the hemodialysis session, and each training lasted around 60 to 80 min. There was a group×time interaction for total BMD, femur BMD, L3-L4 BMD, and femoral neck BMD, revealed by improvements for RT and RT-CS groups (pre versus post). Only femur BMD displayed differences as compared with the CG. Minimum clinically important difference (MCID) values revealed more responsive subjects in the RT-CS group for total BMD, femur BMD, klotho, FGF23, sclerostin, Vitamin D and calcium. In conclusion, RT can be used as a non-pharmacological complementary strategy for the treatment of CKD. RT-CS may be useful for these subjects as more responders were found for this type of training.
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Affiliation(s)
| | | | - Thaís Branquinho de Araújo
- Department of Physical Education, Catholic University of Brasilia, Brasilia, DF, Brazil; NephroClinics, Premium Nephrology Clinic, Brasilia, Brazil
| | - Hugo de Luca Corrêa
- Department of Physical Education, Catholic University of Brasilia, Brasilia, DF, Brazil
| | | | | | - Andrea Lucena Reis
- Department of Physical Education, Catholic University of Brasilia, Brasilia, DF, Brazil
| | | | | | | | | | | | | | - Jonato Prestes
- Department of Physical Education, Catholic University of Brasilia, Brasilia, DF, Brazil
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2
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Abrahim S, Steele AP, Voth J, Krepinsky JC, Lanktree MB, Hawke TJ. Whole body resistance training on functional outcomes of patients with Stage 4 or 5 chronic kidney disease: A systematic review. Physiol Rep 2024; 12:e16151. [PMID: 39134506 PMCID: PMC11319065 DOI: 10.14814/phy2.16151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 07/03/2024] [Accepted: 07/06/2024] [Indexed: 08/16/2024] Open
Abstract
Chronic kidney disease (CKD) causes skeletal muscle wasting, resulting in reduced function and inability to live independently. This systematic review critically appraised the scientific literature regarding the effects of full-body resistance training on clinically-relevant functional capacity measures in CKD. The study population included studies of people with Stage 4 or 5 CKD and a mean age of 40+ years old. Eight databases were searched for eligible studies: Pubmed, Embase, Cochrane, CINAHL, Scopus, Web of Science, MEDLINE, and AGELINE. MeSH terms and keyword combinations were used for screening following the PRISMA conduct. Inclusion criteria were based on PICO principles and no date of publication filter was applied. The intervention was training 2 days/week of structured resistance exercises using major upper and lower muscle groups. Minimum intervention period was 7 weeks. Comparison groups maintained their habitual activity without structured exercise training. Outcome measures of interest were: 6-min walk test, grip strength, timed up-and-go test, and sit-to-stand. Eight randomized controlled trials and one nonequivalent comparison-group study fulfilled the inclusion criteria and underwent data extraction. All studies were of hemodialysis patients. The evidence indicates that full-body resistance exercise significantly improved grip strength, timed up and go and sit to stand tests; metrics associated with enhanced quality and quantity of life.
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Affiliation(s)
- Salma Abrahim
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Alexandra P. Steele
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Jennifer Voth
- Research and Evaluation Services Department, Hôtel‐Dieu Grace HealthcareWindsorOntarioCanada
| | - Joan C. Krepinsky
- Division of Nephrology, St. Joseph Healthcare Hamilton and Department of MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Matthew B. Lanktree
- Division of Nephrology, St. Joseph Healthcare Hamilton and Department of MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Thomas J. Hawke
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonOntarioCanada
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3
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Neves RVP, Corrêa HL, Reis AL, Andrade RV, Araújo TB, Santos RL, Oliveira FFS, Moraes Araújo GEB, Marra AVG, Baracho TA, Martins TO, Barbosa JMDS, Garcia MN, Miller NMG, Deus LA, Rosa TDS. Exercise Improves Respiratory Function, Body Fluid and Nitric Oxide in Hemodialysis Patients. Int J Sports Med 2024. [PMID: 38897226 DOI: 10.1055/a-2348-2684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Emerging evidence suggests that resistance training (RT) can mitigate respiratory muscle weakness in hemodialysis (HD) patients. However, the underlying mechanisms responsible for these beneficial effects remain unclear. The purpose of this study was to assess the impact of periodized RT on respiratory muscle strength and its relationship with handgrip strength (HGS), fat-free mass (FFM), nitric oxide (NO), and interdialytic weight gain (IWG) in HD patients. Thirty-three patients were randomly assigned to two groups: control (CTL; n=18) and RT (n=15). The RT group did not perform any additional exercise training specific to the respiratory tract. Maximal inspiratory (MIP) and expiratory (MEP) pressures, peak expiratory flow (PEF), HGS, FFM, NO, and IWG were measured before and after the intervention period. Participants in the RT group engaged in a 24-week RT program, three times per week. RT resulted in significant improvements in MIP, MEP, PEF, as well as enhancements in HGS, FFM, NO, and IWG (p<0.05). Notably, inverse correlations were observed between MIP (r=-0.37, p=0.03) and PEF (r=-0.4, p=0.02) with IWG. Thus, the amelioration of HGS and FFM coincided with a reduction in respiratory muscle weakness among HD patients. Decreased IWG and increased circulating NO are plausible mechanisms contributing to these improvements.
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Affiliation(s)
| | - Hugo Luca Corrêa
- Physical Education, Catholic University of Brasilia, Taguatinga, Brazil
| | | | | | | | - Rafael Lavarini Santos
- Graduate Program in Genomic Science and Biotechnology, Catholic University of Brasilia, Taguatinga, Brazil
| | | | | | | | - Thaís Amaral Baracho
- Graduate Programm in Physical Education, Catholic University of Brasilia, Taguatinga, Brazil
| | - Taynah Oliveira Martins
- Graduate Program in Physical Education, Catholic University of Brasilia, Riacho Fundo I, Brazil
| | | | - Mariana Neiva Garcia
- Graduate Programm in Physical Education, Catholic University of Brasilia, Taguatinga, Brazil
| | | | - Lysleine Alves Deus
- Graduate Programm in Physical Education, Catholic University of Brasilia, Taguatinga, Brazil
| | - Thiago Dos Santos Rosa
- Graduate Program in Physical Education and Graduate Program in Genomic Sciences and Biotechnology, Catholic University of Brasilia, Taguatinga, Brazil
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4
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Magalhães de Castro B, Dos Santos Rosa T, de Araújo TB, de Luca Corrêa H, de Deus LA, Neves RVP, Reis AL, Dos Santos RL, da Silva Barbosa JM, de Sousa Honorato F, da Motta Vilalva Mestrinho VM, Tzanno-Martins C, Navalta JW, Prestes J. Impact of cluster set resistance training on strength, functional capacity, metabolic and inflammatory state in older hemodialysis subjects: A randomized controlled clinical trial. Exp Gerontol 2023; 182:112297. [PMID: 37741557 DOI: 10.1016/j.exger.2023.112297] [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: 11/20/2022] [Revised: 08/22/2023] [Accepted: 09/20/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND AND AIMS Hemodialysis-associated neuromuscular dysfunction appears to be counteracted by resistance training (RT) in older patients with chronic kidney disease (CKD). Thus, the aim of the present study was to evaluate the impact of cluster-set RT protocol on anthropometric parameters, functional capacities, and biochemical variables in older patients with CKD. METHODS AND RESULTS Seventy-eight older patients (age: 57.55 ± 4.06 years) with CKD undergoing maintenance hemodialysis participated, and were randomly divided into control group (CG, N = 26), traditional RT (RT, N = 26) and cluster-set RT (RT-CS, N = 26) groups. Participants completed 24 weeks of RT three times per week, 1 h and 30 min before the hemodialysis session. Patients from the RT-CS group displayed increased adherence as compared to the RT group (66.35 % versus 61.73 %, p < 0.0001). There was an improvement of all anthropometric variables, handgrip strength, timed up and-go (TUG) and six-minute walking test (6MWT) following both training protocols when compared to control group and pre-intervention values. Fasting blood glucose decreased for both RT and RT-CS groups as compared with pre-intervention, without differences between training protocols and CG. Glycated hemoglobin, inflammatory cytokines, and triglycerides decreased in RT and RT-CS groups as compared with pre-intervention and CG, without differences between them. Furthermore, the RT-CS protocol resulted in a greater number of people who were responsive to training when compared to traditional training. CONCLUSIONS RT-CS is a clinically valuable tool to improve anthropometric parameters, handgrip strength, TUG, 6MWT, fasting blood glucose, and cytokines in CKD older patients.
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Affiliation(s)
| | - Thiago Dos Santos Rosa
- Department of Physical Education, Catholic University of Brasilia, Brasilia, DF, Brazil; Graduate Program in Genomic Science and Biotechnology
| | - Thaís Branquinho de Araújo
- Department of Physical Education, Catholic University of Brasilia, Brasilia, DF, Brazil; NephroClinics, Premium Nephrology Clinic, Brasilia, Brazil
| | - Hugo de Luca Corrêa
- Department of Physical Education, Catholic University of Brasilia, Brasilia, DF, Brazil
| | | | | | - Andrea Lucena Reis
- Department of Physical Education, Catholic University of Brasilia, Brasilia, DF, Brazil
| | | | | | | | | | | | - James W Navalta
- Department Kinesiology and Nutrition Sciences, University of Nevada, Las Vegas, NV, United States of America
| | - Jonato Prestes
- Department of Physical Education, Catholic University of Brasilia, Brasilia, DF, Brazil
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Bishop NC, Burton JO, Graham-Brown MPM, Stensel DJ, Viana JL, Watson EL. Exercise and chronic kidney disease: potential mechanisms underlying the physiological benefits. Nat Rev Nephrol 2023; 19:244-256. [PMID: 36650232 DOI: 10.1038/s41581-022-00675-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 01/19/2023]
Abstract
Increasing evidence indicates that exercise has beneficial effects on chronic inflammation, cardiorespiratory function, muscle and bone strength and metabolic markers in adults with chronic kidney disease (CKD), kidney failure or kidney transplants. However, the mechanisms that underlie these benefits have received little attention, and the available clinical evidence is mainly from small, short-duration (<12 weeks) exercise intervention studies. The available data, mainly from patients with CKD or on dialysis, suggest that exercise-mediated shifts towards a less inflammatory immune cell profile, enhanced activity of the NRF2 pathway and reduced monocyte infiltration into adipose tissue may underlie improvements in inflammatory biomarkers. Exercise-mediated increases in nitric oxide release and bioavailability, reduced angiotensin II accumulation in the heart, left ventricular remodelling and reductions in myocardial fibrosis may contribute to improvements in left ventricular hypertrophy. Exercise stimulates an anabolic response in skeletal muscle in CKD, but increases in mitochondrial mass and satellite cell activation seem to be impaired in this population. Exercise-mediated activation of the canonical wnt pathway may lead to bone formation and improvements in the levels of the bone-derived hormones klotho and fibroblast growth factor 23 (FGF23). Longer duration studies with larger sample sizes are needed to confirm these mechanisms in CKD, kidney failure and kidney transplant populations and provide evidence for targeted exercise interventions.
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Affiliation(s)
- Nicolette C Bishop
- School of Sport, Exercise and Health Sciences and National Centre for Sport and Exercise Medicine, Loughborough University, Loughborough, UK.
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester, UK.
| | - James O Burton
- School of Sport, Exercise and Health Sciences and National Centre for Sport and Exercise Medicine, Loughborough University, Loughborough, UK
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Matthew P M Graham-Brown
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - David J Stensel
- School of Sport, Exercise and Health Sciences and National Centre for Sport and Exercise Medicine, Loughborough University, Loughborough, UK
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester, UK
- Faculty of Sport Sciences, Waseda University, Tokorozawa, Japan
- Department of Sports Science and Physical Education, The Chinese University of Hong Kong, Hong Kong, China
| | - João L Viana
- Research Centre in Sports Sciences, Health Sciences and Human Development, University of Maia, Maia, Portugal
| | - Emma L Watson
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, University Hospitals of Leicester NHS Trust and University of Leicester, Leicester, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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6
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de Araújo TB, de Luca Corrêa H, de Deus LA, Neves RVP, Reis AL, Honorato FS, da S Barbosa JM, Palmeira TRC, Aguiar SS, Sousa CV, Santos CAR, Neto LSS, Amorim CEN, Simões HG, Prestes J, Rosa TS. The effects of home-based progressive resistance training in chronic kidney disease patients. Exp Gerontol 2023; 171:112030. [PMID: 36423855 DOI: 10.1016/j.exger.2022.112030] [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: 07/21/2022] [Revised: 11/09/2022] [Accepted: 11/11/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Faced with lockdowns, it was mandatory the development of supervised home-based RT protocols to keep patients with chronic kidney disease engaged in programs. Nonetheless, there is a lack of scientific literature regarding its effects on patients. PURPOSE To investigate the effects of a supervised home-based progressive resistance training program on functional performance, bone mineral density, renal function, endothelial health, inflammation, glycemic homeostasis, metabolism, redox balance, and the modulation of exerkines in patients with CKD in stage 2. METHODS Patients (n = 31) were randomized and allocated into the control group (CTL; n = 15; 58.07 ± 5.22 yrs) or resistance training group (RT; n = 16; 57.94 ± 2.74 yrs). RT group performed 22 weeks of supervised progressive home-based resistance exercises. Bone mineral density, anthropometric measurements, and functional performance were assessed. Venous blood samples were collected at baseline and after the intervention for the analysis of markers of renal function, endothelial health, inflammation, glycemic homeostasis, metabolism, and redox balance. RESULTS Twenty-two weeks of home-based RT were effective in improving (P < 0.05) functional performance, bone mineral density, uremic profile, ADMA, inflammatory markers, the Klotho-FGF23 axis, glycemic homeostasis markers, and exerkines. These improvements were accompanied by higher concentrations of exerkines and anti-inflammatory cytokines. RT group displayed a decrease in cases of osteopenia after the intervention (RT: 50 % vs. CTL: 86.7 %; X2 = 4.763; P = 0.029). CONCLUSION Results provide new evidence that supervised home-based progressive RT may be a relevant intervention to attenuate the progression of CKD and improve functional capacity, bone mineral density, and the immunometabolic profile. These improvements are associated with positive modulation of several exerkines.
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Affiliation(s)
- Thaís B de Araújo
- Graduate Program in Physical Education, Catholic University of Brasília, Brasília, DF, Brazil
| | - Hugo de Luca Corrêa
- Graduate Program in Physical Education, Catholic University of Brasília, Brasília, DF, Brazil
| | - Lysleine A de Deus
- Graduate Program in Physical Education, Catholic University of Brasília, Brasília, DF, Brazil
| | - Rodrigo V P Neves
- Graduate Program in Physical Education, Catholic University of Brasília, Brasília, DF, Brazil
| | - Andrea L Reis
- Graduate Program in Physical Education, Catholic University of Brasília, Brasília, DF, Brazil
| | - Fernando S Honorato
- Graduate Program in Physical Education, Catholic University of Brasília, Brasília, DF, Brazil
| | - Jessica M da S Barbosa
- Graduate Program in Physical Education, Catholic University of Brasília, Brasília, DF, Brazil
| | - Thalyta R C Palmeira
- Graduate Program in Physical Education, Catholic University of Brasília, Brasília, DF, Brazil
| | - Samuel S Aguiar
- Graduate Program in Physical Education, Federal University of Mato Grosso, Cuiabá, Brazil
| | - Caio V Sousa
- Health Technology Lab, College of Arts, Media and Design, Bouvé College of Health Sciences, Northeastern University, Boston 02115, MA, USA
| | | | - Luiz S S Neto
- Federal University of Tocantins, Medicine Department, Tocantins, Brazil
| | - Carlos E N Amorim
- Federal University of Maranhão, Physical Education Department, Maranhão, Brazil
| | - Herbert G Simões
- Graduate Program in Physical Education, Catholic University of Brasília, Brasília, DF, Brazil
| | - Jonato Prestes
- Graduate Program in Physical Education, Catholic University of Brasília, Brasília, DF, Brazil
| | - Thiago S Rosa
- Graduate Program in Physical Education, Catholic University of Brasília, Brasília, DF, Brazil.
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March DS, Wilkinson TJ, Burnell T, Billany RE, Jackson K, Baker LA, Thomas A, Robinson KA, Watson EL, Graham-Brown MPM, Jones AW, Burton JO. The Effect of Non-Pharmacological and Pharmacological Interventions on Measures Associated with Sarcopenia in End-Stage Kidney Disease: A Systematic Review and Meta-Analysis. Nutrients 2022; 14:1817. [PMID: 35565785 PMCID: PMC9101978 DOI: 10.3390/nu14091817] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/11/2022] [Accepted: 04/14/2022] [Indexed: 02/07/2023] Open
Abstract
This systematic review and meta-analysis provides a synthesis of the available evidence for the effects of interventions on outcome measures associated with sarcopenia in end-stage kidney disease (ESKD). Thirteen databases were searched, supplemented with internet and hand searching. Randomised controlled trials of non-pharmacological or pharmacological interventions in adults with ESKD were eligible. Trials were restricted to those which had reported measures of sarcopenia. Primary outcome measures were hand grip strength and sit-to-stand tests. Sixty-four trials were eligible (with nineteen being included in meta-analyses). Synthesised data indicated that intradialytic exercise increased hand grip strength (standardised mean difference, 0.58; 0.24 to 0.91; p = 0.0007; I2 = 40%), and sit-to-stand (STS) 60 score (mean difference, 3.74 repetitions; 2.35 to 5.14; p < 0.001; I2 = 0%). Intradialytic exercise alone, and protein supplementation alone, resulted in no statistically significant change in STS5 (−0.78 s; −1.86 to 0.30; p = 0.16; I2 = 0%), and STS30 (MD, 0.97 repetitions; −0.16 to 2.10; p = 0.09; I2 = 0%) performance, respectively. For secondary outcomes, L-carnitine and nandrolone-decanoate resulted in significant increases in muscle quantity in the dialysis population. Intradialytic exercise modifies measures of sarcopenia in the haemodialysis population; however, the majority of trials were low in quality. There is limited evidence for efficacious interventions in the peritoneal dialysis and transplant recipient populations.
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Affiliation(s)
- Daniel S. March
- York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (R.E.B.); (K.A.R.); (E.L.W.); (M.P.M.G.-B.); (J.O.B.)
| | - Thomas J. Wilkinson
- NIHR Applied Research Collaboration, Leicester Diabetes Centre, University of Leicester, Leicester LE5 4PW, UK;
| | - Thomas Burnell
- Leicester Medical School, University of Leicester, Leicester LE1 7HA, UK; (T.B.); (K.J.)
| | - Roseanne E. Billany
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (R.E.B.); (K.A.R.); (E.L.W.); (M.P.M.G.-B.); (J.O.B.)
| | - Katherine Jackson
- Leicester Medical School, University of Leicester, Leicester LE1 7HA, UK; (T.B.); (K.J.)
| | - Luke A. Baker
- Department of Respiratory Sciences, College of Life Sciences, University of Leicester, Leicester LE1 7RH, UK;
- NIHR Leicester Biomedical Research Centre, University Hospital of Leicester NHS Trust, University of Leicester, Leicester LE5 4PW, UK
| | - Amal Thomas
- University Hospital of Leicester NHS Trust, Leicester LE1 5WW, UK;
| | - Katherine A. Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (R.E.B.); (K.A.R.); (E.L.W.); (M.P.M.G.-B.); (J.O.B.)
| | - Emma L. Watson
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (R.E.B.); (K.A.R.); (E.L.W.); (M.P.M.G.-B.); (J.O.B.)
- NIHR Leicester Biomedical Research Centre, University Hospital of Leicester NHS Trust, University of Leicester, Leicester LE5 4PW, UK
| | - Matthew P. M. Graham-Brown
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (R.E.B.); (K.A.R.); (E.L.W.); (M.P.M.G.-B.); (J.O.B.)
- NIHR Leicester Biomedical Research Centre, University Hospital of Leicester NHS Trust, University of Leicester, Leicester LE5 4PW, UK
- University Hospital of Leicester NHS Trust, Leicester LE1 5WW, UK;
| | - Arwel W. Jones
- Central Clinical School, Monash University, Melbourne 3004, Australia;
| | - James O. Burton
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK; (R.E.B.); (K.A.R.); (E.L.W.); (M.P.M.G.-B.); (J.O.B.)
- NIHR Leicester Biomedical Research Centre, University Hospital of Leicester NHS Trust, University of Leicester, Leicester LE5 4PW, UK
- University Hospital of Leicester NHS Trust, Leicester LE1 5WW, UK;
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough LE11 3TU, UK
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