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Kyriazopoulou E, Poulakou G, Milionis H, Metallidis S, Adamis G, Tsiakos K, Fragkou A, Rapti A, Damoulari C, Fantoni M, Kalomenidis I, Chrysos G, Angheben A, Kainis I, Alexiou Z, Castelli F, Serino FS, Tsilika M, Bakakos P, Nicastri E, Tzavara V, Kostis E, Dagna L, Koufargyris P, Dimakou K, Savvanis S, Tzatzagou G, Chini M, Cavalli G, Bassetti M, Katrini K, Kotsis V, Tsoukalas G, Selmi C, Bliziotis I, Samarkos M, Doumas M, Ktena S, Masgala A, Papanikolaou I, Kosmidou M, Myrodia DM, Argyraki A, Cardellino CS, Koliakou K, Katsigianni EI, Rapti V, Giannitsioti E, Cingolani A, Micha S, Akinosoglou K, Liatsis-Douvitsas O, Symbardi S, Gatselis N, Mouktaroudi M, Ippolito G, Florou E, Kotsaki A, Netea MG, Eugen-Olsen J, Kyprianou M, Panagopoulos P, Dalekos GN, Giamarellos-Bourboulis EJ. Early treatment of COVID-19 with anakinra guided by soluble urokinase plasminogen receptor plasma levels: a double-blind, randomized controlled phase 3 trial. Nat Med 2021; 27:1752-1760. [PMID: 34480127 PMCID: PMC8516650 DOI: 10.1038/s41591-021-01499-z] [Citation(s) in RCA: 297] [Impact Index Per Article: 99.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/10/2021] [Indexed: 12/20/2022]
Abstract
Early increase of soluble urokinase plasminogen activator receptor (suPAR) serum levels is indicative of increased risk of progression of coronavirus disease 2019 (COVID-19) to respiratory failure. The SAVE-MORE double-blind, randomized controlled trial evaluated the efficacy and safety of anakinra, an IL-1α/β inhibitor, in 594 patients with COVID-19 at risk of progressing to respiratory failure as identified by plasma suPAR ≥6 ng ml-1, 85.9% (n = 510) of whom were receiving dexamethasone. At day 28, the adjusted proportional odds of having a worse clinical status (assessed by the 11-point World Health Organization Clinical Progression Scale (WHO-CPS)) with anakinra, as compared to placebo, was 0.36 (95% confidence interval 0.26-0.50). The median WHO-CPS decrease on day 28 from baseline in the placebo and anakinra groups was 3 and 4 points, respectively (odds ratio (OR) = 0.40, P < 0.0001); the respective median decrease of Sequential Organ Failure Assessment (SOFA) score on day 7 from baseline was 0 and 1 points (OR = 0.63, P = 0.004). Twenty-eight-day mortality decreased (hazard ratio = 0.45, P = 0.045), and hospital stay was shorter.
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Affiliation(s)
- Evdoxia Kyriazopoulou
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Garyfallia Poulakou
- 3rd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Haralampos Milionis
- 1st Department of Internal Medicine, University of Ioannina, Medical School, Ioannina, Greece
| | - Simeon Metallidis
- 1st Department of Internal Medicine, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Georgios Adamis
- 1st Department of Internal Medicine, G. Gennimatas General Hospital of Athens, Athens, Greece
| | - Konstantinos Tsiakos
- 2nd Department of Pulmonary Medicine, Sotiria General Hospital of Chest Diseases, Athens, Greece
| | | | - Aggeliki Rapti
- 2nd Department of Pulmonary Medicine, Sotiria General Hospital of Chest Diseases, Athens, Greece
| | - Christina Damoulari
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Massimo Fantoni
- Dipartimento Scienze di Laboratorio e Infettivologiche - Fondazione Policlinico Gemelli IRCCS, Roma, Italy
| | - Ioannis Kalomenidis
- 1st Department of Critical Care and Pulmonary Medicine, Medical School, National and Kapodistrian University of Athens, Evangelismos General Hospital, Athens, Greece
| | - Georgios Chrysos
- 2nd Department of Internal Medicine, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - Andrea Angheben
- Department of Infectious Tropical Diseases and Microbiology, IRCSS Sacro Cuore Hospital, Negrar, Verona, Italy
| | - Ilias Kainis
- 10th Department of Pulmonary Medicine, Sotiria General Hospital of Chest Diseases of Athens, Athens, Greece
| | - Zoi Alexiou
- 2nd Department of Internal Medicine, Thriasio General Hospital of Eleusis, Athens, Greece
| | - Francesco Castelli
- Spedali Civili, Brescia ASST Spedali Civili Hospital, University of Brescia, Brescia, Italy
| | | | - Maria Tsilika
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Petros Bakakos
- 1st Department of Chest Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Emanuele Nicastri
- Department of Internal Medicine, Spallanzani Institute of Rome, Rome, Italy
| | - Vassiliki Tzavara
- 1st Department of Internal Medicine, Korgialeneion-Benakeion General Hospital, Athens, Greece
| | - Evangelos Kostis
- Department of Therapeutics, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS Ospedale San Raffaele & Vita-Salute San Raffaele University, Milan, Italy
| | - Panagiotis Koufargyris
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Katerina Dimakou
- 5th Department of Pulmonary Medicine, Sotiria General Hospital of Chest Diseases, Athens, Greece
| | - Spyridon Savvanis
- Department of Internal Medicine, Elpis General Hospital, Athens, Greece
| | - Glykeria Tzatzagou
- 1st Department of Internal Medicine, Papageorgiou General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Maria Chini
- 3rd Department of Internal Medicine and Infectious Diseases Unit, Korgialeneion-Benakeion General Hospital, Athens, Greece
| | - Giulio Cavalli
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR), IRCCS Ospedale San Raffaele & Vita-Salute San Raffaele University, Milan, Italy
| | - Matteo Bassetti
- Infectious Diseases Clinic, Ospedale Policlinico San Martino IRCCS and Department of Health Sciences, University of Genova, Genova, Italy
| | - Konstantina Katrini
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Vasileios Kotsis
- 3rd Department of Internal Medicine, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - George Tsoukalas
- 4th Department of Pulmonary Medicine, Sotiria General Hospital of Chest Diseases, Athens, Greece
| | - Carlo Selmi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy & IRCCS Humanitas Research Hospital, Milan, Italy
| | - Ioannis Bliziotis
- 1st Department of Internal Medicine, Asklepieio General Hospital of Voula, Athens, Greece
| | - Michael Samarkos
- 1st Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Michael Doumas
- 2nd Department of Propedeutic Medicine, Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece
| | - Sofia Ktena
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Aikaterini Masgala
- 2nd Department of Internal Medicine, Konstantopouleio General Hospital, Athens, Greece
| | - Ilias Papanikolaou
- Department of Pulmonary Medicine, General Hospital of Kerkyra, Corfu, Greece
| | - Maria Kosmidou
- 1st Department of Internal Medicine, University of Ioannina, Medical School, Ioannina, Greece
| | - Dimitra-Melia Myrodia
- 3rd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Aikaterini Argyraki
- Department of Internal Medicine, Sotiria General Hospital of Chest Diseases, Athens, Greece
| | - Chiara Simona Cardellino
- Department of Infectious Tropical Diseases and Microbiology, IRCSS Sacro Cuore Hospital, Negrar, Verona, Italy
| | | | | | - Vassiliki Rapti
- 3rd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Efthymia Giannitsioti
- 2nd Department of Internal Medicine, Tzaneio General Hospital of Piraeus, Athens, Greece
| | - Antonella Cingolani
- Dipartimento Scienze di Laboratorio e Infettivologiche - Fondazione Policlinico Gemelli IRCCS, Roma, Italy
| | - Styliani Micha
- Hellenic Institute for the Study of Sepsis, Athens, Greece
| | | | | | - Styliani Symbardi
- 1st Department of Internal Medicine, Thriasio General Hospital of Eleusis, Athens, Greece
| | - Nikolaos Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Maria Mouktaroudi
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
- Hellenic Institute for the Study of Sepsis, Athens, Greece
| | - Giuseppe Ippolito
- Department of Internal Medicine, Spallanzani Institute of Rome, Rome, Italy
| | - Eleni Florou
- Hellenic Institute for the Study of Sepsis, Athens, Greece
| | - Antigone Kotsaki
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Mihai G Netea
- Department of Internal Medicine and Center for Infectious Diseases, Radboud University, Nijmegen, The Netherlands
- Department of Immunology and Metabolism, Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Jesper Eugen-Olsen
- Department of Clinical Research, Copenhagen University Hospital, Amager and Hvidovre, Denmark
| | | | - Periklis Panagopoulos
- 2nd Department of Internal Medicine, Democritus University of Thrace, Medical School, Alexandroupolis, Greece
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Evangelos J Giamarellos-Bourboulis
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece.
- Hellenic Institute for the Study of Sepsis, Athens, Greece.
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Tsiakos K, Tsakiris A, Tsibris G, Voutsinas PM, Panagopoulos P, Kosmidou M, Petrakis V, Gravvani A, Gkavogianni T, Klouras E, Katrini K, Koufargyris P, Rapti I, Karageorgos A, Vrentzos E, Damoulari C, Zarkada V, Sidiropoulou C, Artemi S, Ioannidis A, Papapostolou A, Michelakis E, Georgiopoulou M, Myrodia DM, Tsiamalos P, Syrigos K, Chrysos G, Nitsotolis T, Milionis H, Poulakou G, Giamarellos-Bourboulis EJ. Early Start of Oral Clarithromycin Is Associated with Better Outcome in COVID-19 of Moderate Severity: The ACHIEVE Open-Label Single-Arm Trial. Infect Dis Ther 2021; 10:2333-2351. [PMID: 34363189 PMCID: PMC8345236 DOI: 10.1007/s40121-021-00505-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 07/16/2021] [Indexed: 12/27/2022] Open
Abstract
Introduction The anti-inflammatory effect of macrolides prompted the study of oral clarithromycin in moderate COVID-19. Methods An open-label non-randomized trial in 90 patients with COVID-19 of moderate severity was conducted between May and October 2020. The primary endpoint was defined at the end of treatment (EOT) as no need for hospital re-admission and no progression into lower respiratory tract infection (LRTI) for patients with upper respiratory tract infection and as at least 50% decrease of the respiratory symptoms score without progression into severe respiratory failure (SRF) for patients with LRTI. Viral load, biomarkers, the function of mononuclear cells and safety were assessed. Results The primary endpoint was attained in 86.7% of patients treated with clarithromycin (95% CIs 78.1–92.2%); this was 91.7% and 81.4% among patients starting clarithromycin the first 5 days from symptoms onset or later (odds ratio after multivariate analysis 6.62; p 0.030). The responses were better for patients infected by non-B1.1 variants. Clarithromycin use was associated with decreases in circulating C-reactive protein, tumour necrosis factor-alpha and interleukin (IL)-6; by increase of production of interferon-gamma and decrease of production of interleukin-6 by mononuclear cells; and by suppression of SARS-CoV-2 viral load. No safety concerns were reported. Conclusions Early clarithromycin treatment provides most of the clinical improvement in moderate COVID-19. Trial Registration ClinicalTrials.gov, NCT04398004 Supplementary Information The online version contains supplementary material available at 10.1007/s40121-021-00505-8.
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Affiliation(s)
- Konstantinos Tsiakos
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
| | - Antonios Tsakiris
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, ATTIKON University General Hospital, 1 Rimini Street, 124 62, Athens, Greece
| | - Georgios Tsibris
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, ATTIKON University General Hospital, 1 Rimini Street, 124 62, Athens, Greece
| | - Pantazis-Michael Voutsinas
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, ATTIKON University General Hospital, 1 Rimini Street, 124 62, Athens, Greece
| | - Periklis Panagopoulos
- 2nd Department of Internal Medicine, Medical School, Democritus University of Thrace, 681 00, Alexandroupolis, Greece
| | - Maria Kosmidou
- 1st Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Ioannina, 455 00, Ioannina, Greece
| | - Vasileios Petrakis
- 2nd Department of Internal Medicine, Medical School, Democritus University of Thrace, 681 00, Alexandroupolis, Greece
| | - Areti Gravvani
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
| | - Theologia Gkavogianni
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, ATTIKON University General Hospital, 1 Rimini Street, 124 62, Athens, Greece
| | - Eleftherios Klouras
- 1st Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Ioannina, 455 00, Ioannina, Greece
| | - Konstantina Katrini
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, ATTIKON University General Hospital, 1 Rimini Street, 124 62, Athens, Greece
| | - Panagiotis Koufargyris
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, ATTIKON University General Hospital, 1 Rimini Street, 124 62, Athens, Greece
| | - Iro Rapti
- 1st Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Ioannina, 455 00, Ioannina, Greece
| | - Athanassios Karageorgos
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, ATTIKON University General Hospital, 1 Rimini Street, 124 62, Athens, Greece
| | - Emmanouil Vrentzos
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, ATTIKON University General Hospital, 1 Rimini Street, 124 62, Athens, Greece
| | - Christina Damoulari
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, ATTIKON University General Hospital, 1 Rimini Street, 124 62, Athens, Greece
| | - Vagia Zarkada
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, ATTIKON University General Hospital, 1 Rimini Street, 124 62, Athens, Greece
| | | | - Sofia Artemi
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, ATTIKON University General Hospital, 1 Rimini Street, 124 62, Athens, Greece
| | - Anastasios Ioannidis
- Department of Nursing, Faculty of Health Sciences, University of Peloponnese, Tripoli, Greece
| | - Androniki Papapostolou
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, ATTIKON University General Hospital, 1 Rimini Street, 124 62, Athens, Greece
| | - Evangelos Michelakis
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, ATTIKON University General Hospital, 1 Rimini Street, 124 62, Athens, Greece
| | - Maria Georgiopoulou
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, ATTIKON University General Hospital, 1 Rimini Street, 124 62, Athens, Greece
| | - Dimitra-Melia Myrodia
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
| | - Panteleimon Tsiamalos
- 2nd Department of Internal Medicine, Tzaneion General Hospital of Piraeus, Piraeus, Greece
| | - Konstantinos Syrigos
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
| | - George Chrysos
- 2nd Department of Internal Medicine, Tzaneion General Hospital of Piraeus, Piraeus, Greece
| | - Thomas Nitsotolis
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
| | - Haralampos Milionis
- 1st Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Ioannina, 455 00, Ioannina, Greece
| | - Garyphallia Poulakou
- 3rd Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, 115 27, Athens, Greece
| | - Evangelos J Giamarellos-Bourboulis
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, ATTIKON University General Hospital, 1 Rimini Street, 124 62, Athens, Greece.
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Kyriazopoulou E, Panagopoulos P, Metallidis S, Dalekos GN, Poulakou G, Gatselis N, Karakike E, Saridaki M, Loli G, Stefos A, Prasianaki D, Georgiadou S, Tsachouridou O, Petrakis V, Tsiakos K, Kosmidou M, Lygoura V, Dareioti M, Milionis H, Papanikolaou IC, Akinosoglou K, Myrodia DM, Gravvani A, Stamou A, Gkavogianni T, Katrini K, Marantos T, Trontzas IP, Syrigos K, Chatzis L, Chatzis S, Vechlidis N, Avgoustou C, Chalvatzis S, Kyprianou M, van der Meer JW, Eugen-Olsen J, Netea MG, Giamarellos-Bourboulis EJ. An open label trial of anakinra to prevent respiratory failure in COVID-19. eLife 2021; 10:66125. [PMID: 33682678 PMCID: PMC8034977 DOI: 10.7554/elife.66125] [Citation(s) in RCA: 104] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/04/2021] [Indexed: 01/08/2023] Open
Abstract
Background: It was studied if early suPAR-guided anakinra treatment can prevent severe respiratory failure (SRF) of COVID-19. Methods: A total of 130 patients with suPAR ≥6 ng/ml were assigned to subcutaneous anakinra 100 mg once daily for 10 days. Primary outcome was SRF incidence by day 14 defined as any respiratory ratio below 150 mmHg necessitating mechanical or non-invasive ventilation. Main secondary outcomes were 30-day mortality and inflammatory mediators; 28-day WHO-CPS was explored. Propensity-matched standard-of care comparators were studied. Results: 22.3% with anakinra treatment and 59.2% comparators (hazard ratio, 0.30; 95% CI, 0.20–0.46) progressed into SRF; 30-day mortality was 11.5% and 22.3% respectively (hazard ratio 0.49; 95% CI 0.25–0.97). Anakinra was associated with decrease in circulating interleukin (IL)−6, sCD163 and sIL2-R; IL-10/IL-6 ratio on day 7 was inversely associated with SOFA score; patients were allocated to less severe WHO-CPS strata. Conclusions: Early suPAR-guided anakinra decreased SRF and restored the pro-/anti-inflammatory balance. Funding: This study was funded by the Hellenic Institute for the Study of Sepsis, Technomar Shipping Inc, Swedish Orphan Biovitrum, and the Horizon 2020 Framework Programme. Clinical trial number: NCT04357366. People infected with the SARS-CoV-2 virus, which causes COVID-19, can develop severe respiratory failure and require a ventilator to keep breathing, but this does not happen to every infected individual. Measuring a blood protein called suPAR (soluble urokinase plasminogen activator receptor) may help identify patients at the greatest risk of developing severe respiratory failure and requiring a ventilator. Previous investigations have suggested that measuring suPAR can identify pneumonia patients at highest risk for developing respiratory failure. The protein can be measured by taking a blood sample, and its levels provide a snapshot of how the body’s immune system is reacting to infection, and of how it may respond to treatment. Anakinra is a drug that forms part of a class of medications called interleukin antagonists. It is commonly prescribed alone or in combination with other medications to reduce pain and swelling associated with rheumatoid arthritis. Kyriazopoulou et al. investigated whether treating COVID-19 patients who had developed pneumonia with anakinra could prevent the use of a ventilator and lower the risk of death. The findings show that treating COVID-19 patients with an injection of 100 milligrams of anakinra for ten days may be an effective approach because the drug combats inflammation. Kyriazopoulou et al. examined various markers of the immune response and discovered that anakinra was able to improve immune function, protecting a significant number of patients from going on a ventilator. The drug was also found to be safe and cause no significant adverse side effects. Administering anakinra decreased of the risk of progression into severe respiratory failure by 70%, and reduced death rates significantly. These results suggest that it may be beneficial to use suPAR as an early biomarker for identifying those individuals at highest risk for severe respiratory failure, and then treat them with anakinra. While the findings are promising, they must be validated in larger studies.
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Affiliation(s)
- Evdoxia Kyriazopoulou
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Periklis Panagopoulos
- 2nd Department of Internal Medicine, Democritus University of Thrace, Medical School, Alexandroupolis, Greece
| | - Symeon Metallidis
- 1st Department of Internal Medicine, Aristotle University ofThessaloniki, Thessaloniki, Greece
| | - George N Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Garyphallia Poulakou
- 3rd Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Eleni Karakike
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Saridaki
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgia Loli
- 1st Department of Internal Medicine, Aristotle University ofThessaloniki, Thessaloniki, Greece
| | - Aggelos Stefos
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Danai Prasianaki
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Sarah Georgiadou
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Olga Tsachouridou
- 1st Department of Internal Medicine, Aristotle University ofThessaloniki, Thessaloniki, Greece
| | - Vasileios Petrakis
- 2nd Department of Internal Medicine, Democritus University of Thrace, Medical School, Alexandroupolis, Greece
| | - Konstantinos Tsiakos
- 3rd Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Kosmidou
- 1st Department of Internal Medicine,University of Ioannina, School of HealthSciences, Faculty of Medicine, Ioannina, Greece
| | - Vassiliki Lygoura
- Department of Medicine and Research Laboratory of Internal Medicine, National Expertise Center of Greece in Autoimmune Liver Diseases, General University Hospital of Larissa, Larissa, Greece
| | - Maria Dareioti
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Haralampos Milionis
- 1st Department of Internal Medicine,University of Ioannina, School of HealthSciences, Faculty of Medicine, Ioannina, Greece
| | | | - Karolina Akinosoglou
- Department of Internal Medicine, University of Patras, Medical School, Rion, Greece
| | - Dimitra-Melia Myrodia
- 3rd Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Areti Gravvani
- 3rd Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Aliki Stamou
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theologia Gkavogianni
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantina Katrini
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros Marantos
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis P Trontzas
- 3rd Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos Syrigos
- 3rd Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Loukas Chatzis
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Stamatios Chatzis
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Vechlidis
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Christina Avgoustou
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Stamatios Chalvatzis
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Miltiades Kyprianou
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Jos Wm van der Meer
- Department of Internal Medicine and Center for Infectious Diseases, Radboud University, Nijmegen, Netherlands
| | - Jesper Eugen-Olsen
- Clinical Research Centre, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Mihai G Netea
- Department of Internal Medicine and Center for Infectious Diseases, Radboud University, Nijmegen, Netherlands.,Immunology and Metabolism, Life & Medical Sciences Institute, University of Bonn, Bonn, Germany
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