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Dhungel BP, Winburn I, Pereira CDF, Huang K, Chhabra A, Rasko JEJ. Understanding AAV vector immunogenicity: from particle to patient. Theranostics 2024; 14:1260-1288. [PMID: 38323309 PMCID: PMC10845199 DOI: 10.7150/thno.89380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/04/2023] [Indexed: 02/08/2024] Open
Abstract
Gene therapy holds promise for patients with inherited monogenic disorders, cancer, and rare genetic diseases. Naturally occurring adeno-associated virus (AAV) offers a well-suited vehicle for clinical gene transfer due to its lack of significant clinical pathogenicity and amenability to be engineered to deliver therapeutic transgenes in a variety of cell types for long-term sustained expression. AAV has been bioengineered to produce recombinant AAV (rAAV) vectors for many gene therapies that are approved or in late-stage development. However, ongoing challenges hamper wider use of rAAV vector-mediated therapies. These include immunity against rAAV vectors, limited transgene packaging capacity, sub-optimal tissue transduction, potential risks of insertional mutagenesis and vector shedding. This review focuses on aspects of immunity against rAAV, mediated by anti-AAV neutralizing antibodies (NAbs) arising after natural exposure to AAVs or after rAAV vector administration. We provide an in-depth analysis of factors determining AAV seroprevalence and examine clinical approaches to managing anti-AAV NAbs pre- and post-vector administration. Methodologies used to quantify anti-AAV NAb levels and strategies to overcome pre-existing AAV immunity are also discussed. The broad adoption of rAAV vector-mediated gene therapies will require wider clinical appreciation of their current limitations and further research to mitigate their impact.
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Affiliation(s)
- Bijay P. Dhungel
- Gene and Stem Cell Therapy Program Centenary Institute, The University of Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | | | | | | | | | - John E. J. Rasko
- Gene and Stem Cell Therapy Program Centenary Institute, The University of Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, NSW, Australia
- Cell and Molecular Therapies, Royal Prince Alfred Hospital, Sydney, NSW, Australia
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Fukutake K, Togo K, Xu L, Markson LE, Alvir JMJ, Winburn I, Karumori T. Real-World Amount of Clotting Factor Concentrates Dispensed and Annual Medical Expenditures for Japanese Patients with Hemophilia B. J Blood Med 2023; 14:649-661. [PMID: 38143791 PMCID: PMC10749097 DOI: 10.2147/jbm.s418818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 12/11/2023] [Indexed: 12/26/2023] Open
Abstract
Introduction Until extended half-life (EHL) factor IX (FIX) concentrates became available in Japan in 2010, patients with hemophilia B received intravenous FIX replacement therapy with standard half-life (SHL) FIX concentrates. Purpose To investigate the amount of factor dispensed and the associated medical expenditures for the treatment of hemophilia B in the real-world clinical setting in Japan. Methods This retrospective study comprised patients with hemophilia B (N=197) who had filled prescriptions for FIX concentrates reported in Japan's Medical Data Vision database from 2015 to 2019. Patients were included if they had 2 or more prescriptions for the same FIX concentrates within the first 6 months of the study period and the interval between prescriptions was at least 2 weeks. Results Since 2015, there was a decrease in the proportion of patients using SHL FIX concentrates and a corresponding increase in international units of dispensed EHL FIX concentrates. Median annualized dispensed dosages (IU/kg body weight) of EHL FIX concentrates were lower than for SHL concentrates for outpatient use only. Annual total health care expenditures per patient and annual expenditures for prescribed FIX concentrates increased each year during the study period. Following a switch from an SHL to an EHL concentrate, the median amount of prescribed FIX concentrate decreased slightly, although median total health care expenditures and FIX concentrate expenditures increased. Conclusion In the real-world setting in Japan, medical expenditures and the proportion of patients prescribed EHL FIX concentrates for the treatment of hemophilia B have increased.
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Affiliation(s)
- Katsuyuki Fukutake
- Laboratory Medicine, Tokyo Medical University, Shinjuku, Tokyo, Japan
- Department of Blood Coagulation Diseases, Ogikubo Hospital, Suginami, Tokyo, Japan
| | - Kanae Togo
- Pfizer Japan Inc, Shibuya-ku, Tokyo, Japan
| | - Linghua Xu
- Pfizer Japan Inc, Shibuya-ku, Tokyo, Japan
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Schulz M, Bashirians G, Cheng SH, Levy DI, Lundie M, Wilcox L, Winburn I, Somanathan S. Rationale for using centralized transduction inhibition assays in three phase 3 rAAV gene therapy clinical trials. Mol Ther Methods Clin Dev 2023; 31:101119. [PMID: 37868207 PMCID: PMC10585313 DOI: 10.1016/j.omtm.2023.101119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Affiliation(s)
| | | | | | | | - Mark Lundie
- Pfizer, 235 East 42 Street, New York, NY 10017, USA
| | - Lisa Wilcox
- Pfizer, 235 East 42 Street, New York, NY 10017, USA
| | - Ian Winburn
- Pfizer, 235 East 42 Street, New York, NY 10017, USA
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Young L, Chen Y, Alvir J, Burke T, Ferri Grazzi E, Winburn I. The impact of bleeding event frequency on health-related quality of life and work productivity outcomes in a European cohort of adults with haemophilia A: insights from the CHESS II study. Orphanet J Rare Dis 2023; 18:227. [PMID: 37537683 PMCID: PMC10398941 DOI: 10.1186/s13023-023-02690-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 04/02/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Haemophilia A carries a substantial healthcare burden, affecting health-related quality of life (HRQoL). The Cost of Haemophilia in Men: a Socioeconomic Survey II (CHESS II), a retrospective real-world study, characterised the burden of haemophilia and its impact on HRQoL and work productivity. The current analysis explored the impact of bleeding events on HRQoL and work productivity in Europe. This analysis focused on data collected from males aged 18 to 64 years with haemophilia A without inhibitors who were receiving replacement factor products or a monoclonal antibody and were not participating in a clinical trial at the time of study recruitment. Descriptive statistics were analysed using scores from EuroQoL's EQ-5D-5L index and EQ-VAS analogue scale and the Work Productivity and Activity Index Specific Health Problem (WPAI:SHP) percentage scores stratified by the number of annual bleeding events (ABs) 0, 1, 2, 3-4, or ≥ 5. RESULTS Of 918 males with haemophilia A in CHESS II, 318 met inclusion criteria and had data available for HRQoL measures; mean age (SD) was 33.8 (12.1) years and 96% were White. Mean (SD) ABs of 2.7 (2.9) occurred over the preceding 12 months: 20% had 3 or 4 ABs; 17% had ≥ 5 ABs. Mean EQ-5D-5L index scores for patients with 0, 1, 2, 3-4, or ≥ 5 ABs were 0.92, 0.76, 0.76, 0.71, and 0.56, respectively. Mean (SD) EQ-VAS scores were 86.9 (13.6), with 0 ABs versus 69.5 (19.1) for 3 or 4 ABs and 61.2 (17.2) for ≥ 5 ABs. Mean percentage of overall work productivity loss on the WPAI:SHP questionnaire ranged from 9.70 to 0 ABs to 47.65 for ≥ 5 ABs. CONCLUSIONS In this European sample of adult men with haemophilia A, HRQoL and work productivity scores were lower among those reporting more AB events. Bleeding burden appears to affect HRQoL and productivity; however, this cross-sectional analysis limits the ability to draw firm conclusions on causality.
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Affiliation(s)
- Lisa Young
- Pfizer Ltd, Walton-on-the-Hill Tadworth, Surrey, UK.
| | | | | | - Tom Burke
- HCD Economics, Daresbury, Cheshire, UK
- Faculty of Health and Social Care, University of Chester, Chester, UK
| | | | - Ian Winburn
- Pfizer Ltd, Walton-on-the-Hill Tadworth, Surrey, UK
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Schulz M, Levy DI, Petropoulos CJ, Bashirians G, Winburn I, Mahn M, Somanathan S, Cheng SH, Byrne BJ. Binding and neutralizing anti-AAV antibodies: Detection and implications for rAAV-mediated gene therapy. Mol Ther 2023; 31:616-630. [PMID: 36635967 PMCID: PMC10014285 DOI: 10.1016/j.ymthe.2023.01.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/21/2022] [Accepted: 01/06/2023] [Indexed: 01/13/2023] Open
Abstract
Assessment of anti-adeno-associated virus (AAV) antibodies in patients prior to systemic gene therapy administration is an important consideration regarding efficacy and safety of the therapy. Approximately 30%-60% of individuals have pre-existing anti-AAV antibodies. Seroprevalence is impacted by multiple factors, including geography, age, capsid serotype, and assay type. Anti-AAV antibody assays typically measure (1) transduction inhibition by detecting the neutralizing capacity of antibodies and non-antibody neutralizing factors, or (2) total anti-capsid binding antibodies, regardless of neutralizing activity. Presently, there is a paucity of head-to-head data and standardized approaches associating assay results with clinical outcomes. In addition, establishing clinically relevant screening titer cutoffs is complex. Thus, meaningful comparisons across assays are nearly impossible. Although complex, establishing screening assays in routine clinical practice to identify patients with antibody levels that may impact favorable treatment outcomes is achievable for both transduction inhibition and total antibody assays. Formal regulatory approval of such assays as companion diagnostic tests will confirm their suitability for specific recombinant AAV gene therapies. This review covers current approaches to measure anti-AAV antibodies in patient plasma or serum, their potential impact on therapeutic safety and efficacy, and investigative strategies to mitigate the effects of pre-existing anti-AAV antibodies in patients.
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Affiliation(s)
- Martin Schulz
- Pfizer, 235 East 42nd Street, New York, NY 10017, USA
| | - Daniel I Levy
- Pfizer, 235 East 42nd Street, New York, NY 10017, USA
| | | | | | - Ian Winburn
- Pfizer, 235 East 42nd Street, New York, NY 10017, USA
| | - Matthias Mahn
- Pfizer, 235 East 42nd Street, New York, NY 10017, USA
| | | | - Seng H Cheng
- Pfizer, 235 East 42nd Street, New York, NY 10017, USA
| | - Barry J Byrne
- University of Florida, 1600 SW Archer Road, Gainesville, FL 32610, USA.
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Minno MNDD, Martinoli C, Pasta G, la Corte-Rodriguez HD, Samy I, Stephensen D, Timmer MA, Winburn I. How to assess, detect, and manage joint involvement in the era of transformational therapies: Role of point-of-care ultrasound. Haemophilia 2023; 29:1-10. [PMID: 36163646 DOI: 10.1111/hae.14657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 08/11/2022] [Accepted: 08/28/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Patients with haemophilia experience recurring hemarthroses, mainly involving knees, elbows and ankles, which lead to haemophilic arthropathy, the major chronic complication of haemophilia. With new approaches to haemophilia treatment leading to fewer joint bleeds and, in some cases, no bleeding events, assessing whether current outcome assessment tools provide adequate sensitivity and specificity for management and care of patients with haemophilia is needed. METHODS An overview of current imaging tools for monitoring joint health, novel osteochondral damage and synovial proliferation biomarkers, and the relationship between assessments for functionality and imaging modalities is provided. Usefulness and sensitivity of point-of-care ultrasound (POCUS) to complement other assessments and use of ultrasound to monitor haemophilic arthropathy are also examined. RESULTS This review provides rationale for haemophilia teams to move beyond traditional outcomes in joint imaging, as well as guidance and evidence on assessment of joint health for potential new treatment modalities, such as gene therapy. The role of POCUS in the existing paradigm for haemophilia care and management along with the use of ultrasound as a complement to other outcome assessment tools are also discussed. Finally, the clinical effects of subclinical bleeding on joint function are described, to motivate screening for synovial proliferation. CONCLUSION POCUS can facilitate the early detection of joint damage and can monitor disease progression while providing insights into the efficacy of treatment regimens, and should be considered as an essential assessment tool for managing the care of patients with haemophilia.
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Affiliation(s)
| | - Carlo Martinoli
- Department of Health Science - DISSAL, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | | | - David Stephensen
- Kent Haemophilia & Thrombosis Centre, Canterbury, United Kingdom and Royal London Hospital, London, UK
| | - Merel A Timmer
- Van Creveldkliniek, UMC Utrecht, Utrecht, The Netherlands
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Woollacott I, Morgan G, Chowdary P, O'Hara J, Franks B, van Overbeeke E, Dunn N, Michelsen S, Huys I, Martin A, Cawson M, Brownrigg J, Winburn I, Thomson J. Examining patient and professional perspectives in the UK for gene therapy in haemophilia. Haemophilia 2022; 28:588-609. [PMID: 35438818 PMCID: PMC9546085 DOI: 10.1111/hae.14572] [Citation(s) in RCA: 4] [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: 07/14/2021] [Revised: 04/01/2022] [Accepted: 04/08/2022] [Indexed: 11/30/2022]
Abstract
Introduction With the development of gene therapy for people with haemophilia (PWH), it is important to understand how people impacted by haemophilia (PIH) and clinicians prioritise haemophilia treatment attributes to support informed treatment decisions. Objective To examine the treatment attribute preferences of PIH and clinical experts in the United Kingdom (UK) and to develop a profile of gene therapy characteristics fit for use in future discrete choice experiments (DCEs). Methods Semi‐structured interviews were conducted with PIH (n = 14) and clinical experts (n = 6) who ranked pre‐defined treatment attributes by importance. Framework analysis was conducted to identify key themes and treatment attributes; points were allocated based on the rankings. Synthesis of results by a multidisciplinary group informed development of a profile of gene therapy characteristics for use in future research. Results Key themes identified by PIH and clinical experts included patient relevant features and the importance of ‘informed decision making'. The six top‐ranked treatment attributes were ‘effect on factor level’ (79 points), ‘uncertainty regarding long‐term risks’ (57 points), ‘impact on daily life’ (41 points), ‘frequency of monitoring’ (33 points), ‘impact on ability to participate in physical activity’ (29 points), and ‘uncertainty regarding long‐term benefits’ (28 points). The final treatment characteristics were categorised as therapeutic option, treatment effectiveness, safety concerns, impact on self‐management and quality of life (role limitations). Conclusion We identified several gene therapy characteristics important to PIH and clinicians in the UK. These characteristics will be used in a future DCE to further investigate patient preferences for gene therapy.
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Affiliation(s)
| | | | - Pratima Chowdary
- Katharine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, London, UK
| | - Jamie O'Hara
- HCD Economics, Daresbury, UK.,Faculty of Health and Social Care, University of Chester, Chester, UK
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Winburn I, Schulz M, LaRosa G, Azzouz M. Reply to: Gene therapy to cure haemophilia: Is robust scientific inquiry the missing factor? Haemophilia 2021; 27:e628-e629. [PMID: 34156740 DOI: 10.1111/hae.14367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/20/2021] [Accepted: 06/10/2021] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | - Mimoun Azzouz
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, South Yorkshire, UK
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Konkle BA, Coffin D, Pierce GF, Clark C, George L, Iorio A, Mahlangu J, Naccache M, O’Mahony B, Peyvandi F, Pipe S, Quartel A, Sawyer EK, Skinner MW, Tortella B, Watson C, Winburn I. World Federation of Hemophilia Gene Therapy Registry. Haemophilia 2020; 26:563-564. [PMID: 32462720 PMCID: PMC8944922 DOI: 10.1111/hae.14015] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/07/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Barbara A. Konkle
- Bloodworks NW, Washington Center for Bleeding Disorders, Seattle, WA, USA
| | - Donna Coffin
- World Federation of Hemophilia, Montreal, QC, Canada
| | | | - Cary Clark
- International Society on Thrombosis and Hemostasis, Carrboro, NC, USA
| | - Lindsey George
- The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
- Univerisity of Pennsylvania, Philadelphia, PA, USA
| | | | - Johnny Mahlangu
- International Society on Thrombosis and Hemostasis, Carrboro, NC, USA
- Haemophilia Comprehensive Care Centre, University of the Witwatersrand, NHLS and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | | | - Brian O’Mahony
- Irish Haemophilia Society, Dublin, Ireland
- European Hemophilia Consortium, Brussels, Belgium
| | - Flora Peyvandi
- International Society on Thrombosis and Hemostasis, Carrboro, NC, USA
- IRCCS Maggiore Hospital Milan and University of Milan, Milan, Italy
| | - Steve Pipe
- University of Michigan, Pediatrics, Ann Arbor, MI, USA
- National Hemophilia Foundation, New York, NY, USA
| | | | | | | | | | - Crystal Watson
- American Thrombosis and Hemostssasis Network, Chicago, IL, USA
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Winburn I, Ishii T, Sumikawa T, Togo K, Yasunaga H. Estimating the Prevalence of Transthyretin Amyloid Cardiomyopathy in a Large In-Hospital Database in Japan. Cardiol Ther 2019; 8:297-316. [PMID: 31376091 PMCID: PMC6828925 DOI: 10.1007/s40119-019-0142-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 06/07/2019] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Transthyretin amyloid cardiomyopathy (ATTR-CM)-a debilitating, fatal disease resulting from the deposition of transthyretin (TTR) amyloid fibrils-can be hereditary due to mutations in the TTR gene (ATTRm) or wild type (ATTRwt). The global prevalence of ATTR-CM is largely unknown, although likely underestimated, with no formal epidemiological prevalence studies in Japan. This study aimed to estimate the prevalence of ATTR-CM in a large in-hospital database in Japan. METHODS This was a retrospective, observational, cross-sectional study which utilized data from all adult patients (aged ≥ 20 years) in the hospital-based Japan Medical Data Vision (MDV) database from January 2010 to September 2018 to estimate the number of currently diagnosed ATTR-CM patients and describe their demographic and clinical characteristics and diagnostic modalities. ATTR-CM patients (ATTRwt and ATTRm) were identified using a range of diagnosis codes that were applied to create broad and narrow definitions of the disease. RESULTS Over the 9 years of this study, there were 3255 (155.8 per million adult patients in the MDV database) to 3992 (191.1 per million) diagnoses of ATTRwt and 67 (3.2 per million) to 106 (5.1 per million) diagnoses of ATTRm in the MDV database (based on the narrow and broad definitions, respectively). There were 444 (21.2 per million) diagnoses of amyloid light-chain (AL) amyloidosis. Considering only those patients who were also diagnosed with heart failure, there were 1468 (70.3 per million) to 1798 (86.1 per million) diagnoses of ATTRwt and 50 (2.4 per million) to 61 (2.9 per million) diagnoses of ATTRm. Most ATTRwt patients (~ 90%) did not have a record of endomyocardial or abdominal wall biopsy, or of scintigram. CONCLUSION This retrospective study provides an estimate of the number of patients diagnosed with ATTR-CM in a large in-hospital database in Japan over a period of 9 years. Improving awareness of disease prevalence may improve diagnosis and treatment. FUNDING Pfizer.
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Affiliation(s)
| | | | | | | | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, University of Tokyo, Tokyo, Japan
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Winburn I, Yao Y, Hill J, Endre Z, Walker R, Sammut I. ASSESSMENT OF AUTO-REGULATION AND ENDOTHELIAL FUNCTION IN KIDNEYS UNDERGOING HYPOTHERMIC PULSATILE PERFUSION. Transplantation 2008. [DOI: 10.1097/01.tp.0000332636.47264.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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