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Bate S, McGovern D, Costigliolo F, Tan PG, Kratky V, Scott J, Chapman GB, Brown N, Floyd L, Brilland B, Martín-Nares E, Aydın MF, Ilyas D, Butt A, Nic an Riogh E, Kollar M, Lees JS, Yildiz A, Hinojosa-Azaola A, Dhaygude A, Roberts SA, Rosenberg A, Wiech T, Pusey CD, Jones RB, Jayne DR, Bajema I, Jennette JC, Stevens KI, Augusto JF, Mejía-Vilet JM, Dhaun N, McAdoo SP, Tesar V, Little MA, Geetha D, Brix SR. The Improved Kidney Risk Score in ANCA-Associated Vasculitis for Clinical Practice and Trials. J Am Soc Nephrol 2024; 35:335-346. [PMID: 38082490 PMCID: PMC10914211 DOI: 10.1681/asn.0000000000000274] [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: 08/04/2023] [Accepted: 11/03/2023] [Indexed: 01/27/2024] Open
Abstract
SIGNIFICANCE STATEMENT Reliable prediction tools are needed to personalize treatment in ANCA-associated GN. More than 1500 patients were collated in an international longitudinal study to revise the ANCA kidney risk score. The score showed satisfactory performance, mimicking the original study (Harrell's C=0.779). In the development cohort of 959 patients, no additional parameters aiding the tool were detected, but replacing the GFR with creatinine identified an additional cutoff. The parameter interstitial fibrosis and tubular atrophy was modified to allow wider access, risk points were reweighted, and a fourth risk group was created, improving predictive ability (C=0.831). In the validation, the new model performed similarly well with excellent calibration and discrimination ( n =480, C=0.821). The revised score optimizes prognostication for clinical practice and trials. BACKGROUND Reliable prediction tools are needed to personalize treatment in ANCA-associated GN. A retrospective international longitudinal cohort was collated to revise the ANCA renal risk score. METHODS The primary end point was ESKD with patients censored at last follow-up. Cox proportional hazards were used to reweight risk factors. Kaplan-Meier curves, Harrell's C statistic, receiver operating characteristics, and calibration plots were used to assess model performance. RESULTS Of 1591 patients, 1439 were included in the final analyses, 2:1 randomly allocated per center to development and validation cohorts (52% male, median age 64 years). In the development cohort ( n =959), the ANCA renal risk score was validated and calibrated, and parameters were reinvestigated modifying interstitial fibrosis and tubular atrophy allowing semiquantitative reporting. An additional cutoff for kidney function (K) was identified, and serum creatinine replaced GFR (K0: <250 µ mol/L=0, K1: 250-450 µ mol/L=4, K2: >450 µ mol/L=11 points). The risk points for the percentage of normal glomeruli (N) and interstitial fibrosis and tubular atrophy (T) were reweighted (N0: >25%=0, N1: 10%-25%=4, N2: <10%=7, T0: none/mild or <25%=0, T1: ≥ mild-moderate or ≥25%=3 points), and four risk groups created: low (0-4 points), moderate (5-11), high (12-18), and very high (21). Discrimination was C=0.831, and the 3-year kidney survival was 96%, 79%, 54%, and 19%, respectively. The revised score performed similarly well in the validation cohort with excellent calibration and discrimination ( n =480, C=0.821). CONCLUSIONS The updated score optimizes clinicopathologic prognostication for clinical practice and trials.
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Affiliation(s)
- Sebastian Bate
- Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Population Health, Health Services Research, and Primary Care, Centre for Biostatistics, University of Manchester, Manchester, United Kingdom
| | - Dominic McGovern
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Renal Medicine, Vasculitis Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Francesca Costigliolo
- Division of Nephrology, Dialysis and Transplantation, University of Genova, Genova, Italy
- Department of Internal Medicine and IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Pek Ghe Tan
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Renal Unit, Northern Health, Victoria, Australia
| | - Vojtech Kratky
- 1st Faculty of Medicine, Charles University, Prague, Czechia
- Department of Nephrology, General University Hospital, Prague, Czechia
| | - Jennifer Scott
- Trinity Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | - Gavin B. Chapman
- University/BHF Centre for Cardiovascular Science, University of Edinburgh and Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Nina Brown
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
- Renal Department, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Lauren Floyd
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
- Renal Department, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Benoit Brilland
- Service de Néphrologie-Dialyse-Transplantation, CHU d’Angers, Angers, France
| | - Eduardo Martín-Nares
- Departments of Immunology and Rheumatology, Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Duha Ilyas
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
- Renal, Transplantation and Urology Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Arslan Butt
- Renal Department, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | | | - Marek Kollar
- Department of Pathology, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Jennifer S. Lees
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Abdülmecit Yildiz
- Division of Nephrology, Bursa Uludağ University School of Medicine, Bursa, Turkey
| | - Andrea Hinojosa-Azaola
- Departments of Immunology and Rheumatology, Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ajay Dhaygude
- Renal Department, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Stephen A. Roberts
- Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Population Health, Health Services Research, and Primary Care, Centre for Biostatistics, University of Manchester, Manchester, United Kingdom
| | - Avi Rosenberg
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thorsten Wiech
- University Medical Center Hamburg-Eppendorf, Institute of Pathology, Hamburg, Germany
| | - Charles D. Pusey
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Rachel B. Jones
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Renal Medicine, Vasculitis Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - David R.W. Jayne
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Renal Medicine, Vasculitis Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Ingeborg Bajema
- Department of Pathology, Groningen University Medical Center, Groningen, The Netherlands
| | - J. Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kate I. Stevens
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, United Kingdom
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | | | - Juan Manuel Mejía-Vilet
- Departments of Immunology and Rheumatology, Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Neeraj Dhaun
- University/BHF Centre for Cardiovascular Science, University of Edinburgh and Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Stephen P. McAdoo
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Vladimir Tesar
- 1st Faculty of Medicine, Charles University, Prague, Czechia
- Department of Nephrology, General University Hospital, Prague, Czechia
| | - Mark A. Little
- Trinity Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | - Duruvu Geetha
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Silke R. Brix
- Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Renal, Transplantation and Urology Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Division of Cell Matrix Biology and Regenerative Medicine, University of Manchester, Manchester, United Kingdom
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Rovin BH, Ayoub IM, Chan TM, Liu ZH, Mejía-Vilet JM, Floege J. KDIGO 2024 Clinical Practice Guideline for the management of LUPUS NEPHRITIS. Kidney Int 2024; 105:S1-S69. [PMID: 38182286 DOI: 10.1016/j.kint.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 01/07/2024]
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Córdova-Sánchez BM, Ñamendys-Silva SA, Pacheco-Bravo I, García-Guillén FJ, Mejía-Vilet JM, Cruz C, Barraza-Aguirre G, Ramírez-Talavera WO, López-Zamora AR, Monera-Martínez F, Vidal-Arellano LJ, Morales-Buenrostro LE. Renal arterial resistive index, monocyte chemotactic protein 1 and neutrophil gelatinase-associated lipocalin, for predicting acute kidney injury in critically ill cancer patients. Int Urol Nephrol 2023:10.1007/s11255-023-03504-5. [PMID: 36753015 DOI: 10.1007/s11255-023-03504-5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 01/30/2023] [Indexed: 02/09/2023]
Abstract
PURPOSE We evaluated the renal arterial resistive index (RRI), urine monocyte chemotactic protein 1 (uMCP-1), and urine neutrophil gelatinase-associated lipocalin (uNGAL) to predict acute kidney injury (AKI) in critically ill cancer patients. METHODS In this prospective study, we included patients without AKI. We compared the area under the curve (AUC) of RRI, uMCP-1, and uNGAL to predict any stage of AKI and stage-3 AKI with the DeLong method, and we established cutoff points with the Youden index. RESULTS We included 64 patients, and 43 (67.2%) developed AKI. The AUC to predict AKI were: 0.714 (95% CI 0.587-0.820) for the RRI, 0.656 (95% CI 0.526-0.770) for uMCP-1, and 0.677 (95% CI 0.549-0.789) for uNGAL. The AUC to predict stage-3 AKI were: 0.740 (95% CI 0.615-0.842) for the RRI, 0.757 (95% CI 0.633-0.855) for uMCP-1, and 0.817 (95% CI 0.701-0.903) for uNGAL, without statistical differences among them. For stage 3 AKI prediction, the sensitivity and specificity were: 56.3% and 87.5% for a RRI > 0.705; 70% and 79.2% for an uMCP-1 > 2169 ng/mL; and 87.5% and 70.8% for a uNGAL > 200 ng/mL. The RRI was significantly correlated to age (r = 0.280), estimated glomerular filtration rate (r = - 0.259), mean arterial pressure (r = - 0.357), and serum lactate (r = 0.276). CONCLUSION The RRI, uMCP-1, and uNGAL have a similar ability to predict AKI. The RRI is more specific, while urine biomarkers are more sensitive to predict stage 3 AKI. The RRI correlates with hemodynamic variables. The novel uMCP-1 could be a useful biomarker that needs to be extensively studied.
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Affiliation(s)
| | - Silvio A Ñamendys-Silva
- Instituto Nacional de Cancerología, Mexico City, Mexico
- Nephrology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Sección XVI, Tlalpan, C. P. 14080, Mexico City, Mexico
- Hospital Medica Sur, Mexico City, Mexico
| | | | | | - Juan Manuel Mejía-Vilet
- Nephrology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Sección XVI, Tlalpan, C. P. 14080, Mexico City, Mexico
| | - Cristino Cruz
- Nephrology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Sección XVI, Tlalpan, C. P. 14080, Mexico City, Mexico
| | | | | | | | | | | | - Luis Eduardo Morales-Buenrostro
- Nephrology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Sección XVI, Tlalpan, C. P. 14080, Mexico City, Mexico.
- Hospital Medica Sur, Mexico City, Mexico.
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Madera-Salcedo IK, Ramírez-Sánchez AL, Rodríguez-Rodríguez N, García-Quintero R, Rubio RM, Morales-Montes de Oca G, Dávalos E, Cuervo R, Furuzawa-Carballeda J, Alcocer-Varela J, Gómez-Martín D, González-Yáñez M, de la Cruz A, Albarrán-Godínez A, Suárez-Rojas G, Romero-Díaz J, Uribe-Uribe NO, Alarcón-Riquelme M, Furlan-Magaril M, Mejía-Vilet JM, Crispín JC, Rosetti F. Down-Regulation-Resistant STAT4 Risk Haplotype Contributes to Lupus Nephritis Through CD4+ T Cell Interferon-γ Production. Arthritis Rheumatol 2022; 75:961-972. [PMID: 36575804 DOI: 10.1002/art.42435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 12/02/2022] [Accepted: 12/22/2022] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Variants in STAT4 are associated with systemic lupus erythematosus (SLE) and other autoimmune diseases. We undertook this study to investigate how disease-associated variants affect STAT4 expression, in particular in CD4+ T cells where STAT4 plays an essential role. METHODS We compared Th1 differentiation between naive CD4+ T cells from healthy donors homozygous for the risk (R/R) or nonrisk (NR/NR) alleles. We analyzed epigenetic marks in STAT4 and evaluated the relevance of its third intron, assessed the consequences of Stat4 overexpression in vivo in mice, and analyzed the effects of the STAT4 genotype in patients with lupus nephritis. RESULTS Naive CD4+ T cells from NR/NR healthy donors down-regulated STAT4 in response to interleukin-12 (IL-12). In contrast, cells from R/R healthy donors maintained high levels. R/R cells exhibited a higher abundance of transcriptionally active STAT4 and increased interferon-γ production. Accordingly, R/R healthy donors exhibited a stronger induction of local active enhancer marks. Genetic editing confirmed the presence of a negative regulatory region in the STAT4 third intron, where most of the SLE-associated STAT4 single-nucleotide polymorphisms (SNPs) are located. In vivo forced expression demonstrated that increases in Stat4 levels in T cells enhanced glomerulonephritis in mice. Accordingly, the R/R genotype was associated with suboptimal response to treatment and with worse clinical outcomes in patients with proliferative lupus nephritis. CONCLUSION The SLE-associated STAT4 haplotype correlates with an abnormal IL-12-mediated STAT4 transcriptional regulation. Carriers of the risk variant exhibit exaggerated CD4+ proinflammatory capacities that, in the context of SLE, contribute to more severe disease. R/R patients may benefit from blockade of the IL-12/STAT4 pathway.
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Affiliation(s)
- Iris K Madera-Salcedo
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ada L Ramírez-Sánchez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Noé Rodríguez-Rodríguez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Roberto García-Quintero
- Department of Internal Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Rosa M Rubio
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico, and Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | - Gabriela Morales-Montes de Oca
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Emmanuel Dávalos
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Rogelio Cuervo
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Janette Furuzawa-Carballeda
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jorge Alcocer-Varela
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Diana Gómez-Martín
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Marysol González-Yáñez
- Animal Research Facility, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Abigail de la Cruz
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, and Plan de Estudios Combinados en Medicina (PECEM), Facultad de Medicina, UNAM, Mexico City, Mexico
| | - Adrián Albarrán-Godínez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, and Programa de Doctorado en Ciencias Biomédicas, Universidad Nacional Autónoma de México, Ciudad Universitaria, Mexico City, Mexico
| | - Gerardo Suárez-Rojas
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, and Programa de Doctorado en Ciencias Biomédicas, Universidad Nacional Autónoma de México, Ciudad Universitaria, Mexico City, Mexico
| | - Juanita Romero-Díaz
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Norma O Uribe-Uribe
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Marta Alarcón-Riquelme
- Medical Genomics, GENYO. Centre for Genomics and Oncological Research: Pfizer/University of Granada/Andalusian Regional Government, Granada, Spain, and Unit of Inflammatory Chronic Diseases, Institute of Environmental Medicine, Karolinska Institutet, Solna, Sweden
| | - Mayra Furlan-Magaril
- Department of Molecular Genetics, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Juan Manuel Mejía-Vilet
- Department of Nephrology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán Mexico City, Mexico
| | - José C Crispín
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico, and Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Mexico
| | - Florencia Rosetti
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Hinojosa-Azaola A, Mejía-Vilet JM. Comment on the Review Article: ANCA-Associated Vasculitis in Latin America. A Systematic Literature Review: About Their Epidemiology and Their Clinical Features by Victor R. Pimentel-Quiroz et al. (J Clin Rheumatol 2022;28:44-51). J Clin Rheumatol 2022; 28:e682-e683. [PMID: 35471248 DOI: 10.1097/rhu.0000000000001848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 610] [Impact Index Per Article: 203.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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Rovin BH, Caster DJ, Cattran DC, Gibson KL, Hogan JJ, Moeller MJ, Roccatello D, Cheung M, Wheeler DC, Winkelmayer WC, Floege J, Alpers CE, Ayoub I, Bagga A, Barbour SJ, Barratt J, Chan DT, Chang A, Choo JCJ, Cook HT, Coppo R, Fervenza FC, Fogo AB, Fox JG, Glassock RJ, Harris D, Hodson EM, Hogan JJ, Hoxha E, Iseki K, Jennette JC, Jha V, Johnson DW, Kaname S, Katafuchi R, Kitching AR, Lafayette RA, Li PK, Liew A, Lv J, Malvar A, Maruyama S, Mejía-Vilet JM, Mok CC, Nachman PH, Nester CM, Noiri E, O'Shaughnessy MM, Özen S, Parikh SM, Park HC, Peh CA, Pendergraft WF, Pickering MC, Pillebout E, Radhakrishnan J, Rathi M, Ronco P, Smoyer WE, Tang SC, Tesař V, Thurman JM, Trimarchi H, Vivarelli M, Walters GD, Wang AYM, Wenderfer SE, Wetzels JF. Management and treatment of glomerular diseases (part 2): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2020; 95:281-295. [PMID: 30665569 DOI: 10.1016/j.kint.2018.11.008] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [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: 06/26/2018] [Revised: 10/30/2018] [Accepted: 11/01/2018] [Indexed: 02/06/2023]
Abstract
In November 2017, the Kidney Disease: Improving Global Outcomes (KDIGO) initiative brought a diverse panel of experts in glomerular diseases together to discuss the 2012 KDIGO glomerulonephritis guideline in the context of new developments and insights that had occurred over the years since its publication. During this KDIGO Controversies Conference on Glomerular Diseases, the group examined data on disease pathogenesis, biomarkers, and treatments to identify areas of consensus and areas of controversy. This report summarizes the discussions on primary podocytopathies, lupus nephritis, anti-neutrophil cytoplasmic antibody-associated nephritis, complement-mediated kidney diseases, and monoclonal gammopathies of renal significance.
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Affiliation(s)
- Brad H Rovin
- Division of Nephrology, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.
| | - Dawn J Caster
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Daniel C Cattran
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Keisha L Gibson
- University of North Carolina Kidney Center at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jonathan J Hogan
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marcus J Moeller
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany
| | - Dario Roccatello
- CMID (Center of Research of Immunopathology and Rare Diseases), and Division of Nephrology and Dialysis (ERK-Net member), University of Turin, Italy
| | | | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jürgen Floege
- Division of Nephrology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany.
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Chávez-Mendoza CA, Niño-Cruz JA, Correa-Rotter R, Uribe-Uribe NO, Mejía-Vilet JM. Calcineurin Inhibitors With Reduced-Dose Steroids as First-Line Therapy for Focal Segmental Glomerulosclerosis. Kidney Int Rep 2018; 4:40-47. [PMID: 30596167 PMCID: PMC6308907 DOI: 10.1016/j.ekir.2018.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 05/19/2018] [Revised: 08/10/2018] [Accepted: 08/27/2018] [Indexed: 11/28/2022] Open
Abstract
Introduction High-dose corticosteroids remain the first-line therapy for focal and segmental glomerulosclerosis (FSGS), whereas calcineurin inhibitors (CNIs) are reserved for those patients resistant to corticosteroid therapy. Methods This is a retrospective cohort analysis in patients with primary FSGS diagnosed between 2007 and 2014. According to the administered treatment, patients were segregated into 3 groups: high-dose prednisone, first-line CNIs plus low-dose prednisone, and rescue CNIs. Cumulative corticosteroid doses were compared as well as response to therapy and long-term renal survival by Cox regression analysis. Results A total of 66 patients were included (39 treated with high-dose prednisone, 11 treated with first-line CNI, 16 treated with high-dose prednisone followed by rescue CNI). Cumulative doses of prednisone in the high-dose group were 9.3 g (interquartile range [IQR] = 7.5−12.5 g), compared to 2.5 g (IQR = 1.82−3.12 g) in the first-line CNI plus low-dose corticosteroid group and 13.8 g (IQR = 9.2−15.8 g) rescue CNI groups, respectively (P < 0.001). Time under corticosteroid management was also higher in the high-dose prednisone group compared to the first-line CNI group. There was a response to treatment in 76.9%, 72.7%, and 87.5% of high-dose prednisone, first-line CNI and rescue CNI groups, with complete remission in 48.7%, 36.4%, and 31.3% respectively. There was no difference in relapse incidence after treatment (48.4%, 44.4%, and 46.7%) or in 5-year renal survival (87.2%, 81.8%, and 87.5%). Baseline proteinuria, biopsy chronicity score, and response to therapy were independent predictors of renal survival. Conclusion An initial CNI plus low-dose corticosteroid approach in primary FSGS reduces corticosteroid exposure with a response-to-therapy rate similar to that of the currently recommended high-dose corticosteroid regimen. These findings justify a randomized trial to formally test this hypothesis.
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Affiliation(s)
- Carlos Adrián Chávez-Mendoza
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - José Antonio Niño-Cruz
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ricardo Correa-Rotter
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Norma Ofelia Uribe-Uribe
- Department of Pathology and Pathologic Anatomy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Juan Manuel Mejía-Vilet
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Mejía-Vilet JM, Córdova-Sánchez BM, Uribe-Uribe NO, Correa-Rotter R, Morales-Buenrostro LE. Prognostic significance of renal vascular pathology in lupus nephritis. Lupus 2017; 26:1042-1050. [DOI: 10.1177/0961203317692419] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
We performed a retrospective cohort analysis to define the prognostic significance of vascular lesions documented in renal biopsies of lupus nephritis patients. A total of 429 patients were segregated into five groups: (1) no vascular lesions (NVL), (2) arterial sclerosis (AS), (3) non-inflammatory necrotizing vasculitis (NNV), (4) thrombotic microangiopathy (TMA), and (5) true renal vasculitis (TRV). Renal outcomes were analyzed by Cox regression models, and correlations between vascular lesions and activity/chronicity scores were determined by Spearman's coefficients. A total of 200 (46.6%) had NVL, 189 (44.0%) AS, six NNV (1.4%), 23 (5.4%) TMA, and 11 (2.6%) TRV. Patients with NVL were younger, with higher renal function; patients with TMA and TRV had lower renal function and higher arterial pressure at baseline. Antiphospholipid syndrome and positive lupus anticoagulant were more frequently observed in the TMA group. Five-year renal survival was 83% for NVL, 63% for AS, 67% for NNV, 31% for TMA, and 33% for TRV. NNV and TRV were significantly correlated with activity scores, while AS and chronic TMA were correlated with chronicity scores. Renal vascular lesions are associated with renal outcomes but do not behave as independent factors. The addition of vascular lesions to currently used scores should be further explored.
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Affiliation(s)
- J M Mejía-Vilet
- Department of Nephrology and Mineral Metabolism, National Medical Science and Nutrition Institute Salvador Zubirán, Mexico
| | - B M Córdova-Sánchez
- Department of Nephrology and Mineral Metabolism, National Medical Science and Nutrition Institute Salvador Zubirán, Mexico
| | - N O Uribe-Uribe
- Department of Pathology, National Medical Science and Nutrition Institute Salvador Zubirán, Mexico
| | - R Correa-Rotter
- Department of Nephrology and Mineral Metabolism, National Medical Science and Nutrition Institute Salvador Zubirán, Mexico
| | - L E Morales-Buenrostro
- Department of Nephrology and Mineral Metabolism, National Medical Science and Nutrition Institute Salvador Zubirán, Mexico
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Mejía-Vilet JM, Córdova-Sánchez BM, Uribe-Uribe NO, Correa-Rotter R. Immunosuppressive treatment for pure membranous lupus nephropathy in a Hispanic population. Clin Rheumatol 2016; 35:2219-27. [DOI: 10.1007/s10067-016-3366-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Revised: 07/18/2016] [Accepted: 07/21/2016] [Indexed: 01/06/2023]
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Mejía-Vilet JM, Córdova-Sánchez BM, Arreola-Guerra JM, Morales-Buenrostro LE, Uribe-Uribe NO, Correa-Rotter R. Renal flare prediction and prognosis in lupus nephritis Hispanic patients. Lupus 2015; 25:315-24. [DOI: 10.1177/0961203315606985] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 08/25/2015] [Indexed: 11/15/2022]
Abstract
We performed a retrospective cohort analysis focusing on lupus nephritis renal flare incidence and outcome predictors. One hundred and eighteen patients with biopsy-proven lupus nephritis were segregated by induction/maintenance regimes. The primary outcome was the proportion of patients experiencing renal flare. Secondary assessment included doubling of serum creatinine and development of end-stage renal disease. After a median follow-up of 31 months (interquartile range 21–46) from the date of response to induction therapy, 47 patients (39.8%) developed a renal flare. Azathioprine-maintained patients had a higher risk of renal flare compared with mycophenolate mofetil-maintained patients (hazard ratio 2.53, 95% confidence interval 1.39–4.59, p < 0.01). Age (hazard ratio 0.96, 0.92–0.99, p = 0.03), serum creatinine at presentation (hazard ratio 1.76, 1.13–2.76, p = 0.01), complete remission after induction therapy (hazard ratio 0.28, 0.14–0.56, p < 0.001) and azathioprine maintenance therapy (hazard ratio 4.78, 2.16–10.6, p < 0.001) were associated with renal flare on multivariate analysis. Ten patients progressed to end-stage renal disease (8.5%) by a median 32.5 months. Age (hazard ratio 0.88, 0.77–0.99, p = 0.05), complete remission after induction therapy (hazard ratio 0.08, 0.01–0.94, p = 0.04) and severe nephritic flare (hazard ratio 13.6, 1.72–107.7, p = 0.01) were associated with end-stage renal disease development. Azathioprine maintenance therapy is associated with a higher incidence of relapse in the Mexican-mestizo population. Younger age and nephritic flares predict development of end-stage renal disease.
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Affiliation(s)
- J M Mejía-Vilet
- Department of Nephrology and Mineral Metabolism, National Medical Science and Nutrition Institute Salvador Zubirán, Mexico City, Mexico
| | - B M Córdova-Sánchez
- Department of Nephrology and Mineral Metabolism, National Medical Science and Nutrition Institute Salvador Zubirán, Mexico City, Mexico
| | - J M Arreola-Guerra
- Department of Nephrology and Mineral Metabolism, National Medical Science and Nutrition Institute Salvador Zubirán, Mexico City, Mexico
| | - L E Morales-Buenrostro
- Department of Nephrology and Mineral Metabolism, National Medical Science and Nutrition Institute Salvador Zubirán, Mexico City, Mexico
| | - N O Uribe-Uribe
- Department of Pathology, National Medical Science and Nutrition Institute Salvador Zubirán, Mexico City, Mexico
| | - R Correa-Rotter
- Department of Nephrology and Mineral Metabolism, National Medical Science and Nutrition Institute Salvador Zubirán, Mexico City, Mexico
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Mejía-Vilet JM, Arreola-Guerra JM, Córdova-Sánchez BM, Morales-Buenrostro LE, Uribe-Uribe NO, Correa-Rotter R. Comparison of Lupus Nephritis Induction Treatments in a Hispanic Population: A Single-center Cohort Analysis. J Rheumatol 2015; 42:2082-91. [PMID: 26373566 DOI: 10.3899/jrheum.150395] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2015] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To evaluate response rates in an adult lupus nephritis (LN) cohort in Mexico City, Mexico. METHODS We analyzed 165 patients with biopsy-proven LN histological International Society of Nephrology/Renal Pathology Society classes III, IV, or V, distributed by treatment drug in 3 groups: mycophenolate mofetil (MMF; dosage > 2 g/day per 6 mos, n = 63), intravenous cyclophosphamide (IVC; 0.7 g/m(2) body surface area monthly per 6 pulses, n = 66), or azathioprine (AZA; dosage > 1.5 mg/kg/day per 6 mos, n = 36). Median followup was 31 ± 18 months. The primary endpoint was the proportion of patients achieving complete renal response (CR). Secondary endpoints included the proportion of patients achieving renal response (complete or partial), renal flare-free survival, doubling of serum creatinine, and progression to endstage renal disease (ESRD). RESULTS MMF induction was superior to IVC (HR 2.00, 95% CI 1.23-3.25, p = 0.005) and AZA (HR 2.12, 95% CI 1.23-3.66, p = 0.007) in the primary endpoint. Censored CR rates at 6, 12, 24, and 36 months were 32.6%, 56.1%, 76.6%, and 94.1% for MMF; 24.2%, 34.4%, 57.9%, and 62.1% for IVC; and 8.4%, 39.8%, 49.7%, and 49.7% for AZA. MMF was also superior in renal response to treatment and renal flare-free survival outcomes. There were no differences between groups in doubling of serum creatinine or progression to ESRD. The induction treatment with MMF (HR 2.04, 95% CI 1.25-3.33, p = 0.005) and absence of vascular lesions on renal biopsy (HR 2.05, 95% CI 1.25-3.37, p = 0.004) were associated with CR, whereas proteinuria at the time of presentation was negatively associated with CR (HR 0.91, 95% CI 0.84-0.98, p = 0.013). CONCLUSION MMF induction therapy is superior to IVC and AZA in patients with LN of Mexican-mestizo race.
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Affiliation(s)
- Juan Manuel Mejía-Vilet
- From the Department of Nephrology and Mineral Metabolism, and Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.J.M. Mejía-Vilet, MD, Attending Physician, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.M. Arreola-Guerra, MD, Attending Physician, Department of Internal Medicine, and Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; B.M. Córdova-Sánchez, MD, Nephrology Fellow, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; L.E. Morales-Buenrostro, MD, PhD, Research Scientist, Attending Physician, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; N.O. Uribe-Uribe, MD, Pathologist, Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; R. Correa-Rotter, MD, Head of Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán
| | - José Manuel Arreola-Guerra
- From the Department of Nephrology and Mineral Metabolism, and Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.J.M. Mejía-Vilet, MD, Attending Physician, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.M. Arreola-Guerra, MD, Attending Physician, Department of Internal Medicine, and Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; B.M. Córdova-Sánchez, MD, Nephrology Fellow, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; L.E. Morales-Buenrostro, MD, PhD, Research Scientist, Attending Physician, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; N.O. Uribe-Uribe, MD, Pathologist, Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; R. Correa-Rotter, MD, Head of Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán
| | - Bertha M Córdova-Sánchez
- From the Department of Nephrology and Mineral Metabolism, and Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.J.M. Mejía-Vilet, MD, Attending Physician, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.M. Arreola-Guerra, MD, Attending Physician, Department of Internal Medicine, and Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; B.M. Córdova-Sánchez, MD, Nephrology Fellow, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; L.E. Morales-Buenrostro, MD, PhD, Research Scientist, Attending Physician, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; N.O. Uribe-Uribe, MD, Pathologist, Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; R. Correa-Rotter, MD, Head of Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán
| | - Luis Eduardo Morales-Buenrostro
- From the Department of Nephrology and Mineral Metabolism, and Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.J.M. Mejía-Vilet, MD, Attending Physician, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.M. Arreola-Guerra, MD, Attending Physician, Department of Internal Medicine, and Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; B.M. Córdova-Sánchez, MD, Nephrology Fellow, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; L.E. Morales-Buenrostro, MD, PhD, Research Scientist, Attending Physician, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; N.O. Uribe-Uribe, MD, Pathologist, Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; R. Correa-Rotter, MD, Head of Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán
| | - Norma O Uribe-Uribe
- From the Department of Nephrology and Mineral Metabolism, and Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.J.M. Mejía-Vilet, MD, Attending Physician, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.M. Arreola-Guerra, MD, Attending Physician, Department of Internal Medicine, and Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; B.M. Córdova-Sánchez, MD, Nephrology Fellow, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; L.E. Morales-Buenrostro, MD, PhD, Research Scientist, Attending Physician, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; N.O. Uribe-Uribe, MD, Pathologist, Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; R. Correa-Rotter, MD, Head of Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán
| | - Ricardo Correa-Rotter
- From the Department of Nephrology and Mineral Metabolism, and Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.J.M. Mejía-Vilet, MD, Attending Physician, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; J.M. Arreola-Guerra, MD, Attending Physician, Department of Internal Medicine, and Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; B.M. Córdova-Sánchez, MD, Nephrology Fellow, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; L.E. Morales-Buenrostro, MD, PhD, Research Scientist, Attending Physician, Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; N.O. Uribe-Uribe, MD, Pathologist, Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán; R. Correa-Rotter, MD, Head of Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán.
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