Нефрологические аспекты хирургической коррекции массы тела при морбидном ожирении
Нефрологические аспекты хирургической коррекции массы тела при морбидном ожирении
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Аннотация
Во всем мире наблюдается неуклонный рост ожирения, в том числе морбидного. Неблагоприятное воздействие ожирения на почки связывают с развитием коморбидных состояний, являющихся общепризнанными факторами риска хронической болезни почек (ХБП) – инсулинорезистентности (ИР), метаболического синдрома (МС), сахарного диабета (СД), артериальной гипертензии (АГ). Ожирение вызывает и непосредственное повреждение почек с развитием неиммунного фокально-сегментарного гломерулосклероза. Ведущими патофизиологическими механизмами поражения почек при ожирении являются нарушения внутрипочечной гемодинамики с формированием гиперфильтрации, повреждающее действие адипокинов, продуцируемых жировой тканью.
Бариатрическая хирургия (БХ) заняла лидирующее положение в лечении морбидного ожирения, продемонстрировав свою эффективность в плане не только долгосрочного снижения массы тела, но и коррекции ИР, МС, СД, АГ. Нефропротективный эффект значительного и стойкого уменьшения массы тела обусловлен устранением гиперфильтрации, повреждающего действия адипокинов. Результаты наблюдательных исследований, касающиеся ближайших и отдаленных последствий БХ, демонстрируют положительные почечные исходы, в частности, уменьшение альбуминурии/протеинурии, улучшение или стабилизацию скорости клубочковой фильтрации, отдаление развития терминальной почечной недостаточности, а у диализных больных с морбидным ожирением хирургическая коррекция массы тела позволяет в последующем провести трансплантацию почки. В дальнейшем необходимы рандомизированные проспективные исследования с более длительным сроком наблюдения, анализ отдаленных почечных последствий БХ у пациентов с уже имеющимся нарушением функции почек, включая больных на диализе, требуется стратификация риска развития почечных осложнений БХ (острого повреждения почек, нефролитиаза, нефрокальциноза) и разработка эффективной стратегии управления этими рисками.
Ключевые слова: морбидное ожирение, бариатрическая хирургия, хроническая болезнь почек, гиперфильтрация, скорость клубочковой фильтрации, альбуминурия, протеинурия.
Key words: morbid obesity, bariatric surgery, chronic kidney disease, hyperfiltration, glomerular filtration rate, albuminuria, proteinuria.
Бариатрическая хирургия (БХ) заняла лидирующее положение в лечении морбидного ожирения, продемонстрировав свою эффективность в плане не только долгосрочного снижения массы тела, но и коррекции ИР, МС, СД, АГ. Нефропротективный эффект значительного и стойкого уменьшения массы тела обусловлен устранением гиперфильтрации, повреждающего действия адипокинов. Результаты наблюдательных исследований, касающиеся ближайших и отдаленных последствий БХ, демонстрируют положительные почечные исходы, в частности, уменьшение альбуминурии/протеинурии, улучшение или стабилизацию скорости клубочковой фильтрации, отдаление развития терминальной почечной недостаточности, а у диализных больных с морбидным ожирением хирургическая коррекция массы тела позволяет в последующем провести трансплантацию почки. В дальнейшем необходимы рандомизированные проспективные исследования с более длительным сроком наблюдения, анализ отдаленных почечных последствий БХ у пациентов с уже имеющимся нарушением функции почек, включая больных на диализе, требуется стратификация риска развития почечных осложнений БХ (острого повреждения почек, нефролитиаза, нефрокальциноза) и разработка эффективной стратегии управления этими рисками.
Ключевые слова: морбидное ожирение, бариатрическая хирургия, хроническая болезнь почек, гиперфильтрация, скорость клубочковой фильтрации, альбуминурия, протеинурия.
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Key words: morbid obesity, bariatric surgery, chronic kidney disease, hyperfiltration, glomerular filtration rate, albuminuria, proteinuria.
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15. Helal I, Fick-Brosnahan GM, Reed-Gitomer B, Schrier RW. Glomerular hyperfiltration: definitions, mechanisms and clinical implications. Nat Rev Nephrol. 2012;8:293-300. doi: 10.1038/nrneph.2012.19
16. Chagnac A, Herman M, Zingerman B, Erman A, Rozen-Zvi B, Hirsh J, et al. Obesity-induced glomerular hyperfiltration: its involvement in the pathogenesis of tubular sodium reabsorption. Nephrol Dial Transplant. 2008;23:3946-52. doi: 10.1093/ndt/gfn379
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20. Fantuzzi G. Adipose tissue, adipokines, and inflammation. J Allerg Clin Immunol. 2005;115:911-9. doi: 10.1016/j.jaci.2005.02.023
21. Berthoux F, Mariat C, Maillard N. Overweight/obesity revisited as a predictive risk factor in primary IgA nephropathy. Nephrol Dial Transplant. 2013;28 (suppl.4):iv160-iv166. doi: 10.1093/ndt/gft286
22. Kataoka H, Ohara M, Shibui K, et al. Overweight and obesity accelerate the progression of IgA nephropathy: prognostic utility of a combination of BMI and histopathological parameters. Clin Exp Nephrol. 2012;16(5):706-12. doi: 10.1007/s10157-012-0613-7
23. Chen HM, Shen WW, Ge YC, Zhang YD, Xie HL, Liu ZH. The relationship between obesity and diabetic nephropathy in China. BMC Nephrology. 2013;14:69. doi: 10.1186/1471-2369-14-69
24. Retnakaran R, Cull CA, Thorne KI, et al. Risk factors for renal dysfunction in type 2 diabetes: U.K. Prospective Diabetes Study 74. Diabetes. 2006;55:1832-9. doi: 10.2337/db05-1620
25. Arterburn DE, Olsen MK, Smith VA, et al. Association between bariatric surgery and long-term survival. JAMA 2015;313:62-70.
doi: 10.1001/jama.2014.16968
26. Neovius M, Narbro K, Keating C, Peltonen M, Sjöholm K, Agren G, Sjöström L, Carlsson L. Health care use during 20 years following bariatric surgery. JAMA 2012;308:1132-41. doi: 10.1001/2012.jama.11792
27. Angrisani L, Santonicola A, Iovino P, et al. Bariatric surgery worldwide 2013. Obes Surg. 2015;25:1822-32. doi: 10.1007/s11695-015-1657-z
28. Buchwald H. The evolution of metabolic/bariatric surgery. Obes Surg. 2014;24(8):1126-35. doi: 10.1007/s11695-014-1354-3
29. Rubino F, Gagner M, Gentileschi P, et al. The early effect of the Roux-en-Y gastric bypass on hormones involved in body weight regulation and glucose metabolism. Ann Surg. 2004;240(2):236-42.
doi: 10.1097/01.sla.0000133117.12646.48
30. Rubino F, Marescaux J. Effect of duodenal-jejunal exclusion in a non-obese animal model of type 2 diabetes: a new perspective for an old disease. Ann Surg. 2004;239(1):1-11. doi: 10.1097/01.sla.0000102989. 54824.fc
31. Kawada T. Bariatric Surgery in Patients With Type 2 Diabetes Mellitus. Ann Surg. 2015. doi: 10.1097/SLA.0000000000001379
32. Fried M, Yumuk V, Oppert JM, Scopinaro N, Torres A, Weiner R, Yashkov Y, Frühbeck G. Interdisciplinary European guidelines on metabolic and bariatric surgery. International Federation for the Surgery of Obesity and Metabolic Disorders – European Chapter (IFSO-EC) and European Association for the Study of Obesity (EASO). Obes Surg. 2014 Jan;24(1):42-55. doi: 10.1007/s11695-013-1079-8
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doi: 10.1016/j.ekir. 2017.01.010
35. [Yashkov YuI. O khirurgicheckikh metodakh lecheniya ozhireniya [About surgical methods of treatment of obesity]. Moscow; 2016. 52 p. (In Russ.)].
36. Brochner-Mortensen J, Rickers H, Balslev I. Renal function and body composition before and after intestinal bypass operation in obese patients. Scand J Clin Lab Invest. 1980;40(8):695-702. doi: 10.3109/ 00365518009095584
37. Bolignano D, Zoccali C. Effects of weight loss on renal function in obese CKD patients: a systematic review. Nephrol Dial Transplant. 2013;0:1-17. doi: 10.1093/ndt/gft302
38. Chagnac A, Weinstein T, Herman M, et al. The effects of weight loss on renal function in patients with severe obesity. J Am Soc Nephrol. 2003;14:1480-6. doi: 10.1097/01.asn.0000068462.38661.89
39. Navarro-Diaz M, Serra A, Romero R, et al. Effect of drastic weight loss after bariatric surgery on renal parameters in extremely obese patients: long-term follow-up. J Am Soc Nephrol. 2006;17(12 suppl):S213-S217. doi: 10.1681/ASN.2006080917
40. Serpa Neto A, Bianco Rossi FM, Dal Moro Amarante R, et al. Effect of weight loss after Roux-en-Y gastric bypass, on renal function and blood pressure in morbidly obese patients. J Nephrol. 2009;22:637-46.
41. Lieske JC, Collazo-Clavell ML, Sarr MG, et al. Gastric bypass surgery and measured and estimated GFR in women. Am J Kidney Dis. 2014;64:663-5. doi: 10.1053/j.ajkd.2014.06.016
42. Friedman AN, Moe S, Fadel WF, et al. Predicting the glomerular filtration rate in bariatric surgery patients. Am J Nephrol. 2014;39:8-15.
doi: 10.1159/000357231
43. Navaneethan SD, Yehnert H, Moustarah F, et al. Weight loss interventions in chronic kidney disease: a systematic review and meta-analysis. Clin J Am Soc Nephrol. 2009;4:1565-74. doi: 10.2215/CJN.02250409
44. Ruiz-Tovar J, Giner L, Sarro-Sobrin F, Alsina ME, Marco MP, Craver L. Laparoscopic Sleeve Gastrectomy Prevents the Deterioration of Renal Function in Morbidly Obese Patients Over 40 Years. Obes Surg. 2014. doi: 10.1007/s11695-014-1486-5
45. Schuster DP, Teodorescu M, Mikami D, et al. Effect of bariatric surgery on normal and abnormal renal function. Surg Obes Relat Dis. 2011;7:459-64. doi: 10.1016/j.soard.2010.11.015
46. Lee Ying Ngoh C, Bok Yan So J, Ho Yee Tiong, Shabbir A, Boon Wee Teo. Effect of weight loss after bariatric surgery on kidney function in a multiethnic Asian population. Surg Obes Relat Dis. 2016;12(3):600-5. doi: 10.1016/j.soard.2015.07.003
47. Chang AR, Chen Y, Still C, et al. Bariatric surgery is associated with improvement in kidney outcomes. Kidney Int. 2016;90:164-71.
doi: 10.1016/j.kint.2016.02.039
48. Iman TH, Fischer H, Jing B, et al. Estimated GFR before and after bariatric surgery in CKD. Am J Kidney Dis. 2016;69(3):380-8.
doi: 10.1053/j.ajkd.2016.09.020
49. Amor A, Jimenez A, Moize V, Ibarzabal A, Flores L, Lacy AM. Weight loss independently predicts urinary albumin excretion normalization in morbidly obese type 2 diabetic patients undergoing bariatric surgery. Surg Endosc. 2013;27:2046-51. doi: 10.1007/s00464-012-2708-3
50. Li K, Zou J, Ye Z, Di J, Han X, Zhang H, et al. Effects of Bariatric Surgery on Renal Function in Obese Patients: A Systematic Review and Meta Analysis. PLoS ONE. 2016;11(10):e0163907. doi: 10.1371/ journal.pone.0163907
51. Lieske JC, Mehta RA, Milliner DS, et al. Kidney stones are common after bariatric surgery. Kidney Int. 2015;87:839-45. doi: 10.1038/ ki.2014.352
52. Sinha MK, Collazo-Clavell ML, Rule A, et al. Hyperoxaluric nephrolithiasis is a complication of Roux-en-Y gastric bypass surgery. Kidney Int. 2007;72:100-7. doi: 10.1038/sj.ki.5002194
53. Nasr SH, D’Agati VD, Said SM, et al. Oxalate nephropathy complicating Roux-en-Y gastric bypass: an underrecognized cause of irreversible renal failure. Clin J Am Soc Nephrol. 2008;3:1676-83.
doi: 10.2215/CJN.02940608
54. Weingarten TN, Gurrieri C, McCaffrey JM, et al. Acute kidney injury following bariatric surgery. Obes Surg. 2013;23:64-70.
doi: 10.1007/s11695-012-0766-1
55. Abdullah HR, Tan TP, Vaez M, et al. Predictors of perioperative acute kidney injury in obese patients undergoing laparoscopic bariatric surgery: a single-centre retrospective cohort study. Obes Surg. 2016;26:1493-9. doi: 10.1007/s11695-015-1938-6
56. Ettinger J, Marcilio C, Santos-Filho P, et al. Rhabdomyolysis: diagnosis and treatment in bariatric surgery. Obes Surg. 2007;17:525-32.
doi: 10.1007/s11695-007-9091-5
57. Alexander JW, Goodman HR, Gersin K, et al. Gastric bypass in morbidly obese patients with chronic renal failure and kidney transplant. Transplantation. 2004;78:469-74. doi: 10.1097/01.tp.0000128858. 84976.27
58. MacLaughlin HL, Hall WL, Patel AG, Macdougall IC. Laparoscopic sleeve gastrectomy is a novel and effective treatment for obesity in patients with chronic kidney disease. Obes Surg. 2012;22:119-23.
doi: 10.1007/s11695-011-0448-4
59. Freeman CM, Woodle ES, Shi J, et al. Addressing morbid obesity as a barrier to renal transplantation with laparoscopic sleeve gastrectomy. Am J Transplant. 2015;15:1360-8. doi: 10.1111/ajt.13116
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22. Kataoka H, Ohara M, Shibui K, et al. Overweight and obesity accelerate the progression of IgA nephropathy: prognostic utility of a combination of BMI and histopathological parameters. Clin Exp Nephrol. 2012;16(5):706-12. doi: 10.1007/s10157-012-0613-7
23. Chen HM, Shen WW, Ge YC, Zhang YD, Xie HL, Liu ZH. The relationship between obesity and diabetic nephropathy in China. BMC Nephrology. 2013;14:69. doi: 10.1186/1471-2369-14-69
24. Retnakaran R, Cull CA, Thorne KI, et al. Risk factors for renal dysfunction in type 2 diabetes: U.K. Prospective Diabetes Study 74. Diabetes. 2006;55:1832-9. doi: 10.2337/db05-1620
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28. Buchwald H. The evolution of metabolic/bariatric surgery. Obes Surg. 2014;24(8):1126-35. doi: 10.1007/s11695-014-1354-3
29. Rubino F, Gagner M, Gentileschi P, et al. The early effect of the Roux-en-Y gastric bypass on hormones involved in body weight regulation and glucose metabolism. Ann Surg. 2004;240(2):236-42.
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31. Kawada T. Bariatric Surgery in Patients With Type 2 Diabetes Mellitus. Ann Surg. 2015. doi: 10.1097/SLA.0000000000001379
32. Fried M, Yumuk V, Oppert JM, Scopinaro N, Torres A, Weiner R, Yashkov Y, Frühbeck G. Interdisciplinary European guidelines on metabolic and bariatric surgery. International Federation for the Surgery of Obesity and Metabolic Disorders – European Chapter (IFSO-EC) and European Association for the Study of Obesity (EASO). Obes Surg. 2014 Jan;24(1):42-55. doi: 10.1007/s11695-013-1079-8
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36. Brochner-Mortensen J, Rickers H, Balslev I. Renal function and body composition before and after intestinal bypass operation in obese patients. Scand J Clin Lab Invest. 1980;40(8):695-702. doi: 10.3109/ 00365518009095584
37. Bolignano D, Zoccali C. Effects of weight loss on renal function in obese CKD patients: a systematic review. Nephrol Dial Transplant. 2013;0:1-17. doi: 10.1093/ndt/gft302
38. Chagnac A, Weinstein T, Herman M, et al. The effects of weight loss on renal function in patients with severe obesity. J Am Soc Nephrol. 2003;14:1480-6. doi: 10.1097/01.asn.0000068462.38661.89
39. Navarro-Diaz M, Serra A, Romero R, et al. Effect of drastic weight loss after bariatric surgery on renal parameters in extremely obese patients: long-term follow-up. J Am Soc Nephrol. 2006;17(12 suppl):S213-S217. doi: 10.1681/ASN.2006080917
40. Serpa Neto A, Bianco Rossi FM, Dal Moro Amarante R, et al. Effect of weight loss after Roux-en-Y gastric bypass, on renal function and blood pressure in morbidly obese patients. J Nephrol. 2009;22:637-46.
41. Lieske JC, Collazo-Clavell ML, Sarr MG, et al. Gastric bypass surgery and measured and estimated GFR in women. Am J Kidney Dis. 2014;64:663-5. doi: 10.1053/j.ajkd.2014.06.016
42. Friedman AN, Moe S, Fadel WF, et al. Predicting the glomerular filtration rate in bariatric surgery patients. Am J Nephrol. 2014;39:8-15.
doi: 10.1159/000357231
43. Navaneethan SD, Yehnert H, Moustarah F, et al. Weight loss interventions in chronic kidney disease: a systematic review and meta-analysis. Clin J Am Soc Nephrol. 2009;4:1565-74. doi: 10.2215/CJN.02250409
44. Ruiz-Tovar J, Giner L, Sarro-Sobrin F, Alsina ME, Marco MP, Craver L. Laparoscopic Sleeve Gastrectomy Prevents the Deterioration of Renal Function in Morbidly Obese Patients Over 40 Years. Obes Surg. 2014. doi: 10.1007/s11695-014-1486-5
45. Schuster DP, Teodorescu M, Mikami D, et al. Effect of bariatric surgery on normal and abnormal renal function. Surg Obes Relat Dis. 2011;7:459-64. doi: 10.1016/j.soard.2010.11.015
46. Lee Ying Ngoh C, Bok Yan So J, Ho Yee Tiong, Shabbir A, Boon Wee Teo. Effect of weight loss after bariatric surgery on kidney function in a multiethnic Asian population. Surg Obes Relat Dis. 2016;12(3):600-5. doi: 10.1016/j.soard.2015.07.003
47. Chang AR, Chen Y, Still C, et al. Bariatric surgery is associated with improvement in kidney outcomes. Kidney Int. 2016;90:164-71.
doi: 10.1016/j.kint.2016.02.039
48. Iman TH, Fischer H, Jing B, et al. Estimated GFR before and after bariatric surgery in CKD. Am J Kidney Dis. 2016;69(3):380-8.
doi: 10.1053/j.ajkd.2016.09.020
49. Amor A, Jimenez A, Moize V, Ibarzabal A, Flores L, Lacy AM. Weight loss independently predicts urinary albumin excretion normalization in morbidly obese type 2 diabetic patients undergoing bariatric surgery. Surg Endosc. 2013;27:2046-51. doi: 10.1007/s00464-012-2708-3
50. Li K, Zou J, Ye Z, Di J, Han X, Zhang H, et al. Effects of Bariatric Surgery on Renal Function in Obese Patients: A Systematic Review and Meta Analysis. PLoS ONE. 2016;11(10):e0163907. doi: 10.1371/ journal.pone.0163907
51. Lieske JC, Mehta RA, Milliner DS, et al. Kidney stones are common after bariatric surgery. Kidney Int. 2015;87:839-45. doi: 10.1038/ ki.2014.352
52. Sinha MK, Collazo-Clavell ML, Rule A, et al. Hyperoxaluric nephrolithiasis is a complication of Roux-en-Y gastric bypass surgery. Kidney Int. 2007;72:100-7. doi: 10.1038/sj.ki.5002194
53. Nasr SH, D’Agati VD, Said SM, et al. Oxalate nephropathy complicating Roux-en-Y gastric bypass: an underrecognized cause of irreversible renal failure. Clin J Am Soc Nephrol. 2008;3:1676-83.
doi: 10.2215/CJN.02940608
54. Weingarten TN, Gurrieri C, McCaffrey JM, et al. Acute kidney injury following bariatric surgery. Obes Surg. 2013;23:64-70.
doi: 10.1007/s11695-012-0766-1
55. Abdullah HR, Tan TP, Vaez M, et al. Predictors of perioperative acute kidney injury in obese patients undergoing laparoscopic bariatric surgery: a single-centre retrospective cohort study. Obes Surg. 2016;26:1493-9. doi: 10.1007/s11695-015-1938-6
56. Ettinger J, Marcilio C, Santos-Filho P, et al. Rhabdomyolysis: diagnosis and treatment in bariatric surgery. Obes Surg. 2007;17:525-32.
doi: 10.1007/s11695-007-9091-5
57. Alexander JW, Goodman HR, Gersin K, et al. Gastric bypass in morbidly obese patients with chronic renal failure and kidney transplant. Transplantation. 2004;78:469-74. doi: 10.1097/01.tp.0000128858. 84976.27
58. MacLaughlin HL, Hall WL, Patel AG, Macdougall IC. Laparoscopic sleeve gastrectomy is a novel and effective treatment for obesity in patients with chronic kidney disease. Obes Surg. 2012;22:119-23.
doi: 10.1007/s11695-011-0448-4
59. Freeman CM, Woodle ES, Shi J, et al. Addressing morbid obesity as a barrier to renal transplantation with laparoscopic sleeve gastrectomy. Am J Transplant. 2015;15:1360-8. doi: 10.1111/ajt.13116
________________________________________________
2. [Kovesdy CP, Furth S, Zoccali С. Obesity and kidney disease: hidden consequences of the epidemic. Nefrologiya. 2017;21(2):10-9 (In Russ.)].
3. World Health Organization (WHO), Fact Sheet No.311 (updated March 2013). Available at: http://www.who.int/mediacentre/factsheets/ fs311/en/
4. Fruhbeck G, Toplak H, Woodward E, Yumuk V, Maislos M, Oppert JM. Obesity: The gateway to ill health – an EASO Position Statement on a rising public health, clinical and scientific challenge in Europe. Obes Facts. 2013;6:117-20. doi: 10.1159/000350627
5. Forouzanfar MH, Alexander L, Anderson HR, Bachman VF, Biryukov S, Brauer M, et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;86:2287-323. doi: 10.1016/S0140-6736(15)00128-2
6. Díaz MN. Consequences of morbid obesity on the kidney. Where are we going? Clin Kidney J. 2016;1-6. doi: 10.1093/ckj/sfw094
7. Aneja A, El-Atat F, McFarlane SI, Sowers JR. Hypertension and obesity. Recent Progr Horm Res. 2004;59:169-206. doi: 10.1210/rp.59.1.169
8. Rosenberg DE, Jabbour SA, Goldstein BJ. Insulin resistance, diabetes and cardiovascular risk: approaches to treatment. Diabet Obes Metab. 2005;7:642-53. doi: 10.1111/j.1463- 1326.2004.00446.x
9. Zalesin KC, McCullough PA. Bariatric surgery for morbid obesity: risks and benefits in chronic kidney disease patients. Adv Chronic Kidney Dis. 2006;13:403-17. doi: 10.1053/j.ackd.2006.07.008
10. Rosenberg DE, Jabbour SA, Goldstein BJ. Insulin resistance, diabetes and cardiovascular risk: approaches to treatment. Diabet Obes Metab. 2005;7:642-53. doi: 10.1111/j.1463-1326.2004.00446.x
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Авторы
И.Н. Бобкова, С.С. Гуссаова, Е.В. Ставровская, А.В. Cтруве
ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия
I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Moscow, Russia
ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия
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I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Moscow, Russia
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