tisdag 19 maj 2020
Metaboliset taudit pandemian aikana
Mechanism of Inflammatory Response in Associated Comorbidities in COVID-19
Affiliations
- PMID: 32417709
- PMCID: PMC7215143
- DOI: 10.1016/j.dsx.2020.05.025
Abstract
Background and aims:
The outbreak of the new coronavirus, SARS-CoV-2, causes a
respiratory disease and individuals with pre-existing cardiometabolic
disorders display worse prognosis through the infection course. The aim
of this minireview is to present epidemiological data related to
metabolic comorbidities in association with the SARS-CoV-2.
Methods: This is a narrative mini-review with Pubmed search until April 23, 2020 using the keywords COVID-19, SARS-CoV-2, treatment of coronavirus and following terms: diabetes mellitus, obesity, arterial hypertension, ACE-inhibitors, cytokine storm, immune response and vitamin D.
Results: Studies indicate that obese individuals are more likely to develop infections, and that adipose tissue serves as a pathogen reservoir. In diabetic individuals higher rate of inflammatory processes is seen due to constant glucose recognition by C type lectin receptors. Hypertensive individuals, usually grouped with other conditions, are treated with drugs to reduce blood pressure mostly through ACEi and ARB, that leads to increased ACE2 expression, used by SARS-CoV-2 for human's cell entry. Until now, the studies have shown that individuals with those conditions and affected by COVID-19 present an uncontrolled release of pro-inflammatory cytokines and an unbalanced immune response, leading to the cytokine storm phenomenon. Vitamin D is highlighted as a potential therapeutic target, because in addition to acting on the immune system, it plays an important role in the control of cardiometabolic diseases.
Conclusion: Currently, since there is no proven and effective antiviral therapy for SARS-CoV-2, the efforts should focus on controlling inflammatory response and reduce the risks of associated complications.
Keywords:
Diabetes mellitus; Hypertension arterial; Immune response; Obesity; Vitamin D.
Methods: This is a narrative mini-review with Pubmed search until April 23, 2020 using the keywords COVID-19, SARS-CoV-2, treatment of coronavirus and following terms: diabetes mellitus, obesity, arterial hypertension, ACE-inhibitors, cytokine storm, immune response and vitamin D.
Results: Studies indicate that obese individuals are more likely to develop infections, and that adipose tissue serves as a pathogen reservoir. In diabetic individuals higher rate of inflammatory processes is seen due to constant glucose recognition by C type lectin receptors. Hypertensive individuals, usually grouped with other conditions, are treated with drugs to reduce blood pressure mostly through ACEi and ARB, that leads to increased ACE2 expression, used by SARS-CoV-2 for human's cell entry. Until now, the studies have shown that individuals with those conditions and affected by COVID-19 present an uncontrolled release of pro-inflammatory cytokines and an unbalanced immune response, leading to the cytokine storm phenomenon. Vitamin D is highlighted as a potential therapeutic target, because in addition to acting on the immune system, it plays an important role in the control of cardiometabolic diseases.
Conclusion: Currently, since there is no proven and effective antiviral therapy for SARS-CoV-2, the efforts should focus on controlling inflammatory response and reduce the risks of associated complications.
Copyright © 2020 Diabetes India. Published by Elsevier Ltd. All rights reserved.
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Etiketter:
Metaboliset taudit pandemian aikana
lördag 14 mars 2020
COP1, RFWD2 E3 ubikitiiniligaasi ja insuliinin eritys
https://www.ncbi.nlm.nih.gov/pubmed/26627735
Cell. 2015 Dec 3;163(6):1457-67. doi: 10.1016/j.cell.2015.10.076. Epub 2015 Nov 25.
β-Cell Insulin Secretion Requires the Ubiquitin Ligase COP1.
Suriben R1, Kaihara KA2, Paolino M1, Reichelt M3, Kummerfeld SK4, Modrusan Z5, Dugger DL1, Newton K1, Sagolla M3, Webster JD3, Liu J4, Hebrok M2, Dixit VM6.
Abstract
A
variety of signals finely tune insulin secretion by pancreatic β cells
to prevent both hyper-and hypoglycemic states. Here, we show that
post-translational regulation of the transcription factors ETV1, ETV4,
and ETV5 by the ubiquitin ligase COP1 (also called RFWD2)
in β cells is critical for insulin secretion. Mice lacking COP1 in β
cells developed diabetes due to insulin granule docking defects that
were fully rescued by genetic deletion of Etv1, Etv4, and Etv5. Genes
regulated by ETV1, ETV4, or ETV5 in the absence of mouse COP1 were
enriched in human diabetes-associated genes, suggesting that they also
influence human β-cell pathophysiology. In normal β cells, ETV4 was
stabilized upon membrane depolarization and limited insulin secretion
under hyperglycemic conditions. Collectively, our data reveal that ETVs
negatively regulate insulin secretion for the maintenance of
normoglycemia.
Copyright © 2015 Elsevier Inc. All rights reserved.
Comment in
- Metabolism: Keeping insulin secretion in check. [Nat Rev Mol Cell Biol. 2016]
- PMID:
- 26627735
- DOI:
- 10.1016/j.cell.2015.10.076
- [Indexed for MEDLINE]
Etiketter:
COP1 ubikitiiniligaasi ja insuliinin eritys
måndag 9 mars 2020
2'O-ribose methylation
https://www.sciencedirect.com/science/article/pii/S1874939918300804
Highlights
- •
- Ribose 2’-O-methylation is very common RNA modification omnipresent in cellular RNAs (rRNAs/tRNAs/mRNAs/sn(sno)RNAs/miRNAs…).
- •
- Formation of 2’-O-methylated residues is insured by both protein stand-alone enzymes and by C/D-box sno(s)RNP complexes.
- •
- Ribose methylation in RNA is dynamic and responds to physiological state of the cell.
- •
- Ribose methylation is important for regulation of RNA stability, mRNA splicing and translation, as well as innate immune response.
Description
https://www.ebi.ac.uk/interpro/entry/InterPro/IPR013123/
Most
cellular RNAs undergo a number of post-transcriptional nucleoside
modifications. While the biological role of many of these modifications
is unknown, some have been shown to be necessary for cell growth or for
resistance to antibiotics
[1, 2]
.
One of the most common modifications is 2'O-ribose methylation
catalysed by the RNA 2'O-ribose methyltransferases, a large enzyme
family that transfer a methyl group from S-adenosyl-L-methionine
(AdoMet) to the 2'-OH group of the backbone ribose
[3]
.
This
entry represents a substrate-binding domain found in a variety of
bacterial and mitochondrial RNA 2'-O ribose methyltransferases. These
include the bacterial enzyme RlmB, which specifically methylates the
conserved nucleotide guanosine 2251 in 23S RNA, and PET56, which
specifically methylates the equivalent guanosine in mitochondrial 21S
RNA
[4, 1]
. This domain forms a four-stranded mixed beta sheet similar to that found in other RNA binding enzymes
[5]
. It shows considerable conformational flexibility which is thought to be important for its ability to bind RNA.
Wikipedia
2'-O-methylation is a common nucleoside modification of RNA, where a methyl group is added to the 2' hydroxyl of the ribose moiety of a nucleoside, producing a methoxy group. 2'-O-methylated nucleosides are mostly found in ribosomal RNA and small nuclear RNA and occur in the functionally essential regions of the ribosome and spliceosome.[1] Currently, about 1210 2'-O-methylations (2'-O-Me) have been identified in mammals and yeast and deposited in RMBase (RNA Modification Base) database.[2]
Having the chemical properties intermediate between RNA and DNA, 2'-O-methylation is presumed to have one of the reactive group of RNA molecules on early earth that would have given rise to DNA.[3]
Recently a novel method to map 2'-O ribose methylations by high throughput sequencing has been published.[4] The method is quantitative and maps all modifications in a single experiment.
Wikipedia
2'-O-methylation
2'-O-methyl-adenosine, a modified adenosine.
Having the chemical properties intermediate between RNA and DNA, 2'-O-methylation is presumed to have one of the reactive group of RNA molecules on early earth that would have given rise to DNA.[3]
Recently a novel method to map 2'-O ribose methylations by high throughput sequencing has been published.[4] The method is quantitative and maps all modifications in a single experiment.
RIBOOSI , cADPr
cADPr, syklinen ADPriboosi
- Review
- Published:
Cyclic ADP-ribose
Abstract.
The Ca2+-mobilizing
natural compound cyclic ADP-ribose was discovered in sea urchin egg
homogenates. Recently the involvement of cyclic ADP-ribose in Ca2+
signaling has been demonstrated in diverse biological systems spanning
protozoa, plants, and cells from invertebrate, mammalian, and human
sources. ADP-ribosyl cyclases synthesize cyclic ADP-ribose. Several
candidate proteins for these enzymes have been proposed, including
membrane-bound NAD+ glycohydrolases such as CD38 and soluble enzyme activities from various tissues and cells. Ca2+ mobilization by cyclic ADP-ribose is believed to proceed via the ryanodine receptor/Ca2+
channel, probably via binding proteins for cyclic ADP-ribose. Several
antagonistic derivatives of cyclic ADP-ribose have been synthesized,
some of which have been successfully used to demonstrate the involvement
of cyclic ADP-ribose in sea urchin egg fertilization, glucose-dependent
insulin secretion in pancreatic β-cells, and activation and
proliferation of human T-lymphocytes.
torsdag 2 januari 2020
UDP-Gal ja laktaatio
https://www.ncbi.nlm.nih.gov/pubmed/?term=UDP-galactose+%2C+lactation
Search results
Items: 6
1.
Mohammad MA, Hadsell DL, Haymond MW.
Am J Physiol Endocrinol Metab. 2012 Aug 1;303(3):E365-76. doi: 10.1152/ajpendo.00175.2012. Epub 2012 May 29.
- PMID:
- 22649065
2.
Metabolites of lactose synthesis in milk from diabetic and nondiabetic women during lactogenesis II.
Arthur PG, Kent JC, Hartmann PE.
J Pediatr Gastroenterol Nutr. 1994 Jul;19(1):100-8.
- PMID:
- 7965458
3.
Arthur PG, Kent JC, Hartmann PE.
J Pediatr Gastroenterol Nutr. 1991 Oct;13(3):260-6.
- PMID:
- 1791501
4.
Keller KM, Wirth S, Sewell AC, Shin YS.
J Inherit Metab Dis. 1991;14(1):114-5. No abstract available.
- PMID:
- 1861454
5.
Ng WG, Xu YK, Kaufman F, Donnell GN.
J Pediatr. 1989 Jul;115(1):166-7. No abstract available.
- PMID:
- 2738786
6.
Gil A, Sanchez-Medina F.
J Dairy Res. 1982 May;49(2):301-7.
- PMID:
- 6178766
Hyvää Uutta Vuotta 2020. Mielessäni on tärkeä molekyyli UDP-gal.
UDP-Gal
PubMed haku 2.1. 2020.
https://www.ncbi.nlm.nih.gov/pubmed/?term=UDP-galactose
<< First< Prev
Löytöjä:
https://www.ncbi.nlm.nih.gov/pubmed/?term=UDP-galactose++homo+sapiens
<< First< Prev
PubMed haku 2.1. 2020.
https://www.ncbi.nlm.nih.gov/pubmed/?term=UDP-galactose
Best matches for UDP-galactose:
Cryptococcus neoformans UGT1 encodes a UDP-Galactose/UDP-GalNAc transporter.
Li LX et al. Glycobiology.
(2017)
One-Pot Synthesis of Hyperoside by a Three-Enzyme Cascade Using a UDP-Galactose Regeneration System.
Pei J et al. J Agric Food Chem.
(2017)
UDP-Glucose
4-Epimerase and β-1,4-Galactosyltransferase from the Oyster
Magallana gigas as Valuable Biocatalysts for the
Production of Galactosylated Products.
Song HB et al. Int J Mol Sci.
(2018)
Hakulöytöjä muuten seuraavat_
Search results "UDP-galactose"
Items: 1 to 20 of 2671
of 134
Next >Last >>- Poimin muutaman, jotka merkitsevät ihmisen (Homo sapiens) kannalta olennaista:
Löytöjä:
https://www.ncbi.nlm.nih.gov/pubmed/?term=UDP-galactose++homo+sapiens
Best matches for UDP-galactose homo sapiens:
Hereditary galactosemia.
Demirbas D et al. Metabolism.
(2018)
Cryptococcus neoformans UGT1 encodes a UDP-Galactose/UDP-GalNAc transporter.
Li LX et al. Glycobiology.
(2017)
Inherited thrombocytopenia associated with mutation of UDP-galactose-4-epimerase (GALE).
Seo A et al. Hum Mol Genet.
(2019).
Search results
Items: 1 to 20 of 902
of 46
Next >- Artikkeleita kahden viime vuoden ajalta:
Lv X, Chen Y, Luo Y, Li L, Wang H.
Medicine (Baltimore). 2019 Aug;98(31):e16361. doi: 10.1097/MD.0000000000016361.
OUTCOMES:The patient was the rare p phenotype in P1P blood
system and the patient's habitual abortion was caused by anti-PP1P
antibody which was generated naturally in persons with p phenotype.
There was a mutation (903C>G, CCC>CCG) in the 3rd exon of A4GALT
gene, which is likely a significant contributor to p phenotype.LESSONS: This
is the first case of habitual abortion caused by p phenotype due to
independent 903C>G homozygous mutation with no similar record
reported before, which indicates that it is a new class of mutation that
leads to p phenotype.
Free PMC Article ( Asetan linkin Veri ja hyytyminen- blogiini 2.1. 2020 veriryhmätietojen joukkoon)
Free PMC Article ( Asetan linkin Veri ja hyytyminen- blogiini 2.1. 2020 veriryhmätietojen joukkoon)
2.
Ha C, Choi S, Yu H, Chun S, Kim KH, Lee JH, Han IW, Cho D.
Ann Lab Med. 2019 Nov;39(6):602-605. doi: 10.3343/alm.2019.39.6.602. No abstract available.Free PMC Article
3.
Yang YD, Xu LL, Li DZ.
Eur J Obstet Gynecol Reprod Biol. 2019 May;236:257-258. doi: 10.1016/j.ejogrb.2019.03.013. Epub 2019 Mar 19. No abstract available.
4.
Prakash O, Führing J, Post J, Shepherd SM, Eadsforth TC, Gray D, Fedorov R, Routier FH.
Molecules. 2019 Mar 12;24(5). pii: E996. doi: 10.3390/molecules24050996.
Leishmania parasites additionally express a UDP-sugar pyrophosphorylase (USP) responsible for monosaccharides salvage that is able to generate both UDP-Gal and UDP-Glc.
The inactivation of the two parasite pyrophosphorylases UGP and USP,
results in parasite death.
The present study reports on the
identification of structurally diverse scaffolds for the development of
USP inhibitors by fragment library screening. Based on this screening,
we selected a small set of commercially available compounds, and
identified molecules that inhibit both Leishmania major USP and
UGP, with a half-maximal inhibitory concentration in the 100 µM range.
The inhibitors were predicted to bind at allosteric regulation sites,
which were validated by mutagenesis studies. This study sets the stage
for the development of potent USP inhibitors.Free PMC Article
Similar articles (Asetan 2.1. 2020 tämän linkin blogiin INFEKTIOISTA)
5.
Demirbas D, Huang X, Daesety V, Feenstra S, Haskovic M, Qi W, Gubbels CS, Hecht L, Levy HL, Waisbren SE, Berry GT.
Mol Genet Metab. 2019 Apr;126(4):368-376. doi: 10.1016/j.ymgme.2019.01.016. Epub 2019 Jan 22.
GALT deficiency is a rare genetic disorder of carbohydrate metabolism. Due to the decreased activity or absence of the enzyme galactose-1-phosphate uridylyltransferase (GALT), cells from affected individuals are unable to metabolize galactose
normally. Lactose consumption in the newborn period could potentially
lead to a lethal disease process with multi-organ involvement. In
contrast to the newborn-stage disease, however, a galactose-restricted
diet does not prevent long-term complications such as central nervous
system (CNS) dysfunction with speech defects, learning disability and
neurological disease in addition to hypergonadotropic hypogonadism or
primary ovarian insufficiency (POI) in females. As the literature
suggests an association between GALT enzyme activity and the long-term
complications, it is of importance to have a highly sensitive assay to
quantify the GALT enzyme activity. To that end, we had developed a
sensitive and accurate LC-MS/MS method to measure GALT enzyme activity.
Its ability to predict outcome is the subject of this report.RESULTS:
The LC-MS/MS method measured GALT activity as low as 0.2%, whereas other methods showed no detectable activity. Largely due to GALT activities that were over 1%, the LC-MS/MS measurements were not significantly different than values obtained in other laboratories using other methodologies. Severe long-term complications were less frequently noted in subjects with >1% activity. Patients with a p.Q188R/p.Q188R genotype have no residual enzyme activity in erythrocytes.CONCLUSION:
Our LC-MS/MS assay may be necessary to accurately quantify residual GALT activities below 5%. The data suggest that patients with >1% residual activity are less likely to develop diet-independent long-term complications. However, much larger sample sizes are needed to properly assess the clinical phenotype in patients with residual enzyme activities between 0.1 and 5%.
The LC-MS/MS method measured GALT activity as low as 0.2%, whereas other methods showed no detectable activity. Largely due to GALT activities that were over 1%, the LC-MS/MS measurements were not significantly different than values obtained in other laboratories using other methodologies. Severe long-term complications were less frequently noted in subjects with >1% activity. Patients with a p.Q188R/p.Q188R genotype have no residual enzyme activity in erythrocytes.CONCLUSION:
Our LC-MS/MS assay may be necessary to accurately quantify residual GALT activities below 5%. The data suggest that patients with >1% residual activity are less likely to develop diet-independent long-term complications. However, much larger sample sizes are needed to properly assess the clinical phenotype in patients with residual enzyme activities between 0.1 and 5%.
6.
Sosicka P, Bazan B, Maszczak-Seneczko D, Shauchuk Y, Olczak T, Olczak M.
Int J Mol Sci. 2019 Jan 11;20(2). pii: E276. doi: 10.3390/ijms20020276.
7.
Lane
WJ, Aguad M, Smeland-Wagman R, Vege S, Mah HH, Joseph A, Blout CL,
Nguyen TT, Lebo MS, Sidhu M, Lomas-Francis C, Kaufman RM, Green RC,
Westhoff CM; MedSeq Project.
Transfusion. 2019 Mar;59(3):908-915. doi: 10.1111/trf.15089. Epub 2018 Dec 28.
(Viite veriryhmätekijöiden joukkoon Veri ja hyytyminen blogiini 2.1. 2020)
(Viite veriryhmätekijöiden joukkoon Veri ja hyytyminen blogiini 2.1. 2020)
8.
Chatterjee SB, Hou J, Bandaru VVR, Pezhouh MK, Syed Rifat Mannan AA, Sharma R.
Biochem Biophys Res Commun. 2019 Jan 8;508(2):380-386. doi: 10.1016/j.bbrc.2018.11.149. Epub 2018 Nov 28.
- PMID:
- 30502090
9.
Zhang Y, Zheng Y, Li J, Nie L, Hu Y, Wang F, Liu H, Fernandes SM, Zhong Q, Li X, Schnaar RL, Jia Y.
Life Sci. 2019 Jan 1;216:189-199. doi: 10.1016/j.lfs.2018.11.049. Epub 2018 Nov 22.
- PMID:
- 30471282
10.
Bilyard MK, Bailey HJ, Raich L, Gafitescu MA, Machida T, Iglésias-Fernández J, Lee SS, Spicer CD, Rovira C, Yue WW, Davis BG.
Nature. 2018 Nov;563(7730):235-240. doi: 10.1038/s41586-018-0644-7. Epub 2018 Oct 24.
- PMID:
- 30356213
11.
Michelet R, Van Bocxlaer J, Allegaert K, Vermeulen A.
J Pharmacokinet Pharmacodyn. 2018 Dec;45(6):765-785. doi: 10.1007/s10928-018-9607-8. Epub 2018 Oct 8.
- PMID:
- 30298439
12.
Seo A, Gulsuner S, Pierce S, Ben-Harosh M, Shalev H, Walsh T, Krasnov T, Dgany O, Doulatov S, Tamary H, Shimamura A, King MC.
Hum Mol Genet. 2019 Jan 1;28(1):133-142. doi: 10.1093/hmg/ddy334.
13.
Kurz J, Brunkhorst R, Foerch C, Blum L, Henke M, Gabriel L, Ulshöfer T, Ferreirós N, Parnham MJ, Geisslinger G, Schiffmann S.
Clin Sci (Lond). 2018 Aug 17;132(17):1963-1976. doi: 10.1042/CS20180506. Print 2018 Sep 14.
In white blood cells, C16-LacCer and
C24-Cer were down-regulated in MS patients in comparison with healthy
controls.
In plasma, C16-Cer, C24:1-Cer, C16-GluCer, and C24:1-GluCer
were up-regulated and
C16-LacCer was down-regulated in MS patients in
comparison with healthy controls.
Blood samples from MS patients were
characterized by an increased B-cell number. However, there was no
correlation between B-cell number and Cer levels. mRNA expression of Cer
metabolizing enzymes and G-CSF signaling enzymes was significantly
increased in MS patients.
Interestingly, G-CSF receptor (G-CSFR) and
CXCR2 mRNA expression correlated with CerS2 and UDP-glucose
Cer glucosyltransferase (UGCG) mRNA expression.
In conclusion, our
results indicate that Cer metabolism is linked to G-CSF signaling in MS.
14.
Yates
TM, Suri M, Desurkar A, Lesca G, Wallgren-Pettersson C, Hammer TB,
Raghavan A, Poulat AL, Møller RS, Thuresson AC, Balasubramanian M.
Eur J Paediatr Neurol. 2018 Nov;22(6):1095-1102. doi: 10.1016/j.ejpn.2018.08.002. Epub 2018 Aug 27.
- PMID:
- 30194038
15.
Hattori T, Watanabe-Takahashi M, Nishikawa K, Naito M.
Biol Pharm Bull. 2018;41(9):1475-1479. doi: 10.1248/bpb.b18-00277.
- PMID:
- 30175782
16.
Klein
MC, Zimmermann K, Schorr S, Landini M, Klemens PAW, Altensell J, Jung
M, Krause E, Nguyen D, Helms V, Rettig J, Fecher-Trost C, Cavalié A,
Hoth M, Bogeski I, Neuhaus HE, Zimmermann R, Lang S, Haferkamp I.
Nat Commun. 2018 Aug 28;9(1):3489. doi: 10.1038/s41467-018-06003-9.
17.
van Weeghel M, Welling L, Treacy EP, Wanders RJA, Ferdinandusse S, Bosch AM.
Orphanet J Rare Dis. 2018 Aug 24;13(1):146. doi: 10.1186/s13023-018-0888-1.
18.
Westenfield K, Sarafoglou K, Speltz LC, Pierpont EI, Steyermark J, Nascene D, Bower M, Pierpont ME.
BMC Med Genet. 2018 Jun 15;19(1):100. doi: 10.1186/s12881-018-0617-6.
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- 29907092
19.
Pierdominici-Sottile G, Cossio-Pérez R, Da Fonseca I, Kizjakina K, Tanner JJ, Sobrado P.
Biochemistry. 2018 Jul 3;57(26):3713-3721. doi: 10.1021/acs.biochem.8b00323. Epub 2018 May 18.
- PMID:
- 29757624
20.
Kaczmarek
R, Szymczak-Kulus K, Bereźnicka A, Mikołajczyk K, Duk M, Majorczyk E,
Krop-Watorek A, Klausa E, Skowrońska J, Michalewska B, Brojer E,
Czerwinski M.
PLoS One. 2018 Apr 30;13(4):e0196627. doi: 10.1371/journal.pone.0196627. eCollection 2018.
Contrary to the mainstream blood group systems, P1PK continues to puzzle
and generate controversies over its molecular background. The P1PK
system comprises three glycosphingolipid antigens: Pk, P1 and NOR, all
synthesised by a glycosyltransferase called Gb3/CD77 synthase. The Pk
antigen is present in most individuals, whereas P1 frequency is lesser
and varies regionally, thus underlying two common phenotypes: P1, if the
P1 antigen is present, and P2, when P1 is absent. Null and NOR
phenotypes are extremely rare.
To date, several single nucleotide
polymorphisms (SNPs) have been proposed to predict the P1/P2 status, but
it has not been clear how important they are in general and in relation
to each other, nor has it been clear how synthesis of NOR affects the
P1 phenotype. Here, we quantitatively analysed the phenotypes and A4GALT
transcription in relation to the previously proposed SNPs in a sample
of 109 individuals, and addressed potential P1 antigen level
confounders, most notably the red cell membrane cholesterol content.
While all the SNPs were associated with the P1/P2 blood type and
rs5751348 was the most reliable, we found large differences in P1 level
within groups defined by their genotype and substantial intercohort
overlaps, which shows that the P1PK blood group system still eludes full
understanding.Free PMC Article
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