Mice Lacking the 110-kD Isoform of Poly(ADP-Ribose) Glycohydrolase Are Protected against Renal Ischemia/Reperfusion Injury
Nimesh S.A. Patel*,
Ulrich Cortes,
Rosanna Di Poala,
Emanuela Mazzon,
Helder Mota-Filipe,
Salvatore Cuzzocrea,
Zhao-Qi Wang and
Christoph Thiemermann*
* Centre for Experimental Medicine, Nephrology & Critical Care, William Harvey Research Institute, Queen Mary, University of London, United Kingdom; Unit of Gene-Environment Interactions, International Agency for Research on Cancer, Lyon, France; Department of Clinical and Experimental Medicine and Pharmacology, University of Messina, Messina, Italy; and Unit of Pharmacology and Pharmacotoxicology, Faculty of Pharmacy, University of Lisbon, Lisbon, Portugal
Address correspondence to: Prof. C. Thiemermann, Centre for Experimental Medicine, Nephrology & Critical Care, William Harvey Research Institute, Queen Mary, University of London, Charterhouse Square, London, EC1M 6BQ, UK. Phone: +44-0-20-7882-6118; Fax: +44-0-20-7251-1685; E-mail: c.thiemermann{at}qmul.ac.uk
The role of poly(ADP-ribose) (PAR) glycohydrolase (PARG) inthe pathophysiology of renal ischemia/reperfusion (I/R) injuryis not known. Poly(ADP-ribosyl)ation is rapidly stimulated incells after DNA damage caused by the generation of reactiveoxygen and nitrogen species during I/R. Continuous or excessiveactivation of poly(ADP-ribose) polymerase-1 produces extendedchains of ADP-ribose on nuclear proteins and results in a substantialdepletion of intracellular NAD+ and subsequently, ATP, leadingto cellular dysfunction and, ultimately, cell death. The keyenzyme involved in polymer turnover is PARG, which possessesmainly exoglycosidase activity but can remove olig(ADP-ribose)fragments via endoglycosidic cleavage. Thus, the aim of thisstudy was to investigate whether the absence of PARG110 reducedthe renal dysfunction, injury, and inflammation caused by I/Rof the mouse kidney. Here, the renal dysfunction and injurycaused by I/R (bilateral renal artery occlusion [30 min] followedby reperfusion [24 h]) in mice lacking PARG110, the major nuclearisoform of PARG, was investigated. The following markers ofrenal dysfunction and injury were measured: Plasma urea, creatinine,aspartate aminotransferase, and histology. The following markersof inflammation were also measured: Myeloperoxidase activity,malondialdehyde levels, and plasma nitrite/nitrate. The degreeof renal injury and dysfunction caused by I/R was significantlyreduced in PARG110-deficient mice when compared with their wild-typelittermates, and there were no differences in any of the biochemicalparameters measured between sham-operated PARG110/mice and sham-operated wild-type littermates. Thus, it is proposedthat endogenous PARG110 plays a pivotal role in the pathophysiologyof I/R injury of the kidney.
Poly(ADP-ribosylation) of proteins in eukaryotic cells is catalyzedby poly(ADP-ribose) polymerases (PARP), regulating many cellularprocesses, such as DNA replication, repair, recombination, cellproliferation, death, gene transcription, and inflammation.Ischemia/reperfusion (I/R) leads to the generation of reactiveoxygen species (ROS) and nitrogen species, which cause single-and double-strand breaks in DNA and, hence, activation of theDNA repair enzyme PARP-1 (E.C. 2.4.2.30). PARP-1 binds rapidlyto strand breaks in DNA and catalyzes the formation of longand branched poly(ADP-ribose) (PAR) polymers on nuclear targetproteins using NAD+ as a substrate (1, 2). Continuous activationof PARP-1 produces extended chains of ADP-ribose on nuclearproteins (including PARP-1 itself), which results in a rapidand substantial depletion of intracellular NAD+ and, subsequently,ATP, leading to cellular dysfunction and, ultimately, cell death(3, 4).
PAR polymers, however, are extremely short-lived in vivo (t1/2,approximately 1 min), being rapidly degraded (2 to 3 min afterPAR formation) by the constitutively active poly(ADP-ribose)glycohydrolase (PARG; E.C. 3.2.1.143). Two isoforms of PARGare ubiquitously expressed, a 110-kD isoform (PARG110), localizedmainly in the nucleus, and a 60-kD isoform (PARG60), localizedin the cytoplasm (5). Although both isoforms exhibit exo- andendoglycosidase activity, PARG110 is the major form of PARGin the nucleus (6, 7).
Inhibitors of PARP activity reduce the tissue injury causedby I/R of the heart (8, 9), brain (10), gut (11), liver (12),and kidney (13). Most notable, the degree of tissue injury causedby I/R in the heart (14), brain (15), gut (16), and most recentlykidney (17) is reduced in mice in which the gene encoding forPARP-1 has been disrupted (PARP-1/ mice). Thesestudies support the view that the excessive activation of PARP-1plays a key role in the pathophysiology of I/R injury. The levelsof PARP-1 and PARG110 proteins seem to be regulated individually(18) but act sequentially and are closely coordinated (19).This may suggest that PARG110 could be a possible therapeutictarget in I/R injury. Two recent studies have demonstrated thatamide-based, DMSO PARG inhibitors attenuate I/R injury of thebrain (GPI 16552) in the rat (20) and the organ injury and inflammationcaused by zymosan (GPI 18214) in the mouse (21).
Thus, it has been suggested that PARG110 contributes to I/Rinjury of many organs, including the kidney. To test this hypothesis,we performed I/R of the kidney in PARG110-deficient mice (PARG110/).We then compared the effects of ischemia and reperfusion onrenal function, injury, and inflammation in PARG110/mice and in their wild-type littermates. Our data demonstratethat PARG110 plays a pivotal role in I/R of the kidney.
Animals
Eighteen male, wild-type mice from a pure genetic background(129/Sv) and 20 male PARG110/ mice (25 to 30 g)were used in this study. PARG110 mice were generated as describedpreviously (6). Genotyping of mice was performed by PCR usingtwo primers located in intron 1 (5`-TCCTTTTATGTAGCTGCCTG-3`and 5`-GGTTAACGTGAGGTTTAAAT-3`) and one primer located in exon4 (5`-CACAAGTTCCACGGAGACCC-3`) of the PARG gene (6). PARG110mice exhibited no signs of gross or microscopic abnormality(6). Mice were allowed access to food and water ad libitum andwere cared for in compliance with French regulations on protectionof animals used for experimental and other scientific purposes,as well as with the European Economic Community regulations(O.J. of E.C. L358/1 12/18/1986).
Renal I/R
Mice were anesthetized using chloral hydrate (125 mg/kg, intraperitoneally),and core body temperature was maintained at 37°C using ahomeothermic blanket. Renal I/R injury was assessed in wild-typeand PARG110 mice. After a midline laparotomy was performed,mice were then divided into the following four groups:
1. I/Rwild-type group: wild-type mice that underwent renalischemiafor 30 min followed by reperfusion for 24 h (n = 8).
2. I/RPARG110 group: PARG110 knockout mice that underwentrenal ischemiafor 30 min followed by reperfusion for 24 h (n= 10).
3. Shamwild-type group: wild-type mice that were subjectedto the surgicalprocedures described above but were not subjectedto renal I/R(n = 10).
4. Sham PARG110 group: PARG110 knockout micethat weresubjected to the surgical procedures described abovebut werenot subjected to renal I/R (n = 10).
.
Mice were maintained under anesthesia for the duration of ischemia(30 min). After a midline laparotomy was performed, mice fromthe I/R groups were subjected to bilateral renal ischemia for30 min, during which the renal arteries and veins were occludedusing microaneurysm clamps (22). The time of ischemia chosenwas based on that found to maximize reproducibility of renalfunctional impairment while minimizing mortality in these animals(22). After the renal clamps were removed, the kidneys wereobserved for an additional 5 min to ensure reflow, after which1 ml of saline at 37°C was injected into the abdomen andthe incision was sutured in two layers. Mice then were returnedto their cages, where they were allowed to recover from anesthesiaand observed for 24 h. Sham-operated mice underwent identicalsurgical procedures to I/R mice, with the exception that microaneurysmclamps were not applied.
Measurement of Biochemical Parameters
At the end of the 24-h reperfusion period, mice were anesthetizedusing chloral hydrate (125 mg/kg, intraperitoneally) and 1-mlblood samples were collected from mice via cardiac puncture.The samples were centrifuged (6000 x g for 3 min) to separateplasma. All plasma samples were frozen and stored at 80°Cand analyzed for biochemical parameters. Plasma urea and creatinineconcentrations were used as indicators of renal (glomerular)dysfunction (22). The rise in the plasma levels of aspartateaminotransferase (AST), an enzyme located in the proximal tubule,was used as an indicator of reperfusion injury (22).
Histologic Evaluation
Kidneys were removed from mice at the end of the experimentalperiod, after the renal pedicle was tied, and cut in a sagittalsection into two halves. These tissue samples were fixed byimmersion in 10% (wt/vol) formaldehyde in PBS (0.01 M; pH 7.4)at room temperature for 1 d. After dehydration using gradedethanol, the tissue was embedded in Paraplast (Sherwood Medical,Mahwah, NJ) and cut in fine (8 µm) sections and mountedon glass slides. Sections then were deparaffinized with xylene,counterstained with hematoxylin and eosin, and viewed undera light microscope (Dialux 22; Leitz, Milan, Italy).
Myeloperoxidase Activity
Myeloperoxidase (MPO) activity in kidney samples was determinedas an index of polymorphonuclear cell (PMN) accumulation, asdescribed previously (22). There is some evidence that boththe MPO and naphthol-AS-D-chloracetate esterase assays can cross-reactwith monocytes and macrophages (23). We recently demonstrated,however, that PMN counts from histologic sections and MPO activitycorrelate positively (24). Kidneys were homogenized in a solutionthat contained 0.5% hexa-decyl-trimethyl-ammonium bromide and10 mM 3-(N-morpholino)-propane-sulfonic acid dissolved in 80mM sodium phosphate buffer (pH 7) and centrifuged for 30 minat 20,000 x g at 4°C. An aliquot of the supernatant thenwas allowed to react with a solution of tetra-methyl-benzidine(16 mM) and 1 mM hydrogen peroxide. The rate of change in absorbancewas measured by a spectrophotometer at 650 nm. MPO activitywas defined as the quantity of enzyme that degraded 1 µmolof peroxide/min at 37°C.
Malondialdehyde Measurement
Malondialdehyde (MDA) levels in kidney samples were determinedas an indicator of lipid peroxidation, as described previously(22). Tissues were homogenized in a 1.15% KCl solution. An aliquotof the homogenate was added to a reaction mixture that contained200 µl of 8.1% SDS, 1500 µl of 20% acetic acid (pH3.5), 1500 µl of 0.8% thiobarbituric acid, and 700 µlof distilled water. The mixture then was boiled for 1 h at 95°Cand centrifuged at 3000 x g for 10 min. The absorbency of thesupernatant was measured by spectrophotometry at 550 nm.
Nitrite/Nitrate Measurement
Nitrate in the plasma was enzymatically converted to nitriteusing a protocol similar to previously described (25). Briefly,nitrate was stoichiometrically reduced to nitrite by incubationof the sample aliquot (50 µl) for 15 min at 37°C inthe presence of nitrate reductase (E.C. 1.6.6.2; 0.1 iu/ml),-NADPH (50 µM), and flavin adenine dinucleotide (FAD;50 µM) in a final volume of 80 µl. When nitratereduction was complete, unused -NADPH, which interferes withthe subsequent nitrite determination, was oxidized by l-lactatedehydrogenase (LDH; 100 IU/ml) and sodium pyruvate (100 mM)in a final reduction volume of 100 µl and incubated for5 min at 37°C. Subsequently, total nitrite in the mediumwas assayed by adding 100 µl of Griess reagent (0.1% [wt/vol]naphthalethylenediamine dihydrochloride in water and 1% [wt/vol]sulfanilamide in 5% [vol/vol] phosphoric acid) to each sample.Optical density at 550 nm (OD550) was measured using a spectrophotometer(Anthos Labtec Microplate Reader HT3, v1.21). Total nitrite/nitrateconcentration for each sample was calculated by comparison ofthe OD550 of a standard solution of sodium nitrate (also stoichiometricallyconverted to nitrite) prepared in ultradistilled water.
Materials
Unless otherwise stated, all compounds used in this study werepurchased from Sigma-Aldrich Company Ltd. (Milan, Italy). Allsolutions used in vivo were prepared using nonpyrogenic saline(0.9% [wt/vol] NaCl).
Statistical Analyses
All values described in the text and the figures are expressedas mean ± SEM for n observations. Each data point representsbiochemical measurements obtained from eight to 10 separateanimals. One-way ANOVA with Bonferroni posttest was performedusing GraphPad Prism version 4.02 for Windows (GraphPad Software,San Diego, CA; www.graphpad.com), and P < 0.05 was consideredto be significant.
Renal Dysfunction (Plasma Urea and Creatinine) in PARG110 Mice
When compared with sham-operated mice, I/R caused a significantincrease in the plasma levels of urea and creatinine in wild-typemice (Figure 1), suggesting a significant degree of renal dysfunction.When compared with wild-type mice that were subjected to I/R,plasma levels of urea and creatinine and, therefore, renal dysfunctionwere significantly lower in PARG110 mice that were subjectedto I/R (Figure 1).
Figure 1. Renal dysfunction in mice with 110-kD isoform of poly(ADP-ribose) glycohydrolase (PARG110). Plasma urea (A) and creatinine levels (B) were measured, from PARG110 mice, as biochemical markers of renal dysfunction subsequent to sham operation (wild-type [WT] sham, n = 10; PARG110 sham, n = 10) or renal ischemia/reperfusion (I/R; WT I/R, n = 8; PARG110 I/R, n = 10). Data represent mean ± SEM for n observations; P < 0.05 versus WT I/R group; +P < 0.05 versus WT sham group.
Reperfusion Injury (Plasma AST) in PARG110 Mice
When compared with sham-operated mice, I/R caused a significantincrease in the plasma level of AST in wild-type mice, suggestingsignificant reperfusion injury (Figure 2). When compared withwild-type mice that were subjected to I/R, the plasma levelof AST and, therefore, reperfusion injury was significantlylower in PARG110 mice that were subjected to I/R (Figure 2),similar to values obtained from sham-operated mice (Figure 2).
Figure 2. Reperfusion injury in PARG110 mice. Plasma aspartate aminotransferase (AST) levels were measured, from PARG110 mice, as a biochemical markers of reperfusion injury subsequent to sham operation (WT sham, n = 10; PARG110 sham, n = 10) or renal I/R (WT I/R, n = 8; PARG I/R, n = 10). Data represent mean ± SEM for n observations; P < 0.05 versus WT I/R group; +P < 0.05 versus WT sham group.
Renal Injury (Histologic Evaluation) in PARG110 Mice
When compared with sham-operated mice (Figure 3A), histologicexamination of kidneys that were obtained from wild-type micethat were subjected to I/R demonstrated a significant degreeof renal injury (Figure 3B). Specifically, kidneys that wereobtained from these animals exhibited degeneration of tubularstructure, tubular dilation, swelling and necrosis, and luminalcongestion. In contrast, renal sections that were obtained fromPARG110 mice that underwent I/R (Figure 3C) demonstrated a markedreduction in the severity of these histologic features of renalinjury when compared with kidneys that were obtained from wild-typemice that were subjected to I/R only (Figure 3B).
Figure 3. Renal injury in PARG110 mice: Histologic examination. A renal section taken from a sham-operated mouse (A) is compared with that of kidney sections prepared from mice that were subjected to ischemia followed by reperfusion for 24 h demonstrated recognized features of renal injury (B), including glomerular degeneration (GD), tubular dilation (TD), and tubular congestion (TC). PARG110 mice that were subjected to I/R (C) displayed reduction in renal injury. Figures are representative of at least three experiments performed on different days. Magnification, x150 (hematoxylin and eosin).
Renal Inflammation (MPO Activity, MDA Levels, and Nitrite/Nitrate Levels) in PARG110 Mice
When compared with sham-operated mice, the kidneys that wereobtained from wild-type mice that were subjected to I/R demonstrateda significant increase in MPO activity (Figure 4A), suggestingincreased PMN infiltration into renal tissues. The increasein the tissue level of MPO seen in PARG110 mice that were subjectedto I/R (Figure 4A) was significantly smaller than those seenin their wild-type littermates that were subjected to I/R.
Figure 4. Renal inflammation in PARG110 mice. Kidney myeloperoxidase (MPO) activity (A) was measured as an indicator of polymorphonuclear cell (PMN) infiltration. Kidney malondialdehyde (MDA) levels (B) were measured as an indicator of lipid peroxidation. Plasma nitrite/nitrate concentrations (C) were measured as an indictor of nitric oxide production. Measurements were performed subsequent to sham operation (WT sham, n = 10; PARG110 sham, n = 10) or renal I/R (WT I/R, n = 8; PARG110 I/R, n = 10). Data represent mean ± SEM for n observations; P < 0.05 versus WT I/R group; +P < 0.05 versus WT sham group.
When compared with sham-operated mice, the kidneys that wereobtained from wild-type mice that were subjected to I/R demonstrateda significant increase in MDA levels (Figure 4B), suggestingincreased lipid peroxidation in renal tissues. The increasein the tissue level of MDA seen in PARG110 mice (Figure 4B)was significantly smaller than those seen in their wild-typelittermates that were subjected to I/R.
When compared with sham-operated mice, the plasma that was obtainedfrom wild-type mice that were subjected to I/R demonstrateda significant increase in nitrite/nitrate levels (Figure 4C),suggesting increased nitric oxide formation. The increase inthe plasma level of nitrite/nitrate seen in PARG110 mice thatwere subjected to I/R (Figure 4C) was significantly smallerthan those seen in their wild-type littermates that were subjectedto I/R. There were no differences in any of the above biochemicalparameters measured between sham-operated PARG110 mice or sham-operatedwild-type littermates (Figures 1, 2, and 4).
Mice that were subjected to renal I/R demonstrated characteristicsigns of renal dysfunction, injury, and inflammation. Specifically,renal I/R caused (1) renal dysfunction (increased plasma creatinineand urea levels), (2) reperfusion injury (increased plasma ASTlevels), (3) characteristic histologic signs of marked tubularinjury, (4) PMN infiltration (increased MPO activity), (5) lipidperoxidation (increased MDA levels), and (6) nitric oxide formation(increased plasma nitrite/nitrate levels). All of these dataconfirmed a well-known pattern of renal dysfunction and injurycaused by I/R of the kidney (2628) and that renal I/Rcauses both renal and tubular dysfunction (29). We show herefor the first time that inhibition of PARG110 via genetic disruptioncan attenuate the injury, dysfunction, and inflammation causedby renal I/R in the mouse.
In 1997, we demonstrated for the first time that inhibitorsof PARP activity reduce the tissue injury associated with I/Rof the heart and skeletal muscle in vivo. We therefore proposedthat the activation of PARP contributes to the pathophysiologyof I/R injury (30). In 1999, we demonstrated that activationof PARP mediates the cell death caused by hydrogen peroxidein cultured proximal tubule cells. On the basis of this work,we proposed that the excessive activation of PARP plays a rolein the pathophysiology of renal disorders associated with oxidantstress (31). In 2000, we (32) and others (33) reported thatinhibitors of PARP activity reduce the tissue injury causedby I/R of the kidney. What is the role of PARP-1 in cell injury?Exposure of cells to oxidants such as superoxide, hydrogen peroxide,and nitric oxide leads to the subsequent generation of hydroxylradicals and peroxynitrite, which causes DNA damage within seconds,leading to excessive activation of PARP-1 (34, 35). Excessiveactivation of PARP-1 results in the subsequent depletion ofNAD+ pools within minutes, the main consequence of which isATP depletion (36). NAD+ is an essential co-factor in glycolysis.It is required for the production of 1,3-diphosphoglyceratefrom inorganic phosphate and glyceraldehyde-3-phosphate. NAD+is also required in fatty acid oxidation, which therefore isalso affected by PARP-1 activation (37). In addition, ATP isconsumed in the resynthesis of NAD+ from nicotinamide-releasedADP-ribosylation (38). Treatment with PARP inhibitors, suchas 3-aminobenzimide, does not affect the development of DNAstrand breaks but does block NAD+ and ATP depletion, improvingcell viability (34, 39). Studies on PARP-1 mice have also supportedthe role of PARP-1 in oxidant-mediated cell injury. Pulmonaryepithelial cells from PARP-1 mice are more resistant to ROS-mediatedinjury when compared with wild-type littermates (40), as arepancreatic islet cells against nitric oxide-mediated injury(41). Although cellular suicide may seem drastic, it representsa physiologic mechanism by which cells with severe DNA damageare eliminated. The "suicide hypothesis" is a safety mechanismthat prevents cells with severe DNA damage from attempting ineffectuallyto repair themselves and consequently surviving with high mutationfrequency. This reduces the likelihood of cells survivingwith highly mutant phenotypes and therefore reduces the potentialfor malignant transformation.
The pharmacologic tools that are available to study the roleof PARG in disease models are very limited, but some syntheticand nonsynthetic PARG inhibitors are available. In 2001, Yinget al. (42) used hydrolyzable tannins such as gallotannin (extractedfrom green tea and pine cones) and nobotanin B (extracted fromthe plant Tibouchina semidecandra Cogn.) to investigate theirbeneficial effects in PARP-mediated neuronal cell death. Thesecompounds are able to inhibit PARG by competing with PAR atbinding sites on PARG. They demonstrated that these naturalPARG inhibitors are unable to inhibit PARP-1 directly but bypreventing PARP-1-mediated cell death by slowing the turnoverof PAR and thus limiting NAD+ consumption (42). However, itis possible that (at least some) of the observed beneficialeffects of these agents are due to nonspecific effects. Forinstance, Falsig et al. (43) reported that the cytoprotectiveproperties of gallotannin were not due to the inhibition ofPARG but secondary to the ability of gallotannin to scavengeROS. In fact, gallotannin enhanced the damage in astrocytesassociated with the nonoxidative DNA-damaging agent N-methyl-N`-nitro-N-nitrosoguanidine.In the same study, the authors looked at the synthetic PARGinhibitor GPI 16552, which was shown recently to be protectivein a model of brain I/R (20). It was found that GPI 16552 hadno effect on astrocyte death models, and the maximal inhibitionof PARG achieved with GPI 16552 was only 40% (43). It was concludedthat neither GPI 16552 nor gallotannin is suitable for the evaluationof PARG in cellular death models and that any previous conclusionsdrawn from the use of these compounds should be interpretedwith caution (43).
The use of genetically modified mice has advanced our knowledgeof mechanisms that are involved in conditions such as I/R ofthe kidney (44). This study uses, for the first time, mice deficientfor PARG110 in a model of I/R. There is currently little knownon the phenotype of the PARG110 mice, but from what is known,there seem to be no abnormalities in phenotype (6). It has beenshown in the kidney that the specific activity of PARG in PARG110mice is attenuated by 74% compared with wild-type littermates(6), suggesting almost complete PARG inactivity in the kidney.However, these PARG110 mutant mice are highly sensitive to alkylatingagents, ionizing radiation, streptozotocin-induced diabetes,and endotoxic shock, which is most likely due to dysregulationof nuclear poly(ADP-ribosyl)ation (6). PARP-1 mice, however,have been shown to be protected in conditions associated withendotoxic shock (45, 46). This contradiction was attributedto reduced NAD+ biosynthesis resulting in a slower turnoverof ADP-ribose in PARG110 mice. This dysregulation of nuclearpoly(ADP-ribosyl)ation, however, seems to benefit the conditionof renal I/R injury here, which is somewhat surprising as wewould expect, from previous findings, to be much worse. In particular,it has been shown that disturbed PARP/PARG balance (overexpressionof PARP-1) reduces cell survival after DNA damage in mammaliancells (47).
We show here that not only renal injury is attenuated but alsoneutrophil infiltration, lipid peroxidation, and nitric oxideformation (all hallmarks of an inflammatory response) causedby I/R are attenuated in PARG110 mice. This finding supportsthe hypothesis postulated by Genovese et al. (21) that earlyROS production causes PARP/PARG-related endothelial injury,thus leading to neutrophil infiltration, cytokine release, andfinally organ injury. The inhibition of PARG activity in thiscycle, therefore, would prevent endothelial injury in the kidneyand subsequent tissue injury caused by the infiltration of neutrophils,as shown by this study.
We have demonstrated that endogenous PARG110 plays a role inthe injury, dysfunction, and inflammation in a mouse model ofrenal I/R injury. We therefore propose that potent, specific,and water-soluble inhibitors of PARG activity may be helpfulin conditions associated with I/R of the kidney.
Acknowledgments
N.S.A.P. and this work were supported by a Ph.D.-Studentshipof the William Harvey Research Foundation. U.C. was funded bya grant from Ligne Nationale Contre le Cancer
Footnotes
Published online ahead of print. Publication date availableat www.jasn.org.
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Received for publication August 17, 2004.
Accepted for publication December 13, 2004.
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