Skip to main content
Erschienen in: Clinical and Experimental Nephrology 5/2010

01.10.2010 | Original Article

Progression of cyclophosphamide-induced acute renal metabolic damage in carnitine-depleted rat model

verfasst von: Mohamed M. Sayed-Ahmed

Erschienen in: Clinical and Experimental Nephrology | Ausgabe 5/2010

Einloggen, um Zugang zu erhalten

Abstract

Background

Little information is available regarding the mechanism of cyclophosphamide (CP)-induced renal damage. Therefore, this study examined whether carnitine deficiency constitutes a risk factor in and should be viewed as a mechanism during development of CP-induced nephrotoxicity and explored whether carnitine supplementation, using propionyl-l-carnitine (PLC), could offer protection against this toxicity.

Methods

Experimental rats were assigned to one of six groups; the first three groups were injected intraperitoneally with normal saline, PLC (250 mg/kg/day) or d-carnitine (250 mg/kg/day) + Mildronate (200 mg/kg/day), respectively, for 10 successive days. The 4th, 5th and 6th groups received the same doses of normal saline, PLC or d-carnitine + Mildronate, respectively, for 5 successive days before and after a single dose of CP (200 mg/kg).

Results

CP significantly increased serum creatinine, blood urea nitrogen (BUN), intramitochondrial acetyl-coenzyme A (CoA) and thiobarbituric acid reactive substances, significantly decreased total carnitine, intramitochondrial CoA-SH, adenosine triphosphate (ATP) and ATP/adenosine diphosphate (ADP) and reduced glutathione in kidney tissues. In carnitine-depleted rats, CP resulted in dramatic increase in serum nephrotoxicity indices and acetyl-CoA and induced progressive reduction in total carnitine, CoA-SH and ATP as well as severe histopathological lesions in kidney tissues. Interestingly, PLC completely reversed the biochemical and histopathological changes induced by CP to normal values.

Conclusions

Oxidative stress is not involved in CP-induced renal injury in this model. Carnitine deficiency and energy starvation constitute risk factors in and should be viewed as a mechanism during CP-induced nephrotoxicity. PLC prevents development of CP-induced nephrotoxicity by increasing intracellular carnitine content, intramitochondrial CoA-SH/acetyl-CoA ratio and energy production.
Literatur
1.
Zurück zum Zitat Preiss R, Baumann F. Cyclophosphamide and related anticancer drugs. J Chromatogr B Biomed Sci Appl. 2001;764:173–92.CrossRefPubMed Preiss R, Baumann F. Cyclophosphamide and related anticancer drugs. J Chromatogr B Biomed Sci Appl. 2001;764:173–92.CrossRefPubMed
2.
Zurück zum Zitat Murphy SB, Bowman WP, Abromowitch M, Mirro J, Ochs J, Rivera G, et al. Results of treatment of advanced-stage Burkitt’s lymphoma and B cell (SIg+) acute lymphoblastic leukemia with high-dose fractionated cyclophosphamide and coordinated high-dose methotrexate and cytarabine. J Clin Oncol. 1986;4:1732–9.PubMed Murphy SB, Bowman WP, Abromowitch M, Mirro J, Ochs J, Rivera G, et al. Results of treatment of advanced-stage Burkitt’s lymphoma and B cell (SIg+) acute lymphoblastic leukemia with high-dose fractionated cyclophosphamide and coordinated high-dose methotrexate and cytarabine. J Clin Oncol. 1986;4:1732–9.PubMed
3.
Zurück zum Zitat Luo XO, Mo Y, Ke ZY, Xu L, Jiang XY, Zhang TT, et al. High-dose chemotherapy without stem cell transplantation for refractory childhood systemic lupus erythematosus. Chemotherapy. 2008;54:331–5.CrossRefPubMed Luo XO, Mo Y, Ke ZY, Xu L, Jiang XY, Zhang TT, et al. High-dose chemotherapy without stem cell transplantation for refractory childhood systemic lupus erythematosus. Chemotherapy. 2008;54:331–5.CrossRefPubMed
4.
Zurück zum Zitat Nissim I, Weinberg JM. Glycine attenuates maleate or ifosfamide induced Fanconi syndrome in rats. Kidney Int. 1996;49:684–95.CrossRefPubMed Nissim I, Weinberg JM. Glycine attenuates maleate or ifosfamide induced Fanconi syndrome in rats. Kidney Int. 1996;49:684–95.CrossRefPubMed
5.
Zurück zum Zitat Badary OA. Thymoquinone attenuates ifosfamide-induced Fanconi syndrome in rats and enhances its antitumor activity in mice. J Ethnopharmacol. 1999;67:135–42.CrossRefPubMed Badary OA. Thymoquinone attenuates ifosfamide-induced Fanconi syndrome in rats and enhances its antitumor activity in mice. J Ethnopharmacol. 1999;67:135–42.CrossRefPubMed
6.
Zurück zum Zitat Nissim I, Horyn O, Daikhin Y, Nissim I, Luhovyy B, Phillips BC, et al. Ifosfamide-induced nephrotoxicity: mechanism and prevention. Cancer Res. 2006;66:7824–31.CrossRefPubMed Nissim I, Horyn O, Daikhin Y, Nissim I, Luhovyy B, Phillips BC, et al. Ifosfamide-induced nephrotoxicity: mechanism and prevention. Cancer Res. 2006;66:7824–31.CrossRefPubMed
7.
Zurück zum Zitat Yaseen Z, Michoudet C, Baverel G, Dubourg L. Mechanisms of the ifosfamide-induced inhibition of endocytosis in the rat proximal kidney tubule. Arch Toxicol. 2008;82:607–14.CrossRefPubMed Yaseen Z, Michoudet C, Baverel G, Dubourg L. Mechanisms of the ifosfamide-induced inhibition of endocytosis in the rat proximal kidney tubule. Arch Toxicol. 2008;82:607–14.CrossRefPubMed
8.
Zurück zum Zitat Mizushima Y, Sassa K, Hamazaki T, Fujishita T, Oosaki R, Kobayashi M. Diuretic response to cyclophosphamide in rats bearing a matrix metalloproteinase-9-producing tumour. BJC. 1998;78:1030–4.PubMed Mizushima Y, Sassa K, Hamazaki T, Fujishita T, Oosaki R, Kobayashi M. Diuretic response to cyclophosphamide in rats bearing a matrix metalloproteinase-9-producing tumour. BJC. 1998;78:1030–4.PubMed
9.
Zurück zum Zitat Stankiewicz A, Skrzydlewska E. Protection against cyclophosphamide-induced renal oxidative stress by amifostine: the role of antioxidative mechanisms. Toxicol Mech Methods. 2003;13:301–8.CrossRefPubMed Stankiewicz A, Skrzydlewska E. Protection against cyclophosphamide-induced renal oxidative stress by amifostine: the role of antioxidative mechanisms. Toxicol Mech Methods. 2003;13:301–8.CrossRefPubMed
10.
Zurück zum Zitat Abraham P, Indirani K, Sugumar E. Effect of cyclophosphamide treatment on selected lysosomal enzymes in the kidney of rats. Exp Toxicol Pathol. 2007;59:143–9.CrossRefPubMed Abraham P, Indirani K, Sugumar E. Effect of cyclophosphamide treatment on selected lysosomal enzymes in the kidney of rats. Exp Toxicol Pathol. 2007;59:143–9.CrossRefPubMed
11.
Zurück zum Zitat Abraham P, Sugumar E. Enhanced PON1 activity in the kidneys of cyclophosphamide treated rats may play a protective role as an antioxidant against cyclophosphamide induced oxidative stress. Arch Toxicol. 2008;82:237–8.CrossRefPubMed Abraham P, Sugumar E. Enhanced PON1 activity in the kidneys of cyclophosphamide treated rats may play a protective role as an antioxidant against cyclophosphamide induced oxidative stress. Arch Toxicol. 2008;82:237–8.CrossRefPubMed
12.
Zurück zum Zitat Abraham P, Rabi S. Nitrosative stress, protein tyrosine nitration, PARP activation and NAD depletion in the kidneys of rats after single dose of cyclophosphamide. Clin Exp Nephrol. 2009;13:281–7.CrossRefPubMed Abraham P, Rabi S. Nitrosative stress, protein tyrosine nitration, PARP activation and NAD depletion in the kidneys of rats after single dose of cyclophosphamide. Clin Exp Nephrol. 2009;13:281–7.CrossRefPubMed
13.
Zurück zum Zitat Ayhanci A, Günes S, Sahinturk V, Appak S, Uyar R, Cengiz M, et al. Seleno l-methionine acts on cyclophosphamide-induced kidney toxicity. Biol Trace Elem Res. 2009;136(2):171–9.CrossRefPubMed Ayhanci A, Günes S, Sahinturk V, Appak S, Uyar R, Cengiz M, et al. Seleno l-methionine acts on cyclophosphamide-induced kidney toxicity. Biol Trace Elem Res. 2009;136(2):171–9.CrossRefPubMed
14.
Zurück zum Zitat Fatani AG, Darweesh AQ, Rizwan L, Aleisa AM, Al-Shabanah OA, Sayed-Ahmed MM. Carnitine deficiency aggravates cyclophosphamide-induced cardiotoxicity in rats. Chemotherapy. 2010;56:71–81.CrossRefPubMed Fatani AG, Darweesh AQ, Rizwan L, Aleisa AM, Al-Shabanah OA, Sayed-Ahmed MM. Carnitine deficiency aggravates cyclophosphamide-induced cardiotoxicity in rats. Chemotherapy. 2010;56:71–81.CrossRefPubMed
15.
Zurück zum Zitat Kerner J, Hoppel C. Fatty acid import into mitochondria. Biochim Biophys Acta. 2000;1486:1–17.PubMed Kerner J, Hoppel C. Fatty acid import into mitochondria. Biochim Biophys Acta. 2000;1486:1–17.PubMed
16.
Zurück zum Zitat Mancinelli A, Longo A, Shanahan K, Evans AM. Disposition of l-carnitine and acetyl-l-carnitine in the isolated perfused rat kidney. J Pharmacol Exp Ther. 1995;274:1122–8.PubMed Mancinelli A, Longo A, Shanahan K, Evans AM. Disposition of l-carnitine and acetyl-l-carnitine in the isolated perfused rat kidney. J Pharmacol Exp Ther. 1995;274:1122–8.PubMed
17.
Zurück zum Zitat Paulson DJ, Shug AL. Tissue specific depletion of l-carnitine in rat heart and skeletal muscle by d-carnitine. Life Sci. 1981;28:2931–8.CrossRefPubMed Paulson DJ, Shug AL. Tissue specific depletion of l-carnitine in rat heart and skeletal muscle by d-carnitine. Life Sci. 1981;28:2931–8.CrossRefPubMed
18.
Zurück zum Zitat Whitmer JT. l-carnitine treatment improves cardiac performance and restores high energy phosphate pools in cardiomyopathic Syrian hamster. Circ Res. 1987;61:396–408.PubMed Whitmer JT. l-carnitine treatment improves cardiac performance and restores high energy phosphate pools in cardiomyopathic Syrian hamster. Circ Res. 1987;61:396–408.PubMed
19.
Zurück zum Zitat Tsoko M, Beau-Seigneur F, Greste J, Niot I, Demarquoy J, Biochot J, et al. Enhancement of activities relative to fatty acid oxidation in the liver of rats depleted of l-carnitine by d-carnitine and a γ-butyrobetaine hydroxylase inhibitor. Biochem Pharmacol. 1995;49:1403–10.CrossRefPubMed Tsoko M, Beau-Seigneur F, Greste J, Niot I, Demarquoy J, Biochot J, et al. Enhancement of activities relative to fatty acid oxidation in the liver of rats depleted of l-carnitine by d-carnitine and a γ-butyrobetaine hydroxylase inhibitor. Biochem Pharmacol. 1995;49:1403–10.CrossRefPubMed
20.
Zurück zum Zitat Kuwajima M, Harashima H, Hayashi M, Ise S, Sei M, Lu K, et al. Pharmacokinetic analysis of the cardioprotective effect of 3-(2, 2, 2-trimethylhydrazinium) propionate in mice: inhibition of carnitine transport in kidney. J Pharmacol Exp Ther. 1999;289:93–102.PubMed Kuwajima M, Harashima H, Hayashi M, Ise S, Sei M, Lu K, et al. Pharmacokinetic analysis of the cardioprotective effect of 3-(2, 2, 2-trimethylhydrazinium) propionate in mice: inhibition of carnitine transport in kidney. J Pharmacol Exp Ther. 1999;289:93–102.PubMed
21.
Zurück zum Zitat Spaniol M, Brooks H, Auer L, Zimmermann A, Solioz M, Stieger B, et al. Development and characterization of an animal model of carnitine deficiency. Eur J Biochem. 2001;268:1876–87.CrossRefPubMed Spaniol M, Brooks H, Auer L, Zimmermann A, Solioz M, Stieger B, et al. Development and characterization of an animal model of carnitine deficiency. Eur J Biochem. 2001;268:1876–87.CrossRefPubMed
22.
Zurück zum Zitat Peschechera A, Scalibastri M, Russo F, Giarrizzo MG, Carminati P, Giannessi F, et al. Carnitine depletion in rat pups from mothers given mildronate: a model of carnitine deficiency in late fetal and neonatal life. Life Sci. 2005;77:3078–91.CrossRefPubMed Peschechera A, Scalibastri M, Russo F, Giarrizzo MG, Carminati P, Giannessi F, et al. Carnitine depletion in rat pups from mothers given mildronate: a model of carnitine deficiency in late fetal and neonatal life. Life Sci. 2005;77:3078–91.CrossRefPubMed
23.
Zurück zum Zitat Tobacco A, Meiattini F, Moda E, Tarii P. Simplified enzymic/colorimetric serum urea nitrogen determination. Clin Chem. 1979;25:336–7. Tobacco A, Meiattini F, Moda E, Tarii P. Simplified enzymic/colorimetric serum urea nitrogen determination. Clin Chem. 1979;25:336–7.
24.
Zurück zum Zitat Fabiny DL, Ertingshausen G. Automated reaction-rate method for determination of serum creatinine with the Centrifichem. Clin Chem. 1971;17:696–700.PubMed Fabiny DL, Ertingshausen G. Automated reaction-rate method for determination of serum creatinine with the Centrifichem. Clin Chem. 1971;17:696–700.PubMed
26.
Zurück zum Zitat Ohkawa H, Ohish N, Yagi K. Assay for lipid peroxides in animal tissues by thiobarbituric acid. Anal Biochem. 1979;95:351–8.CrossRefPubMed Ohkawa H, Ohish N, Yagi K. Assay for lipid peroxides in animal tissues by thiobarbituric acid. Anal Biochem. 1979;95:351–8.CrossRefPubMed
27.
Zurück zum Zitat Botker HE, Kimose M, Helligso P, Nielsen TT. Analytical evaluation of high-energy phosphate determination by high performance liquid chromatography in myocardial tissue. J Mol Cell Cardiol. 1994;26:41–8.CrossRefPubMed Botker HE, Kimose M, Helligso P, Nielsen TT. Analytical evaluation of high-energy phosphate determination by high performance liquid chromatography in myocardial tissue. J Mol Cell Cardiol. 1994;26:41–8.CrossRefPubMed
28.
Zurück zum Zitat Prieto JA, Andrade F, Aldmiz-Echevarra L, Sanjurjo P. Determination of free and total carnitine in plasma by an enzymatic reaction and spectrophotometric quantitation spectrophotometric determination of carnitine. Clin Biochem. 2006;39:1022–7.CrossRefPubMed Prieto JA, Andrade F, Aldmiz-Echevarra L, Sanjurjo P. Determination of free and total carnitine in plasma by an enzymatic reaction and spectrophotometric quantitation spectrophotometric determination of carnitine. Clin Biochem. 2006;39:1022–7.CrossRefPubMed
29.
Zurück zum Zitat Bradford MM. A rapid and sensitive method for the quantitation of microgram quantities of protein utilizing the principle of protein-dye binding. Anal Biochem. 1976;72:248–54.CrossRefPubMed Bradford MM. A rapid and sensitive method for the quantitation of microgram quantities of protein utilizing the principle of protein-dye binding. Anal Biochem. 1976;72:248–54.CrossRefPubMed
30.
Zurück zum Zitat Lysiak W, Lilly K, DiLisa F, Toth PP, Bieber LL. Quantitation of the effect of l-carnitine on the levels of acid-soluble short-chain acyl-CoA and CoASH in rat heart and liver mitochondria. J Biol Chem. 1988;263:1151–6.PubMed Lysiak W, Lilly K, DiLisa F, Toth PP, Bieber LL. Quantitation of the effect of l-carnitine on the levels of acid-soluble short-chain acyl-CoA and CoASH in rat heart and liver mitochondria. J Biol Chem. 1988;263:1151–6.PubMed
31.
Zurück zum Zitat Senthilkumar S, Devaki T, Manohar BM, Babu MS. Effect of squalene on cyclophosphamide-induced toxicity. Clin Chim Acta. 2006;364:335–42.CrossRefPubMed Senthilkumar S, Devaki T, Manohar BM, Babu MS. Effect of squalene on cyclophosphamide-induced toxicity. Clin Chim Acta. 2006;364:335–42.CrossRefPubMed
32.
Zurück zum Zitat Ahmed S, Thomas H, Golper TA, Wolfson M, Kurtin P, Katz LA, et al. Multi-center trial of l-carnitine in maintenance hemodialysis patients II. Clinical and biochemical effects. Kidney Int. 1990;38:912–8.CrossRef Ahmed S, Thomas H, Golper TA, Wolfson M, Kurtin P, Katz LA, et al. Multi-center trial of l-carnitine in maintenance hemodialysis patients II. Clinical and biochemical effects. Kidney Int. 1990;38:912–8.CrossRef
33.
Zurück zum Zitat Marthaler NP, Visarius T, Küpfer A, Lauterburg BH. Increased urinary losses of carnitine during ifosfamide chemotherapy. Cancer Chemother Pharmacol. 1999;44:170–2.CrossRefPubMed Marthaler NP, Visarius T, Küpfer A, Lauterburg BH. Increased urinary losses of carnitine during ifosfamide chemotherapy. Cancer Chemother Pharmacol. 1999;44:170–2.CrossRefPubMed
34.
Zurück zum Zitat Heuberger W, Berardi S, Jacky E, Pey P, Krahenbuhl S. Increased urinary excretion of carnitine in patients treated with cisplatin. Eur J Clin Pharmacol. 1998;54:503–8.CrossRefPubMed Heuberger W, Berardi S, Jacky E, Pey P, Krahenbuhl S. Increased urinary excretion of carnitine in patients treated with cisplatin. Eur J Clin Pharmacol. 1998;54:503–8.CrossRefPubMed
35.
Zurück zum Zitat Arafa HM. Carnitine deficiency aggravates carboplatin nephropathy through deterioration of energy status, oxidant/anti-oxidant balance, and inflammatory endocoids. Toxicol. 2008;254:51–60.CrossRef Arafa HM. Carnitine deficiency aggravates carboplatin nephropathy through deterioration of energy status, oxidant/anti-oxidant balance, and inflammatory endocoids. Toxicol. 2008;254:51–60.CrossRef
36.
Zurück zum Zitat Sayed-Ahmed MM, Eissa MA, Kenawy SA, Mostafa N, Calvani M, Osman AM. Progression of cisplatin-induced nephrotoxicity in a carnitine-depleted rat model. Chemotherapy. 2004;50:162–70.CrossRefPubMed Sayed-Ahmed MM, Eissa MA, Kenawy SA, Mostafa N, Calvani M, Osman AM. Progression of cisplatin-induced nephrotoxicity in a carnitine-depleted rat model. Chemotherapy. 2004;50:162–70.CrossRefPubMed
37.
Zurück zum Zitat Al-Shabanah OA, Aleisa AM, Al-Yahya AA, Al-Rejaie SS, Bakheet SA, Fatani AG, et al. Increased urinary losses of carnitine and decreased intramitochondrial coenzyme A in gentamicin-induced acute renal failure in rats. Nephrol Dial Transplant. 2010;25:69–76.CrossRefPubMed Al-Shabanah OA, Aleisa AM, Al-Yahya AA, Al-Rejaie SS, Bakheet SA, Fatani AG, et al. Increased urinary losses of carnitine and decreased intramitochondrial coenzyme A in gentamicin-induced acute renal failure in rats. Nephrol Dial Transplant. 2010;25:69–76.CrossRefPubMed
38.
Zurück zum Zitat Steiber A, Kerner J, Hoppel CL. Carnitine: a nutritional, biosynthetic, and functional perspective. Mol Aspects Med. 2004;25:455–73.CrossRefPubMed Steiber A, Kerner J, Hoppel CL. Carnitine: a nutritional, biosynthetic, and functional perspective. Mol Aspects Med. 2004;25:455–73.CrossRefPubMed
39.
Zurück zum Zitat Abdel-aleem S, Nada MA, Sayed-Ahmed MM, Hendrickson SC, St Louis J, Walthall HP, et al. Regulation of fatty acid oxidation by acetyl-CoA generated from glucose utilization in isolated myocytes. J Mol Cell Cardiol. 1996;28:825–33.CrossRefPubMed Abdel-aleem S, Nada MA, Sayed-Ahmed MM, Hendrickson SC, St Louis J, Walthall HP, et al. Regulation of fatty acid oxidation by acetyl-CoA generated from glucose utilization in isolated myocytes. J Mol Cell Cardiol. 1996;28:825–33.CrossRefPubMed
40.
Zurück zum Zitat Dayanandan A, Kumar P, Panneerselvam C. Protective role of l-carnitine on liver and heart lipid peroxidation in atherosclerotic rats. J Nutr Biochem. 2001;12:254–7.CrossRefPubMed Dayanandan A, Kumar P, Panneerselvam C. Protective role of l-carnitine on liver and heart lipid peroxidation in atherosclerotic rats. J Nutr Biochem. 2001;12:254–7.CrossRefPubMed
41.
Zurück zum Zitat Sayed-Ahmed MM, Khattab MM, Gad MZ, Mostafa N. l-carnitine prevents the progression of atherosclerotic lesions in hypercholesterolaemic rabbits. Pharmacol Res. 2001;44:235–42.CrossRefPubMed Sayed-Ahmed MM, Khattab MM, Gad MZ, Mostafa N. l-carnitine prevents the progression of atherosclerotic lesions in hypercholesterolaemic rabbits. Pharmacol Res. 2001;44:235–42.CrossRefPubMed
42.
Zurück zum Zitat Sayed-Ahmed MM, Mansour HH, Gharib OA, Hafez HF. Acetyl-l-carnitine modulates bleomycin-induced oxidative stress and energy depletion in lung tissues. J Egypt Natl Cancer Inst. 2004;16:237–43. Sayed-Ahmed MM, Mansour HH, Gharib OA, Hafez HF. Acetyl-l-carnitine modulates bleomycin-induced oxidative stress and energy depletion in lung tissues. J Egypt Natl Cancer Inst. 2004;16:237–43.
43.
Zurück zum Zitat Al-Majed AA, Sayed-Ahmed MM, Al-Yahya AA, Aleisa AM, Al-Rejaie SS, Al-Shabanah OA. Propionyl-l-carnitine prevents the progression of cisplatin-induced cardiomyopathy in a carnitine-depleted rat model. Pharmacol Res. 2006;53:278–86.CrossRefPubMed Al-Majed AA, Sayed-Ahmed MM, Al-Yahya AA, Aleisa AM, Al-Rejaie SS, Al-Shabanah OA. Propionyl-l-carnitine prevents the progression of cisplatin-induced cardiomyopathy in a carnitine-depleted rat model. Pharmacol Res. 2006;53:278–86.CrossRefPubMed
44.
Zurück zum Zitat Al-Rejaie SS, Aleisa AM, Al-Yahya AA, Bakheet SA, Alsheikh A, Fatani AG, et al. Progression of diethylnitrosamine-induced hepatic carcinogenesis in carnitine-depleted rats. World J Gastroenterol. 2009;15:1373–80.CrossRefPubMed Al-Rejaie SS, Aleisa AM, Al-Yahya AA, Bakheet SA, Alsheikh A, Fatani AG, et al. Progression of diethylnitrosamine-induced hepatic carcinogenesis in carnitine-depleted rats. World J Gastroenterol. 2009;15:1373–80.CrossRefPubMed
Metadaten
Titel
Progression of cyclophosphamide-induced acute renal metabolic damage in carnitine-depleted rat model
verfasst von
Mohamed M. Sayed-Ahmed
Publikationsdatum
01.10.2010
Verlag
Springer Japan
Erschienen in
Clinical and Experimental Nephrology / Ausgabe 5/2010
Print ISSN: 1342-1751
Elektronische ISSN: 1437-7799
DOI
https://doi.org/10.1007/s10157-010-0321-0

Weitere Artikel der Ausgabe 5/2010

Clinical and Experimental Nephrology 5/2010 Zur Ausgabe

Leitlinien kompakt für die Innere Medizin

Mit medbee Pocketcards sicher entscheiden.

Seit 2022 gehört die medbee GmbH zum Springer Medizin Verlag

Update Innere Medizin

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.