Correlation between Hepcidin and Ferritin with Insulin and Hba1C

as Biochemical Markers of Pancreas Damage in β-Thalassemia

Patients

Irbath Hamdani

, Qodri Santosa

Joko Setyono

, Hernayanti

, and Lantip Rujito

Department of Molecular Biology, Faculty of Medicine, Universitas Jenderal Soedirman, Purwokerto, Indonesia

Department of Pediatrics, Faculty of Medicine, Universitas Jenderal Soedirman, Purwokerto, Indonesia

Department of Biochemistry, Faculty of Medicine, Universitas Jenderal Soedirman, Purwokerto, Indonesia

Department of Biochemistry, Faculty of Biology, Universitas Jenderal Soedirman, Purwokerto, Indonesia

Keywords: Hepcidin, Ferritin, Insulin, HbA1c, β-thalassemia

Abstract: Iron overload in β-thalassemia patients can damage various organs, including the pancreas. Impairment of the

pancreas will be causing the failure and reduces insulin secretion, contributing to impaired glucose

metabolism to diabetes mellitus in patients with β-thalassemia. This study analysed the correlation between

hepcidin and ferritin levels as markers of iron overload with insulin levels and HbA1c as markers of pancreatic

damage in patients with β thalassemia. Subjects of 35 thalassemia β patients were included in a cross-sectional

study. Hepcidin, insulin, and HbA1c data were measured using the ELISA method. Ferritin data obtained

through patient medical records. Bivariate analysis is using the Pearson test.: There were 97.1% of subjects

with low hepcidin levels, whereas the ferritin data were in the high category. The data showed that 88.6% of

subjects had low insulin levels. Most of the subjects (85.7%) were in the low category of HbA1c levels.

Pearson test had a p-value = 0.001 which it indicates a significant relationship between hepcidin and insulin

(r=0.771) and HbA1c (r=0.849). However, the ferritin levels showed no significant relationship with insulin

(p=0.785 ; r=0.057) and HbA1c (p=0.420 ; r=0.169). In conclusion, the study found the lower the hepcidin

level, the lower the insulin and HbA1c levels. Ferritin levels do not have a significant relationship with insulin

and HbA1c levels.

1 INTRODUCTION

Thalassemia is a hereditary disorder syndrome caused

by mutations in the globin gene that decrease or do

not produce one or more globin chains (Origa, 2017;

Soteriades and Weatherall, 2014). The International

Thalassemia Foundation data shows that 7% of the

world’s population are carriers of thalassemia traits,

and most of them are in developing countries.

Indonesia, one of the endemic countries, has a high

frequency of the β thalassemia gene with a rate of 3-

10% (Rujito et al., 2015).

β thalassemia patients have decreased β globin

chain synthesis, leading to a faster hemolysis process.

https://orcid.org/0000-0002-1147-7846

https://orcid.org/0000-0001-7712-2549

https://orcid.org/0000-0003-0843-5298

https://orcid.org/0000-0002-3468-7563

https://orcid.org/0000-0001-6595-3265

Patients then require repeat transfusions every 4-6

weeks to maintain total erythrocytes and

haemoglobin levels than 10g/dL. However, these

long-term transfusions can cause iron overload

(Vasudev and Sawhney, 2014). Hepcidin, the main

protein acting as a negative regulator of iron,

decreased due to ineffective erythropoietic activity.

The decreased hepcidin levels can increase iron

absorption in the intestine and the release of iron by

macrophages, leading to the burden of iron overload

in patients with β thalassemia (Jones et al., 2015).

The iron overload condition tends to an increase

in ferritin levels. The increased ferritin levels exceed

their capacity to bind iron that can cause an increase

126

Hamdani, I., Santosa, Q., Setyono, J., Hernayanti, . and Rujito, L.

Correlation between Hepcidin and Ferritin with Insulin and Hba1C as Biochemical Markers of Pancreas Damage in -Thalassemia Patients.

DOI: 10.5220/0010488901260130

In Proceedings of the 1st Jenderal Soedirman International Medical Conference in conjunction with the 5th Annual Scientiﬁc Meeting (Temilnas) Consortium of Biomedical Science Indonesia

(JIMC 2020), pages 126-130

ISBN: 978-989-758-499-2

in free iron levels. The increase in free iron levels

through the Fenton reaction will produce free radicals

such as hydroxyl radicals (OH-) and hydroxyl anions

(OH *), which can oxidise lipid components,

denaturation proteins, and damage cell DNA

replication (He et al., 2016; Maslowska, Makiela-

Dzbenska and Fijalkowska, 2019). The pancreas also

one of the organs which be affected and at risk of

damage. Free radicals in the pancreas cause β cell

death, impairing insulin secretion, which contributes

to impaired glucose metabolism to diabetes mellitus

in thalassemia patients (Nakavachara et al., 2020).

HbA1c is an indicator that can assess pancreatic

function by measuring the average blood glucose

level for three months (Gupta, Jain, and Chauhan,

2017). Evaluation of the iron overload condition in

thalassemia patients can help the clinician to predict

the damage on various organs, including the pancreas.

This study aimed to determine the relationship

between hepcidin and ferritin levels as markers of

iron overload conditions with insulin and HbA1c

levels as biochemical markers of pancreatic damage

in β thalassemia patients.

2 MATERIALS AND METHODS

The study used an analytic observational with a cross-

sectional study to determine the role of hepcidin and

ferritin in pancreatic damage due to iron overload in

patients with β thalassemia. The sampling method

was a total sampling using 35 β-thalassemia patients

registered in the parent’s association of Indonesian

thalassemia (POPTI) Samarinda East Kalimantan in

2019 had signed the consent form.

Hepcidin, insulin, and HbA1c examination were

performed using the enzyme-linked immunosorbent

assay (ELISA) sandwich method at the Research

Laboratory of the Faculty of Medicine, Jenderal

Soedirman University using BT Technology Elisa Kit

manufacturer. Technical analysis for detection used

the ELISA reader 270 Biomerieux, while the software

used was https://www.elisaanalysis.com available on

the online platform. In summary, the standards and

samples were pipetted to the well coated with the

antibody. The primary antibody was then added,

followed by incubation. Secondary antibody and

chromogen substance are added. The colour formed

was then read in the absorbance value at the 450 nm.

At the same time, Ferritin data were obtained from

patient medical records.

Ethics approval came from the Health Research

Ethics Commission, Faculty of Medicine, Jenderal

Soedirman University. The Shapiro-Wilk test

analysed numerical data distribution, while the

analysis between variables was using the Pearson

correlation on IBM SPSS Statistics 26 software.

3 RESULTS

Tables depicted the data from 35 patients with β-

thalassemia, as shown in Table 1, Table 2. Most of

the subjects were adolescence (48.6%) and children

40%). Only several subjects were below five years

old and the elderly.

The number of male and female subjects was not

much different. Most of the subjects’ hepcidin levels

were in a low category (97.1%) with a median value

of 0.19 (0.12-2.55) ng/mL. Data on ferritin levels in

research subjects only obtained 25 patients from a

total of 35 patients, and all were in the high category

with a median value of 3283 (1059-9748) ng/mL.

Ferritin, at this point, were collected and averaged

using three sequential times for recent measurement.

The subjects’ insulin levels had a median value of

2.19 (1.19-60.83) µU/mL, and most of them were in

a low category (88.6%). Patients who have lower

HbA1c levels (85.7%) were more than subjects who

had an average (11.4%) and high (2.9%) levels with

a median value of 26.95 (16.37-159.39) mg/dL.

Table 1. Characteristics of Respondents

Variable Frequenc

N %

e<5

ears ol

1 2,9

5-11

ears ol

14 40

12-25

ears ol

17 48,6

26-45

ears ol

2 5,7

>45

ears ol

1 2,9

Total 35 100

Gender Male 17 48,6

Female 18 51,4

Total 35 100

Hepcidin Low (<2n

/ml) 34 97,1

ormal (2-56n

/ml) 1 2,9

Total 35 100

ritin Hi

h (>200n

/ml) 25 71,4

Total 25 71,4

Insulin Low (<10

U/mL) 31 88,6

ormal (10-

100

U/mL)

4 11,4

Total 35 100

HbA1c Low (<80m

/dL) 30 85,7

ormal (80-

130m

/dL)

4 11,4

h (>130m

/dL) 1 2,9

Total 35 100

Correlation between Hepcidin and Ferritin with Insulin and Hba1C as Biochemical Markers of Pancreas Damage in -Thalassemia Patients

127

Table 2. The value of Hepcidin, Ferritin, Insulin, and HbA1c

No. Levels N Min Max Median Normal Range

1. Hepcidin (n

/mL) 35 0.12 2.55 0.19 2-56

2. Fe

itin (n

/mL) 25 1059 9747 3283 20-200

3. Insulin (

U/mL) 35 1.19 60.83 2.19 10-100

4. HbA1c (m

/dL) 35 16.37 159.39 26.95 80-130

Table 3. Correlation between markers of iron overload with insulin levels and HbA1c levels in patients with β thalassemia

The Pearson correlation test (Table 3) showed that

hepcidin levels had no significant relationship with

ferritin levels (p = 0.964; r = -0.010), but had a

significant relationship with insulin and HbA1c levels

(p = 0.001) in patients with β thalassemia. Hepcidin

levels had a strong positive correlation with insulin (r

= 0.771) and a very strong positive correlation with

HbA1c (r = 0.849). Ferritin levels did not show a

significant relationship with insulin (p = 0.785; r =

0.057) and HbA1c (p = 0.420; r = 0.169) in patients

with β thalassemia.

4 DISCUSSIONS

The study revealed that most of the subjects were

adolescents and children, but we also found two adult

and one elderly thalassemia patient. Previous studies

have shown that the quality and duration of life of β

thalassemia patients had improved over the past ten

years due to regular blood transfusions balanced with

iron chelation therapy and better patient compliance

(Mokhtar et al., 2013). Based on gender, the female

was 51.4% of thalassemia patients, and 48.6% were

male. The number of female patients is not much

different from male patients. It is related that

thalassemia is a genetic disease caused by a single

autosomal recessive allele factor, not a congenital

disorder caused by allele factors linked to sex

chromosomes (Taher, Weatherall, and Cappellini,

2018).

Hepcidin levels in this study had a median value

of 0.19ng / mL, and most of the subjects had a

decrease in hepcidin levels. The reductions in

hepcidin levels previously have been reported by

several studies. Ineffective erythropoietic activity is

the cause of the decrease in hepcidin synthesis in

thalassemia patients (Huang et al., 2019; Jones et al.,

2015; Pasricha et al., 2013).

Decreasing hepcidin levels will increase ferritin

levels. The increased ferritin levels that reach the

threshold will lead to the formation of free iron,

which is toxic and can damage various organs,

including the pancreas, which results in decreasing

insulin secretion capacity and disruption of glucose

metabolism to diabetes in thalassemia patients

(Leecharoenkiat et al., 2016; Wang et al., 2014). This

study showed decreased hepcidin levels below

average in most subjects and increased ferritin levels

in all study subjects. Still, statistically, there was no

relationship between hepcidin levels and ferritin

levels in the study subjects.

Ferritin levels in this study also did not show a

relationship to insulin and HbA1c levels. It can be due

to the measurement of ferritin data taken from patient

medical records and not direct measurements that

coincide with hepcidin, insulin, and HbA1c levels

(Wang et al., 2014). Besides, serum ferritin levels can

be influenced by various factors such as transfusions,

iron chelation therapy, inflammatory disease, liver

disease, and malignancy. The serum ferritin level is

not the best examination to mark iron accumulation

in various organs (Fernández-Real and Manco, 2014).

Magnetic Resonance Imaging (MRI) and non-

transferrin bound iron (NTBI) examinations have

been reported to be better at assessing organ damage

from iron accumulation (Elalfy et al., 2015).

This study showed a significant positive

correlation between hepcidin levels and insulin levels

in thalassemia patients; the lower the hepcidin level,

the lower the insulin level. This result was the same

as Al-Hakeim et al.’s result, which showed a positive

correlation between hepcidin levels and insulin levels

in patients with β thalassemia (Al-Hakeim, Al-

Khakani, and Al-Kindi, 2015). Hepcidin is the main

regulatory protein in regulating iron levels in the

No. Levels N Min Max Median Normal Range

1. Hepcidin (n

/mL) 35 0.12 2.55 0.19 2-56

2. Fe

itin (n

/mL) 25 1059 9747 3283 20-200

3. Insulin (

U/mL) 35 1.19 60.83 2.19 10-100

4. HbA1c (m

/dL) 35 16.37 159.39 26.95 80-130

JIMC 2020 - 1’s t Jenderal Soedirman International Medical Conference (JIMC) in conjunction with the Annual Scientiﬁc Meeting

(Temilnas) Consortium of Biomedical Science Indonesia (KIBI )

128

body. The decrease in hepcidin levels in thalassemia

patients contributes to the occurrence of iron overload

conditions, which can cause pancreatic damage

characterised by failure and decreased insulin

secretion by pancreatic β cells (Huang et al., 2019).

Ineffective erythropoietic activity may cause a

decrease in hepcidin synthesis. The increased

erythroid expansion in the bone marrow will trigger

the production of several erythroid factors such as

erythrofferone, twisted-gastrulation 1 (TWSG1), and

GDF-15, which directly reduces the hepatic synthesis

of hepcidin (Tanno et al., 2009; Kautz et al., 2015).

The decrease in hepcidin levels results in an increase

in iron absorption in enterocyte cells. The rise of

ferroportin activity and the mobilisation of iron stores

from macrophages contribute to iron overload in

thalassemia patients (Larissi et al., 2019).

Iron overload caused by decreasing hepcidin

levels can cause an increase in free iron levels (NTBI)

circulating in plasma and deposited in cells through

the L-type voltage-dependent Ca2 + (LVDCC) and

Zip14 channels (Leecharoenkiat et al., 2016). An

increase in free iron levels beyond cells’ ability to

form ferritin can turn this free iron into toxic. This

free iron through the Fenton reaction can produce

ROS free radicals such as hydroxyl radicals (OH-)

and hydroxyl anions (OH*), which can oxidise lipids,

protein denaturation, organelle damage, and even cell

death (Chutvanichkul et al., 2018). The pancreas is

very susceptible to ROS because it has low

antioxidants levels (Shams et al., 2010). Increasing

ROS such as hydroxyl radicals in the pancreas can

trigger apoptosis of pancreatic β cells through

interactions between mitochondria and the

endoplasmic reticulum. It also inhibits adenosine

triphosphate production (ATP), failing and

decreasing insulin secretion (Backe et al., 2016).

This study also showed a significant positive

correlation between hepcidin levels and HbA1c

levels; the lower the hepcidin level, the lower the

HbA1c level. The reduction of hepcidin levels and

HbA1c levels is still unclear. It might relate to

hemoglobinopathy’s coincidence in thalassemia

patients (Zhang, Xiao, and Fan, 2018; Tsilingiris et

al., 2019).

The hemoglobinopathy incidence among

thalassemia patients may lead to abnormalities in the

erythrocyte cell membrane leading to cell damage.

The erythrocyte cell’s destruction is faster, and the

erythrocyte age is shorter than average (Hoffman et

al., 2013). It can lead to reduced glycosylation time

resulting in a decrease in HbA1c levels to below. On

the other hand, hemoglobinopathy in thalassemia

patients can cause chronic hypoxia due to anaemia.

This hypoxic condition will increase erythropoietic

activity, suppressing hepcidin levels’ synthesis to be

low (Huang et al., 2019).

Ji and colleagues assumed that a low HbA1c

value in thalassemia patients could be misinterpreted

compared to the standard reference. Other parameters

than HbA1c, such as glucose levels and glycated

albumin levels, are needed to appropriately assess

glucose abnormalities in thalassemia patients (Ji et

al., 2015; Wu et al., 2016).

5 CONCLUSIONS

The study found the lower the hepcidin level, the

lower the insulin and hba1c levels. ferritin levels do

not have a significant relationship with insulin and

hba1c levels

ACKNOWLEDGEMENTS

Thankful goes to the Ministry of Research and

Technology of the Republic of Indonesia for the

funding provided. We also thanks to thalassemia

patients and parents who participated in this study.

REFERENCES

Al-Hakeim, H., Al-Khakani, M., and Al-Kindi, M., 2015.

Correlation of Hepcidin Level with Insulin Resistance

and Endocrine Glands Function in Major Thalassemia.

Advances in Clinical and Experimental Medicine,

[online] 24(1), pp.69–78.

Backe, M.B., Moen, I.W., Ellervik, C., Hansen, J.B., and

Mandrup-Poulsen, T., 2016. Iron Regulation of

Pancreatic Beta-Cell Functions and Oxidative Stress.

Annual Review of Nutrition, [online] 36(1), pp.241–

273.

Chutvanichkul, B., Vattanaviboon, P., Mas-oodi, S., U-

pratya, Y., and Wanachiwanawin, W., 2018. Labile iron

pool as a parameter to monitor iron overload and

oxidative stress status in β-thalassemic erythrocytes.

Cytometry Part B: Clinical Cytometry, [online] 94(4),

pp.631–636.

Elalfy, M.S., Adly, A.M., Wali, Y., Tony, S., Samir, A. and

Elhenawy, Y.I., 2015. Efficacy and safety of a novel

combination of two oral chelators

deferasirox/deferiprone over deferoxamine/deferiprone

in severely iron overloaded young beta-thalassemia

major patients. European Journal of Haematology,

[online] 95(5), pp.411–420.

Fernández-Real, J.M., and Manco, M., 2014. Effects of iron

overload on chronic metabolic diseases. The Lancet.

Diabetes & endocrinology, [online] 2(6), pp.513–26.

Correlation between Hepcidin and Ferritin with Insulin and Hba1C as Biochemical Markers of Pancreas Damage in -Thalassemia Patients

129

Gupta, S, Jain U, Chauhan, N., 2017. Laboratory Diagnosis

of HbA1c: A Review. Journal of Nanomedicine

Research, [online] 5(4). pp 4-8

He, J., Yang, X., Men, B. and Wang, D., 2016. Interfacial

mechanisms of heterogeneous Fenton reactions

catalysed by iron-based materials: A review. Journal of

Environmental Sciences, [online] 39, pp.97–109.

Hoffman, R., Silberstein, L.E., Heslop, H., and Weitz, J.,

2013. Hematology: Basic Principles and Practice.

[online] Philadelphia, USA: Saunders/Elsevier.

Huang, Y., Lei, Y., Liu, R., Liu, J., Yang, G., Xiang, Z.,

Liang, Y. and Lai, Y., 2019. Imbalance of

erythropoiesis and iron metabolism in patients with

thalassemia. International Journal of Medical Sciences,

[online] 16(2), pp.302–310.

Ji, L., Yu, J., Zhou, Y., Xia, Y., Xu, A., Li, W., and Li, L.,

2015. Erroneous HbA1c measurements in the presence

of β-thalassemia and common Chinese hemoglobin

variants. Clinical Chemistry and Laboratory Medicine

(CCLM), 53(9).

Jones, E., Pasricha, S.-R., Allen, A., Evans, P., Fisher, C.A.,

Wray, K., Premawardhena, A., Bandara, D., Perera, A.,

Webster, C., Sturges, P., Olivieri, N.F., St. Pierre, T.,

Armitage, A.E., Porter, J.B., Weatherall, D.J. and

Drakesmith, H., 2015. Hepcidin is suppressed by

erythropoiesis in hemoglobin E β-thalassemia and β-

thalassemia trait. Blood, 125(5), pp.873–880.

Kautz, L., Jung, G., Du, X., Gabayan, V., Chapman, J.,

Nasoff, M., Nemeth, E., and Ganz, T., 2015.

Erythroferrone contributes to hepcidin suppression and

iron overload in a mouse model of β-thalassemia.

Blood, [online] 126(17), pp.2031–2037.

Larissi, K., Politou, M., Margeli, A., Poziopoulos, C.,

Flevari, P., Terpos, E., Papassotiriou, I. and

Voskaridou, E., 2019. The Growth Differentiation

Factor-15 (GDF-15) levels are increased in patients

with compound heterozygous sickle cell and beta-

thalassemia (HbS/βthal), correlate with markers of

hemolysis, iron burden, coagulation, endothelial

dysfunction, and pulmonary hy. Blood Cells,

Molecules, and Diseases, [online] 77, pp.137–141.

Leecharoenkiat, K., Lithanatudom, P., Sornjai, W., and

Smith, D.R., 2016. Iron dysregulation in beta-

thalassemia. Asian Pacific Journal of Tropical

Medicine, [online] 9(11), pp.1035–1043.

Maslowska, K.H., Makiela‐Dzbenska, K., and Fijalkowska,

I.J., 2019. The SOS system: A complex and tightly

regulated response to DNA damage. Environmental

and Molecular Mutagenesis, [online] 60(4), pp.368–

384.

Mokhtar, G.M., Gadallah, M., El Sherif, N.H.K., and Ali,

H.T.A., 2013. Morbidities and Mortality in

Transfusion-Dependent Beta-Thalassemia Patients

(Single-Center Experience). Pediatric Hematology-

Oncology, [online] 30(2), pp.93–103.

Nakavachara, P., Kajchamaporn, W., Pooliam, J., and

Viprakasit, V., 2020. Early development of decreased

β‐cell insulin secretion in children and adolescents with

hemoglobin H disease and its relationship with levels of

anemia. Pediatric Blood & Cancer, [online] 67(4).

Origa, R., 2017. β-Thalassemia. Genetics in Medicine,

[online] 19(6), pp.609–619.

Pasricha, S.-R., Frazer, D.M., Bowden, D.K., and

Anderson, G.J., 2013. Transfusion suppresses

erythropoiesis and increases hepcidin in adult patients

with β-thalassemia major: a longitudinal study. Blood,

122(1), pp.124–133.

Rujito, L., Basalamah, M., Mulatsih, S., and Sofro, A.S.M.,

2015. Molecular Scanning of β-Thalassemia in the

Southern Region of Central Java, Indonesia; a Step

Towards a Local Prevention Program. Hemoglobin,

39(5), pp.330–333.

Shams, S., Ashtiani, M.T.H., Monajemzadeh, M.,

Koochakzadeh, L., Irani, H., Jafari, F., and Mohseni,

A., 2010. Evaluation of Serum Insulin, Glucose, Lipid

Profile, and Liver Function in β-Thalassemia Major

Patients and Their Correlation With Iron Overload.

Laboratory Medicine, [online] 41(8), pp.486–489.

Soteriades, E.S., and Weatherall, D., 2014. The

Thalassemia International Federation: a global public

health paradigm. Thalassemia Reports, [online] 4(2),

pp.23-3

Taher, A.T., Weatherall, D.J., and Cappellini, M.D., 2018.

Thalassaemia. The Lancet, [online] 391(10116),

pp.155–167.

Tanno, T., Porayette, P., Sripichai, O., Noh, S.-J., Byrnes,

C., Bhupatiraju, A., Lee, Y.T., Goodnough, J.B.,

Harandi, O., Ganz, T., Paulson, R.F. and Miller, J.L.,

2009. Identification of TWSG1 as a second novel

erythroid regulator of hepcidin expression in murine

and human cells. Blood, [online] 114(1), pp.181–186.

Tsilingiris, D., Makrilakis, K., Voskaridou, E., Pagkrati, S.,

Dalamaga, M., and Liatis, S., 2019. Effect of

heterozygous beta-thalassemia on HbA1c levels in

individuals without diabetes mellitus: A cross-sectional

study. Clinica Chimica Acta, [online] 494, pp.132–137.

Vasudev, R., and Sawhney, V., 2014. Thalassemia major

and intermedia in Jammu and Kashmir, India: a

regional transfusion center experience. Indian journal

of hematology & blood transfusion : an official journal

of Indian Society of Hematology and Blood

Transfusion, 30(4), pp.297–300.

Wang, H., Li, H., Jiang, X., Shi, W., Shen, Z., and Li, M.,

2014. Hepcidin Is Directly Regulated by Insulin and

Plays an Important Role in Iron Overload in

Streptozotocin-Induced Diabetic Rats. Diabetes,

[online] 63(5), pp.1506–1518.

Wu, W.-C., Ma, W.-Y., Wei, J.-N., Yu, T.-Y., Lin, M.-S.,

Shih, S.-R., Hua, C.-H., Liao, Y.-J., Chuang, L.-M. and

Li, H.-Y., 2016. Serum Glycated Albumin to Guide the

Diagnosis of Diabetes Mellitus. PLOS ONE, 11(1),

p.e0146780.

Zhang, X., Xiao, Y., and Fan, Y., 2018. Investigating the

Reliability of HbA1c Monitoring for Blood Glucose

Control During Late Pregnancy in Patients with

Gestational Diabetes Mellitus (GDM) with and without

β-Thalassemia Minor. Diabetes Therapy, [online] 9(6),

pp.2305–2313.

JIMC 2020 - 1’s t Jenderal Soedirman International Medical Conference (JIMC) in conjunction with the Annual Scientiﬁc Meeting

(Temilnas) Consortium of Biomedical Science Indonesia (KIBI )

130