{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,16]],"date-time":"2026-09-16T20:34:31Z","timestamp":1789590871863,"version":"build-2803163510"},"reference-count":46,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2025,5,14]],"date-time":"2025-05-14T00:00:00Z","timestamp":1747180800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"University Of Medicine And Pharmacy Timisoara, Romania"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Life"],"abstract":"<jats:p>Background: Heart failure (HF), chronic kidney disease (CKD), and atrial fibrillation (AF) frequently coexist, forming a high-risk triad that amplifies morbidity and mortality through shared pathophysiological mechanisms such as neurohormonal activation, fluid overload, and inflammation. Current risk stratification tools, including CHA2DS2-VASc and HAS-BLED, inadequately capture the complexity of these multimorbid patients. This study aims to explore the influence of comorbidities, hypertension severity, anticoagulation strategy, and risk scores on hospitalization outcomes in patients with coexisting HF, CKD, and AF. Materials and Methods: A retrospective case study was conducted on 174 hospitalized patients with HF, CKD, and AF. Clinical data included hypertension grade, HF phenotype (HFpEF vs. HFrEF), NYHA classification, renal function (KDIGO stage), stroke and bleeding risk scores (CHA2DS2-VASc: congestive heart failure, hypertension, age \u2265 75, diabetes, and stroke\/TIA; HAS-BLED: hypertension, abnormal renal\/liver function, stroke, bleeding, labile INR, elderly, and drugs\/alcohol), comorbidities (neurological, psychiatric, COPD, and diabetes), anticoagulation type (DOACs vs. VKAs), and length of hospital stay. Statistical analysis included Spearman correlation, independent t-tests, and multivariate regression to evaluate associations between variables and clinical outcomes. Results: Most patients were elderly (mean age 75 \u00b1 12), with advanced CKD (stage 3b) and systolic HF (77% HFrEF). Mean CHA2DS2-VASc was 5.67, HAS-BLED was 4.40, and ATRIA was 4.74, indicating high stroke and bleeding risk. Anticoagulation was predominantly via DOACs (69.5%). Hypertension severity did not significantly correlate with NYHA class (\u03c1 = \u22120.14, p = 0.068). Neurological, psychiatric, and metabolic comorbidities showed no significant associations with HF severity. COPD and diabetes correlated inversely with CHA2DS2-VASc scores (\u03c1 = \u22120.83, p = 0.014). No significant differences were observed in hospital stay between HF phenotypes or prior stroke history. In-hospital mortality was low (2.3%). Conclusions: Traditional risk scores do not fully capture the complexity of multimorbid patients. Metabolic comorbidities showed an inverse correlation with stroke risk scores, and no significant correlation was observed between hypertension severity and HF symptom burden. Hypertension and common comorbidities did not correlate with HF symptom burden, and metabolic diseases may paradoxically associate with lower stroke risk scores. These findings highlight the need for improved multimodal risk assessment strategies that consider the heterogeneity of multimorbid populations. Personalized, integrated approaches are essential to optimize anticoagulation, reduce hospitalization, and improve prognosis.<\/jats:p>","DOI":"10.3390\/life15050786","type":"journal-article","created":{"date-parts":[[2025,5,14]],"date-time":"2025-05-14T10:06:52Z","timestamp":1747217212000},"page":"786","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":24,"title":["Multifactorial Risk Stratification in Patients with Heart Failure, Chronic Kidney Disease, and Atrial Fibrillation: A Comprehensive Analysis"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7641-8687","authenticated-orcid":false,"given":"Mihai Sorin","family":"Iacob","sequence":"first","affiliation":[{"name":"Doctoral School, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 3000041 Timisoara, Romania"},{"name":"University Clinic of Internal Medicine and Ambulatory Care, Prevention and Cardiovascular Recovery, Department VI\u2014Cardiology, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 3000041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2824-7182","authenticated-orcid":false,"given":"Nilima Rajpal","family":"Kundnani","sequence":"additional","affiliation":[{"name":"University Clinic of Internal Medicine and Ambulatory Care, Prevention and Cardiovascular Recovery, Department VI\u2014Cardiology, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 3000041 Timisoara, Romania"},{"name":"Research Centre of Timisoara Institute of Cardiovascular Diseases, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 3000041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0865-0054","authenticated-orcid":false,"given":"Abhinav","family":"Sharma","sequence":"additional","affiliation":[{"name":"Doctoral School, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 3000041 Timisoara, Romania"},{"name":"University Clinic of Internal Medicine and Ambulatory Care, Prevention and Cardiovascular Recovery, Department VI\u2014Cardiology, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 3000041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vlad","family":"Meche","sequence":"additional","affiliation":[{"name":"Doctoral School, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 3000041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul","family":"Ciobotaru","sequence":"additional","affiliation":[{"name":"Doctoral School, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 3000041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ovidiu","family":"Bedreag","sequence":"additional","affiliation":[{"name":"University Clinic of Anaesthesia and Intensive Care, Department X Surgery II, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 3000041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dorel","family":"Sandesc","sequence":"additional","affiliation":[{"name":"University Clinic of Anaesthesia and Intensive Care, Department X Surgery II, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 3000041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3892-0211","authenticated-orcid":false,"given":"Simona Ruxanda","family":"Dragan","sequence":"additional","affiliation":[{"name":"University Clinic of Internal Medicine and Ambulatory Care, Prevention and Cardiovascular Recovery, Department VI\u2014Cardiology, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 3000041 Timisoara, Romania"},{"name":"Research Centre of Timisoara Institute of Cardiovascular Diseases, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 3000041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4065-3650","authenticated-orcid":false,"given":"Marius","family":"Papurica","sequence":"additional","affiliation":[{"name":"University Clinic of Anaesthesia and Intensive Care, Department X Surgery II, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 3000041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Livia Claudia","family":"Stanga","sequence":"additional","affiliation":[{"name":"Department XIV\u2014Microbiology, \u201cVictor Babes\u201d University of Medicine and Pharmacy, 3000041 Timisoara, Romania"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,5,14]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1002\/ehf2.13699","article-title":"Chronic kidney disease and risk of atrial fibrillation and heart failure in general population-based cohorts: The BiomarCaRE project","volume":"9","author":"Rehm","year":"2022","journal-title":"ESC Heart Fail."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Szlagor, M., Dybiec, J., M\u0142ynarska, E., Rysz, J., and Franczyk, B. (2023). Chronic Kidney Disease as a Comorbidity in Heart Failure. Int. J. Mol. Sci., 24.","DOI":"10.3390\/ijms24032988"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"euae281","DOI":"10.1093\/europace\/euae281","article-title":"CHA2DS2-VA instead of CHA2DS2-VASc for stroke risk stratification in patients with atrial fibrillation: Not just a matter of sex","volume":"26","author":"Boriani","year":"2024","journal-title":"Europace"},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Morrone, D., Kroep, S., Ricci, F., Renda, G., Patti, G., Kirchhof, P., Chuang, L.H., van Hout, B., and De Caterina, R. (2020). Mortality Prediction of the CHA2DS2-VASc Score, the HAS-BLED Score, and Their Combination in Anticoagulated Patients with Atrial Fibrillation. J. Clin. Med., 9.","DOI":"10.3390\/jcm9123987"},{"key":"ref_5","unstructured":"Golla, M.S.G., Hajouli, S., and Ludhwani, D. (2025). Heart failure and ejection fraction. StatPearls, StatPearls Publishing LLC."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1038\/s41371-022-00751-4","article-title":"Hypertension and cardiomyopathy associated with chronic kidney disease: Epidemiology, pathogenesis and treatment considerations","volume":"37","author":"Law","year":"2023","journal-title":"J. Hum. Hypertens."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1157","DOI":"10.1161\/CIRCULATIONAHA.120.050686","article-title":"Cardiovascular Disease in Chronic Kidney Disease","volume":"143","author":"Jankowski","year":"2021","journal-title":"Circulation"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e840","DOI":"10.1161\/CIR.0000000000000664","article-title":"Cardiorenal Syndrome: Classification, Pathophysiology, Diagnosis, and Treatment Strategies: A Scientific Statement from the American Heart Association","volume":"139","author":"Rangaswami","year":"2019","journal-title":"Circulation"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"40","DOI":"10.31083\/j.rcm2402040","article-title":"Acute Cardiorenal Syndrome: Epidemiology, Pathophysiology, Assessment, and Treatment","volume":"24","author":"Peng","year":"2023","journal-title":"Rev. Cardiovasc. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"2017","DOI":"10.1093\/cvr\/cvad083","article-title":"Cardiovascular complications in chronic kidney disease: A review from the European Renal and Cardiovascular Medicine Working Group of the European Renal Association","volume":"119","author":"Zoccali","year":"2023","journal-title":"Cardiovasc. Res."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1136\/hrt.2004.042473","article-title":"Left ventricular hypertrophy in hypertension: Its arrhythmogenic potential","volume":"91","author":"Kahan","year":"2005","journal-title":"Heart"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"e028496","DOI":"10.1161\/JAHA.122.028496","article-title":"Association of Chronic Kidney Disease with Atrial Fibrillation in the General Adult Population: A Nationwide Population-Based Study","volume":"12","author":"Kim","year":"2023","journal-title":"J. Am. Heart Assoc."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1002\/ehf2.13118","article-title":"Congestive nephropathy: A neglected entity? Proposal for diagnostic criteria and future perspectives","volume":"8","author":"Assmus","year":"2021","journal-title":"ESC Heart Fail."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Wu, Y., Kong, X.-J., Ji, Y.-Y., Fan, J., Ji, C.-C., Chen, X.-M., Ma, Y.-D., Tang, A.-L., Cheng, Y.-J., and Wu, S.-H. (2024). Serum electrolyte concentrations and risk of atrial fibrillation: An observational and mendelian randomization study. BMC Genom., 25.","DOI":"10.1186\/s12864-024-10197-2"},{"key":"ref_15","unstructured":"(2025, January 17). Available online: https:\/\/www.theguardian.com\/society\/2024\/dec\/28\/algorithm-could-help-prevent-thousands-of-strokes-in-uk-each-year."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e1","DOI":"10.1161\/CIR.0000000000001193","article-title":"2023 ACC\/AHA\/ACCP\/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines","volume":"149","author":"Joglar","year":"2024","journal-title":"Circulation"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"860","DOI":"10.1161\/CIRCULATIONAHA.111.060061","article-title":"Use of the CHA2DS2-VASc and HAS-BLED Scores to Aid Decision Making for Thromboprophylaxis in Nonvalvular Atrial Fibrillation","volume":"126","author":"Lane","year":"2012","journal-title":"Circulation"},{"key":"ref_18","first-page":"e895","article-title":"2022 AHA\/ACC\/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines","volume":"145","author":"Heidenreich","year":"2022","journal-title":"Circulation"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"273","DOI":"10.1093\/ndt\/gfae209","article-title":"KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease in Children and Adults: A commentary from the European Renal Best Practice (ERBP)","volume":"40","author":"Iatridi","year":"2025","journal-title":"Nephrol. Dial. Transplant."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"597","DOI":"10.1016\/j.amjcard.2018.04.049","article-title":"Usefulness of the Addition of Renal Function to the CHA2DS2-VASc Score as a Predictor of Thromboembolism and Mortality in Patients Without Atrial Fibrillation","volume":"122","author":"Parsons","year":"2018","journal-title":"Am. J. Cardiol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1737","DOI":"10.1007\/s11739-021-02799-5","article-title":"Does CHA2DS2-VASc score predict mortality in chronic kidney disease?","volume":"16","author":"Goudis","year":"2021","journal-title":"Intern Emerg. Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"4230","DOI":"10.1038\/s41467-024-48618-1","article-title":"AI-enhanced integration of genetic and medical imaging data for risk assessment of Type 2 diabetes","volume":"15","author":"Huang","year":"2024","journal-title":"Nat. Commun."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"66","DOI":"10.1016\/j.annepidem.2012.11.004","article-title":"B-type natriuretic peptide, C-reactive protein, and cause-specific mortality","volume":"23","author":"Oluleye","year":"2013","journal-title":"Ann. Epidemiol."},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Inserra, F., Forcada, P., Castellaro, A., and Castellaro, C. (2021). Chronic Kidney Disease and Arterial Stiffness: A Two-Way Path. Front. Med., 8.","DOI":"10.3389\/fmed.2021.765924"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1681\/ASN.2013050465","article-title":"Fibroblast growth factor-23 and cardiovascular events in CKD","volume":"25","author":"Scialla","year":"2014","journal-title":"J. Am. Soc. Nephrol."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Liu, M., Xia, P., Tan, Z., Song, T., Mei, K., Wang, J., Ma, J., Jiang, Y., Zhang, J., and Zhao, Y. (2022). Fibroblast growth factor-23 and the risk of cardiovascular diseases and mortality in the general population: A systematic review and dose-response meta-analysis. Front. Cardiovasc. Med., 9.","DOI":"10.3389\/fcvm.2022.989574"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"625","DOI":"10.1056\/NEJMoa1105594","article-title":"Stroke and bleeding in atrial fibrillation with chronic kidney disease","volume":"367","author":"Olesen","year":"2012","journal-title":"N. Engl. J. Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1588","DOI":"10.1161\/01.STR.0000170642.39876.f2","article-title":"Avoiding central nervous system bleeding during antithrombotic therapy: Recent data and ideas","volume":"36","author":"Hart","year":"2005","journal-title":"Stroke"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"2204","DOI":"10.1016\/j.jacc.2019.08.1031","article-title":"Anticoagulation in Concomitant Chronic Kidney Disease and Atrial Fibrillation","volume":"74","author":"Kumar","year":"2019","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"40","DOI":"10.1186\/s12959-024-00608-5","article-title":"Efficacy and safety of direct oral anticoagulants in patients with atrial fibrillation combined with chronic kidney disease: A systematic review and meta-analysis","volume":"22","author":"Li","year":"2024","journal-title":"Thromb. J."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1604","DOI":"10.1016\/j.hlc.2022.09.003","article-title":"Oral Anticoagulant Use in Patients with Atrial Fibrillation and Chronic Kidney Disease: A Review of the Evidence with Recommendations for Australian Clinical Practice","volume":"31","author":"Hammett","year":"2022","journal-title":"Heart Lung Circ."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"2888","DOI":"10.1016\/j.jacc.2016.02.082","article-title":"Nonvitamin K Anticoagulant Agents in Patients with Advanced Chronic Kidney Disease or on Dialysis with AF","volume":"67","author":"Chan","year":"2016","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1519","DOI":"10.1161\/CIRCULATIONAHA.118.035418","article-title":"Outcomes Associated with Apixaban Use in Patients with End-Stage Kidney Disease and Atrial Fibrillation in the United States","volume":"138","author":"Siontis","year":"2018","journal-title":"Circulation"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"774","DOI":"10.1002\/clc.23196","article-title":"Anticoagulation in chronic kidney disease: From guidelines to clinical practice","volume":"42","author":"Aursulesei","year":"2019","journal-title":"Clin. Cardiol."},{"key":"ref_35","first-page":"290","article-title":"SAMe-TT2R2 Score in the Outpatient Anticoagulation Clinic to Predict Time in Therapeutic Range and Adverse Events","volume":"108","author":"Scheffel","year":"2017","journal-title":"Arq. Bras. Cardiol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"e036719","DOI":"10.1161\/JAHA.124.036719","article-title":"Effect of Intensive Blood Pressure Control and Comorbidity Status on the Prognosis of Patients with Hypertension: Insights from SPRINT","volume":"14","author":"Zheng","year":"2025","journal-title":"J. Am. Heart Assoc."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1050","DOI":"10.1161\/CIRCRESAHA.122.321762","article-title":"Hypertension as Cardiovascular Risk Factor in Chronic Kidney Disease","volume":"132","author":"Burnier","year":"2023","journal-title":"Circ. Res."},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Sheikh-Taha, M., and Asmar, M. (2021). Polypharmacy and severe potential drug-drug interactions among older adults with cardiovascular disease in the United States. BMC Geriatr., 21.","DOI":"10.1186\/s12877-021-02183-0"},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Turner, R.M., de Koning, E.M., Fontana, V., Thompson, A., and Pirmohamed, M. (2020). Multimorbidity, polypharmacy, and drug-drug-gene interactions following a non-ST elevation acute coronary syndrome: Analysis of a multicentre observational study. BMC Med., 18.","DOI":"10.1186\/s12916-020-01827-z"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"2149","DOI":"10.1016\/j.jacc.2018.03.022","article-title":"Multimorbidity in Older Adults with Cardiovascular Disease","volume":"71","author":"Boyd","year":"2018","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"2125","DOI":"10.1002\/ehf2.15223","article-title":"SGLT2i reduce arrhythmic events in heart failure patients with cardiac implantable electronic devices","volume":"12","author":"Mariani","year":"2025","journal-title":"ESC Heart Fail."},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Suhov, L., Apostol, A., D\u0103niluc, L., Haj Ali, L., Sandu, O.E., Bogdan, C., and Andor, M. (2025). Implications of Heart Failure Treatment on Atrial Fibrillation Onset: A Retrospective Study. Medicina, 61.","DOI":"10.3390\/medicina61030414"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"835","DOI":"10.1016\/j.recesp.2024.02.013","article-title":"Dynamic assessment of CHA2DS2-VASc and HAS-BLED scores for predicting ischemic stroke and major bleeding in atrial fibrillation patients","volume":"77","author":"Serna","year":"2024","journal-title":"Rev. Espa\u00f1ola De Cardiol. (Engl. Ed.)"},{"key":"ref_44","first-page":"1762","article-title":"Distinct Comorbidity Clusters in Patients With Acute Heart Failure: Data From RELAX-AHF-2","volume":"12","author":"Gomez","year":"2024","journal-title":"J. Am. Coll. Cardiol. Heart Fail."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"214","DOI":"10.1093\/ehjqcco\/qcab028","article-title":"GARFIELD-AF risk score for mortality, stroke, and bleeding within 2 years in patients with atrial fibrillation","volume":"8","author":"Fox","year":"2022","journal-title":"Eur. Heart J. Qual. Care Clin. Outcomes"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1582","DOI":"10.1093\/eurheartj\/ehw054","article-title":"The ABC (age, biomarkers, clinical history) stroke risk score: A biomarker-based risk score for predicting stroke in atrial fibrillation","volume":"37","author":"Hijazi","year":"2016","journal-title":"Eur. Heart J."}],"container-title":["Life"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-1729\/15\/5\/786\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:32:34Z","timestamp":1760031154000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-1729\/15\/5\/786"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5,14]]},"references-count":46,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2025,5]]}},"alternative-id":["life15050786"],"URL":"https:\/\/doi.org\/10.3390\/life15050786","relation":{},"ISSN":["2075-1729"],"issn-type":[{"value":"2075-1729","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,5,14]]}}}