Supplemental Digital Content is available in the text. We assessed the effect of once-weekly semaglutide and once-daily liraglutide on kidney outcomes in type 2 diabetes.Pooled (n=12 637) and by-trial data from SUSTAIN 6  and LEADER  were assessed for albuminuria change, annual slope of estimated glomerular filtration rate (eGFR) change, and time to persistent eGFR reduction  from baseline.P<0.001). Significant reductions were also observed in by-trial data analyses , the largest being with semaglutide 1.0 mg  at 2 years. With semaglutide 1.0 mg and liraglutide, eGFR slope decline was significantly slowed by 0.87 and 0.26 mL/min/1.73 m2/y (P<0.0001 and P<0.001), respectively, versus placebo. Effects appeared larger in patients with baseline eGFR <60 versus ≥60 mL/min/1.73 m2 . Semaglutide/liraglutide significantly lowered risk of persistent 40% and 50% eGFR reductions versus placebo . Similar, nonsignificant, directional results were observed for 30% and 57% eGFR reductions . In patients with baseline eGFR 30 to <60 mL/min/1.73 m2, the likelihood of persistent reduction for all thresholds was increased, ranging from HR 0.71 for 30% reduction  to 0.54 for 57% reduction .The median follow-up durations were 2.1 years for SUSTAIN 6 and 3.8 years for LEADER. In the pooled analysis, semaglutide/liraglutide lowered albuminuria from baseline to 2 years after randomization by 24% versus placebo (95% CI, 20%–27%; In patients with type 2 diabetes, semaglutide/liraglutide offered kidney-protective effects, which appeared more pronounced in patients with preexisting chronic kidney disease. Data suggest a kidney-protective effect with glucagon-like peptide-1 receptor agonists driven primarily by beneficial albuminuria outcomes, but definitive data on more severe kidney outcomes are lacking.In this analysis of SUSTAIN 6  and LEADER , we demonstrate the benefit of using once-weekly semaglutide and once-daily liraglutide on a number of clinically important kidney outcomes: changes in albuminuria, annual slope of estimated glomerular filtration rate change, time to persistent proportional estimated glomerular filtration rate reductions of 40% and 50% from baseline, and a composite end point .The results of this study suggest that the glucagon-like peptide-1 receptor agonists semaglutide and liraglutide may add to the kidney-protective treatment options available to people with type 2 diabetes and diabetic kidney disease.Further studies are required to investigate the full effect of glucagon-like peptide-1 receptor agonists on primary kidney end points in dedicated trials in diabetic kidney disease. SUSTAIN 6 and LEADER examined kidney end points as secondary outcomes and enrolled a majority of patients without diabetic kidney disease but with cardiovascular disease.1 Approximately 50% of people with T2D will develop DKD in their lifetime, and approximately half of kidney failure cases are ascribed to diabetes.2 As the global burden of T2D is increasing,3 so is the prevalence of kidney failure. The prevalence of kidney failure is predicted to exceed 5 million people by 2030.4Type 2 diabetes (T2D) is a major risk factor for the development and progression of chronic kidney disease, commonly referred to as diabetic kidney disease (DKD).5 A limited number of treatments have been shown to lower this risk. Therefore, it is important to identify treatments that reduce the risk of cardiovascular complications and of progression to kidney failure in people with DKD.People with DKD have a high risk of cardiovascular morbidity and mortality and generate increased costs associated with their treatment.12 Secondary kidney outcomes in these cardiovascular outcome trials have suggested kidney benefits.16 In the first designated T2D kidney outcome trials, the sodium-glucose cotransporter-2 inhibitors canagliflozin and dapagliflozin were shown to substantially lower the risk of hard kidney outcomes compared with placebo .18Recent developments in the management of T2D have identified treatments that reduce the risk of DKD progression. In cardiovascular outcome trials, sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) have lowered the risk of major adverse cardiovascular events.This post hoc analysis aimed to evaluate the effect of once-weekly semaglutide and once-daily liraglutide therapy on a broad range of clinically important kidney outcomes, including changes in albuminuria, estimated glomerular filtration rate (eGFR) slope, and persistent reductions in eGFR.Deidentified individual participant data, the study protocol, and a redacted clinical study report will be available according to Novo Nordisk data sharing commitments. The data will be made available permanently after research completion and approval of product and product use in both the European Union and United States. Data will be shared with bona fide researchers submitting a research proposal requesting access to data and for use as approved by the independent review board according to the independent review board charter. This and the access request proposal form and access criteria can be found at novonordisk-trials.com. The data will be made available on a specialized SAS data platform.https://www.clinicaltrials.gov; Unique identifier: NCT01720446) and LEADER  were randomized, double-blinded, placebo-controlled trials. Detailed methods of both trials have been published previously.7 The 2 trials included patients with T2D at high risk of cardiovascular events and with a glycohemoglobin (HbA1c) level ≥7%. In SUSTAIN 6, patients were randomized to once-weekly semaglutide 0.5 mg subcutaneously, once-weekly semaglutide 1.0 mg subcutaneously, or matching placebo for 2 years. In LEADER, patients were randomized to once-daily liraglutide up to 1.8 mg subcutaneously or matching placebo for 3.5 to 5 years (median 3.8 years). The primary outcome in both trials was major adverse cardiovascular events, consisting of nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death. Kidney end points were collected as secondary outcomes. Both cardiovascular and kidney outcomes were adjudicated by an external blinded event adjudication committee.7SUSTAIN 6  was collected at baseline and after baseline at weeks 16, 30, 44, 56, 80, and 104.In SUSTAIN 6, serum creatinine was collected at screening, randomization (baseline), and after baseline at weeks 2, 4, 8, 16, 30, 44, 56, 68, 80, 92, and 104. Calculation of eGFR was performed using the MDRD equation .19 UACR was collected at baseline and after baseline annually until final visit.In LEADER, serum creatinine was collected at screening, randomization (baseline), and after baseline at the 6-month visit, and then annually until final visit. Calculation of eGFR was performed using the MDRD equation.Urinary albumin values below the lower limit of quantification of 3 mg/g were imputed as 1.5 mg/g (lower limit of quantification/2) in the post hoc calculation of UACR. Approximately 17% of randomized patients had UACR values below the lower limit of quantification in both SUSTAIN 6 and LEADER at baseline.2, 60–<90 mL/min/1.73 m2, 30–<60 mL/min/1.73 m2, or <30 mL/min/1.73 m2) and albuminuria stage . Effects of semaglutide and liraglutide versus placebo on albuminuria over time, average annual eGFR decline (slope), and eGFR at the 2-year visit were also evaluated in the populations treated with semaglutide 0.5 and 1.0 mg and liraglutide 1.8 mg, respectively.We evaluated outcomes for the overall pooled population and according to preexisting kidney disease, defined by baseline eGFR (using the MDRD formula) and albuminuria. Patients were stratified by baseline eGFR , annual change in eGFR from baseline , and time to persistent 30%, 40%, 50%, and 57% eGFR  reductions from baseline, defined by time to first occurrence from randomization of the relevant reduction confirmed by a subsequent measurement. If no subsequent visit was performed, the confirmation was omitted. The CKD-EPI equation (Chronic Kidney Disease Epidemiology Collaboration) was used to calculate the eGFR used in the total slope analysis.We explored the effects of semaglutide in SUSTAIN 6 and liraglutide in LEADER, compared with placebo, on clinically important kidney outcomes,7Other outcomes included a composite of time from randomization to first occurrence of kidney death, need for maintenance kidney replacement therapy, or first occurrence of a reduction in eGFR of 40%, 50%, or 57% . We estimated total loss of eGFR over 2 years from randomization for both trials according to treatment groups. We assessed these outcomes in the overall pooled population and in subgroups defined by UACR and eGFR at baseline, as defined previously. Kidney failure and death, as components of the original secondary end points of both trials, were confirmed by the event adjudication committee.Data from all randomized patients in LEADER and SUSTAIN 6 were included from date of randomization to the end of follow-up visit. In the pooled analyses, both semaglutide treatment arms and the liraglutide treatment arm were pooled and compared with placebo. For the pooled analyses, the trial was used as a fixed effect.Effects of semaglutide and liraglutide by trial on albuminuria over time as compared with placebo were assessed using a mixed model for repeated measures with UACR as dependent variable , treatment and visits as fixed factors, baseline UACR (log-transformed) as a covariate, and the interactions between visits and treatment/baseline UACR, respectively. An unstructured covariance matrix for repeated measures was used. Least square means, differences, and 95% CIs between treatments were then back-transformed to the original scale. Because of the different trial durations of LEADER and SUSTAIN 6, treatment ratios were evaluated at 2 years from randomization to align comparisons of both trials. Pooled analyses were done using the same model with trial included as an additional factor.Slope analyses of eGFR were performed using a random-slope model by trial, with change from baseline as dependent variable, baseline value and time (in years) as covariate, treatment as a fixed factor, and the interaction between treatment and time. The intent-to-treat populations were used. Changes from baseline were assessed between each visit and used as the repeated measure, with the time from randomization as the underlying continuous time scale for the slope analyses. Patient-specific intercepts and time as random effects assuming a bivariate normal distribution for these effects were included in the model. Analyses by subgroups were performed by including the respective subgroups as a fixed factor and the interaction with treatment.Time-to-first-event analyses were performed using Cox proportional hazard models, with pooled treatment as a fixed factor and stratified by trial. Patients without respective events were censored at death or end of follow-up, whichever came first. Time to persistent reduction of eGFR from baseline  was analyzed independently from each other. Subgroup analyses were performed by including subgroup as a fixed factor and the interaction between subgroup and treatment. A quadratic spline Cox regression model was also used to analyze the time to persistent reduction end points , showing the hazard ratios (HRs) between the treatments (pooled GLP-1 RAs vs placebo) according to continuous measures.I2 test was used to measure the heterogeneity between the 2 trials when assessing the effect of semaglutide and liraglutide versus placebo on the annual eGFR slope at 2 years visit in the overall population and subgroups with preexisting DKD defined by the level of albuminuria and eGFR at baseline.An No adjustment for multiplicity or missing values was performed. A significance level of 5% was used overall. Statistical analysis was performed with SAS version 9.4 (SAS Institute).7) and were conducted according to the principles of the Declaration of Helsinki.21 All participants provided written informed consent before participation in trial-related activities.7Both studies received full approval by ethics committees or institutional review boards at each participating site  patients had an eGFR <60 mL/min/1.73 m2 and 4726 (38.2%) patients had elevated albuminuria, either microalbuminuria (27.0%) or macroalbuminuria (11.2%).A total of 12 637 patients were included in the pooled analysis (3297 from SUSTAIN 6 and 9340 from LEADER), with 6316 patients in the combined semaglutide/liraglutide group  and 6321 patients in the combined placebo group. The median durations of follow-up (after randomization) were 2.1 and 3.8 years for SUSTAIN 6 and LEADER, respectively.P<0.001; Figure Pinteraction=0.021; Figure S1).In the pooled analysis, semaglutide/liraglutide treatment lowered albuminuria from baseline to 2 years after randomization by 24% (placebo-corrected geometric mean ratio of relative change from baseline) compared with placebo  and the 1.0 mg dose lowered albuminuria by 33% compared with placebo . At 2 years after randomization, albuminuria was 23% lower in liraglutide-treated patients compared with placebo . The effect of the semaglutide 1.0 mg dose was statistically greater than that of liraglutide (P=0.024) at 2 years after randomization.Both semaglutide and liraglutide lowered albuminuria compared with placebo Figure . At 2 ye2/y]) and LEADER  in the overall population, and this was broadly consistent at different levels of baseline kidney function , whereas randomization to semaglutide 1.0 mg slowed kidney function loss by 0.87 mL/min/1.73 m2/y versus placebo .In the overall population, patients randomized to semaglutide 0.5 mg had a nonsignificant reduction in eGFR slope versus placebo . The difference was 0.67 versus 0.21 mL/min/1.73 m2/y (Pinteraction=0.37) for patients randomized to semaglutide 0.5 mg with baseline eGFR <60 or >60 mL/min/1.73 m2/y, respectively. Patients receiving liraglutide with baseline eGFR <60 mL/min/1.73 m2 lost 0.67 mL/min/1.73 m2/y less kidney function than patients receiving placebo, whereas patients with baseline eGFR ≥60 mL/min/1.73 m2 lost 0.15 mL/min/1.73 m2/y .The results were similar when the total loss of kidney function over 2 years after randomization of all treatments was considered  in the subgroup with normoalbuminuria to 0.29 mL/min/1.73 m2  in the subgroup with macroalbuminuria (Pinteraction=0.98) at 2 years after randomization. Semaglutide 1.0 mg effect on eGFR slope compared with placebo ranged from 1.48 mL/min/1.73 m2  in the subgroup with normoalbuminuria to 2.33 mL/min/1.73 m2  in the subgroup with macroalbuminuria (Pinteraction=0.84). The effect of liraglutide on eGFR slope compared with placebo appeared to be modified by the degree of albuminuria at baseline, with eGFR slope differences ranging from 0.20 mL/min/1.73 m2  with normoalbuminuria to 1.64 mL/min/1.73 m2  with macroalbuminuria at 2 years after randomization .The effect of semaglutide on eGFR slope compared with placebo was not clearly modified by level of albuminuria at baseline. Semaglutide 0.5 mg effect on eGFR slope compared with placebo ranged from 0.59 mL/min/1.73 mP=0.039 and HR, 0.80 ; P=0.023, respectively; Figure P=0.10) or a persistent 57% reduction  was not significantly reduced but showed similar directional results  versus placebo on the risk of persistent reductions in eGFR using a range of clinically relevant thresholds is shown in Figure 2 at baseline, persistent reduction in eGFR for all thresholds occurred in fewer patients in the semaglutide/liraglutide group compared with the placebo group, with a trend to greater effect sizes as eGFR thresholds increased. The HR  values were as follows: 30% reduction: 0.71 (0.59–0.85), P=0.0003 (14.4% vs 19.2%); 40% reduction: 0.67 (0.52–0.86), P=0.0017 (7.7% vs 11.0%); 50% reduction: 0.56 (0.40–0.78), P=0.0006 (4.0% vs 6.8%); 57% reduction: 0.54 (0.36–0.81), P=0.003 , especially for 30% and 57% reduction thresholds .In subgroups of patients with an eGFR of 30 to <60 mL/min/1.73 mP=0.004 for 30% reduction in eGFR to 0.77 ; P=0.050 for 50% reduction in eGFR) and microalbuminuria or macroalbuminuria at baseline .The results were broadly consistent for subgroups on the basis of baseline albuminuria Figure , with seFigure S4). The effect of semaglutide/liraglutide therapy on persistent reduction in eGFR for all thresholds appeared to be larger in subgroups of patients with eGFR 30 to <60 mL/min/1.73 m2 and microalbuminuria or macroalbuminuria at baseline than in subgroups with baseline eGFR of ≥60 mL/min/1.73 m2 or normoalbuminuria as well as subgroups with eGFR <30 mL/min/1.73 m2 and microalbuminuria or macroalbuminuria at baseline.Similar patterns were observed in subgroups of patients stratified on the basis of a combination of baseline eGFR and albuminuria criteria .When persistent reductions in eGFR were combined with kidney failure and kidney death to form 3 composite outcomes, similar findings were observed , dulaglutide was found to slow eGFR decline compared with insulin glargine in people with advanced chronic kidney disease,22 with identical control of HbA1c in both groups. Dulaglutide also reduced the risk of substantial loss of kidney function compared with placebo in the REWIND trial , which examined kidney outcomes as key secondary end points.9 ELIXA 23 and EXSCEL 24 monitored kidney outcomes only as adverse events and failed to demonstrate benefits for kidney function per se, despite moderate lowering albuminuria or lower incidence of new microalbuminuria with lixisenatide and exenatide, respectively. In a post hoc analysis of EXSCEL, the positive effect of exenatide on the eGFR slope was more pronounced in patients with higher albuminuria at baseline versus patients with normal albuminuria.25 Exenatide, in a post hoc analysis, also reduced composites of either 40% or 30% eGFR decline and kidney replacement therapy.24 Variability in effects of GLP-1 RAs on cardiovascular outcomes has also been demonstrated,13 highlighting the inability to generalize effects across different members of the drug class at doses that generally lead to comparable lowering of HbA1c. These variable cardiovascular and kidney benefits may be attributable to differences in trial conduct or to the medicines or their degradation products potentially having favorable effects with human-based, but not exendin-based, GLP-1 RAs in T2D.26The likelihood of a kidney-protective effect with GLP-1 RA therapy is supported by the results of other studies. In AWARD-7  specifically addresses the question regarding slowing progression of DKD. The trial will enroll 3508 patients with T2D and kidney disease to either semaglutide 1.0 mg subcutaneously or matching placebo. The primary outcome is a composite of kidney failure , a persistent ≥50% reduction in eGFR, and kidney or cardiovascular death. FLOW will provide a definitive assessment of the kidney protection suggested in this analysis. In addition, kidney outcomes in patients treated with semaglutide will be investigated as secondary end points in both SOUL  and SELECT .The larger magnitude of effect of the semaglutide 1.0 mg dose compared with both the semaglutide 0.5 mg dose and liraglutide on both albuminuria and eGFR, along with likely benefits on substantial reductions in kidney function, suggests that this agent in particular might have an important role in protecting kidney function in diabetes. This may be especially relevant in people with existing DKD. Although these post hoc analyses of secondary outcomes are promising, a specific, a sufficiently powered trial aiming to assess the effects of semaglutide/liraglutide on kidney outcomes in people with diabetes and kidney disease is needed. FLOW  were included in the analysis. This likely influenced the sustained eGFR reduction analysis (Table S1).The main strength of our analysis is the incorporation of 2 large randomized clinical trials that prospectively defined adjudicated kidney outcomes as key secondary outcomes. There are also some limitations. This is an exploratory analysis and was not prespecified. SUSTAIN 6 and LEADER were not originally powered to evaluate kidney outcomes and included patients with relatively low kidney risk at baseline. We did not take into account competing risk from terminal events , which could favor especially the liraglutide arm versus placebo, as for this end point there was a 22% risk reduction compared with placebo overall.This pooled analysis suggests a kidney-protective effect of semaglutide and liraglutide. This effect seems to be more pronounced in people with DKD. FLOW will prospectively test the effect of semaglutide in this patient group and may identify an additional therapeutic strategy for people with T2D and kidney disease.The authors thank the trial personnel and participants.The study was funded by Novo Nordisk A/S. The authors thank Jin Heppell, PhD, Aneela Majid, PhD, and Izabel James, MBBS, of Ashfield MedComms, an Ashfield Health company (funded by Novo Nordisk A/S), for incorporation of comments and editorial assistance.Dr Shaman reports no conflicts of interest. Dr Bain reports personal fees from AstraZeneca (modest), Boehringer Ingelheim (modest), Eli Lilly (modest), Merck Sharp & Dohme (modest), Novo Nordisk (significant), and Sanofi-Aventis (modest). Dr Bakris reports monies paid to his institution (University of Chicago Medicine) for steering committee participation and consulting fees from Merck, Relypsa, Vifor, and AstraZeneca . Dr Buse reports contracted consulting fees and travel support for contracted activities paid to the University of North Carolina by Adocia, AstraZeneca, Dance Biopharm, Dexcom, Eli Lilly, Fractyl, GI Dynamics, Intarcia Therapeutics, Lexicon, MannKind, Metavention, NovaTarg, Novo Nordisk, Orexigen, PhaseBio, Sanofi, Senseonics, vTv Therapeutics, and Zafgen; receives grant support from AstraZeneca, Eli Lilly, Intarcia Therapeutics, Johnson & Johnson, Lexicon, Medtronic, NovaTarg, Novo Nordisk, Sanofi, Theracos, Tolerion, and vTv Therapeutics; is a consultant to Cirius Therapeutics Inc, CSL Behring, Mellitus Health, Neurimmune AG, Pendulum Therapeutics, and Stability Health; holds stock/options in Mellitus Health, Pendulum Therapeutics, PhaseBio, and Stability Health; and receives grant support from the National Institutes of Health (UL1TR002489 and P30DK124723). Dr Idorn is a Novo Nordisk employee and stockholder (modest). Dr Mahaffey reports research grants from the American Heart Association, Apple, Inc, Bayer, California Institute Regenerative Medicine, Eidos, Ferring, Gilead, Google (Verily), Idorsia‚ Johnson & Johnson, Luitpold, PAC-12‚ Precordior‚ and Sanifit; consulting or other service fees (including CME) from Amgen, Applied Therapeutics, AstraZeneca, Bayer, CSL Behring, Elsevier, Fibrogen‚ Inova, Johnson & Johnson, Lexicon‚ Myokardia, Novartis, Novo Nordisk, Otsuka, PhaseBio, Portola, Sanofi, and Theravance (significant for the Novo Nordisk relationship). Dr Mann has received speaker honoraria from AstraZeneca, Medice, Novartis, Novo Nordisk, Roche, and Vifor Pharma; research support from the European Union, Population Health Research Institute, AstraZeneca, Bayer, Boehringer Ingelheim, Idorisia, and Novo Nordisk; and consultation fees from AstraZeneca, Bayer, Merck, Novo Nordisk, and Vifor Pharma . Dr Nauck has served on advisory boards or consulted for AstraZeneca (modest), Boehringer Ingelheim (modest), Eli Lilly & Co (significant), Menarini/Berlin Chemie (modest), Merck, Sharp & Dohme (significant), and Novo Nordisk (significant); his institution has received grant support from AstraZeneca, Boehringer Ingelheim, Eli Lilly & Co, GlaxoSmithKline, Intarcia, Menarini/Berlin-Chemie, Merck, Sharp & Dohme, Novartis Pharma, and Novo Nordisk A/S; he has served on speakers’ bureaus of AstraZeneca (modest), Boehringer Ingelheim (modest), Eli Lilly & Co (modest), GlaxoSmithKline (modest), Menarini/Berlin Chemie (modest), Sun Pharma (modest), Merck, Sharp & Dohme (significant), and Novo Nordisk A/S (significant). Dr Rasmussen is a Novo Nordisk employee and stockholder (significant). Dr Rossing is on the steering committee of the following clinical trials: CADA-DIA (Bayer), Fidelio (Bayer), Figaro (Bayer), DAPA-CKD (Astra Zeneca), and FLOW (Novo-Nordisk); and The Steno Diabetes Center Copenhagen has received fees for consultancy and/or speaking from Astellas, AstraZeneca, Bayer, Boehringer Ingelheim, Gilead, Eli Lilly, Mundi, Novo Nordisk, and Sanofi Aventis . Dr Wolthers is a Novo Nordisk employee and stockholder. Dr Zinman has received consulting fees from Merck, Novo Nordisk, Sanofi-Aventis, Eli Lilly, AstraZeneca, Janssen, and Boehringer Ingelheim . Dr Perkovic reports consultancy for AbbVie, Inc, Amgen, AstraZeneca, Bayer Healthcare, Boehringer Ingelheim, Chinook Therapeutics, Dimerix Bioscience, Gilead Sciences Inc, GlaxoSmithKline, Janssen Global Services, LLC, Metavant Sciences, Mundipharma, Novartis Pharma, Novo Nordisk AS, Travere Therapeutics, Inc, and Tricida; and other for George Clinical, Mitsubishi Tanabe Pharma Corporation, and UpToDate. Drs Idorn, Rasmussen, and Wolthers verified the underlying data and Dr Rasmussen performed the statistical analyses. Drs Shaman and Perkovic wrote the first draft of the manuscript. Dr Perkovic had final responsibility for the decision to submit for publication. All authors contributed significantly to the design and conduct of the study and acquisition of clinical data, reviewed and interpreted the data, were involved in drafting and critically revising the manuscript, approved the final version of the manuscript, and take full responsibility for the content.Table S1Figures S1–S7


Introduction: Cardiovascular system is the vitally important system in the dynamical adaptation process of the newborns to the extrauterine environment. To reliably detect immaturity in the given organ system, it is crucial to study the development of the organ functions in relation to maturation process.Objectives: The objective was to determine the changes in the spontaneous short-term blood pressure variability (BPV) and baroreflex sensitivity (BRS) reflecting various aspects of cardiovascular control during the process of maturation in preterm babies and to separate effects of gestational age and postnatal age.Methods: Thirty-three prematurely born infants without any signs of cardio-respiratory disorders  were enrolled. Continuous peripheral blood pressure signal was obtained by non-invasive volume-clamp photoplethysmography method during supine rest. The recordings of 250 continuous beat-to-beat blood pressure values were processed by spectral analysis of BPV  and BRS calculation. For each infant we also assessed systolic, diastolic and mean blood pressures, heart rate and respiratory rate.Results: With the postconceptional age, BPV measures decreased ; and BRS increased significantly . The further analysis demonstrated that these effects were more attributable to gestational age than to postnatal age. BRS correlated negatively with BPV magnitude . Mean blood pressure and diastolic blood pressure increased during maturation  while heart rate and respiratory rate decreased .Conclusion: We conclude that maturation process is accompanied by an increased involvement of baroreflex buffering of spontaneous short-term blood pressure oscillations. Gestational age plays a dominant role not only in BPV changes but also in BRS, mean blood pressure, diastolic blood pressure and heart rate changes. Premature infants represent a specific group of individuals with different degrees of maturation. The degree of maturity/immaturity determines their prognosis, including various abnormalities in cardiovascular system (CVS) as well as subsequently increased risk of hypertension in adulthood –3. To reThe immaturity of CVS and its control as one of the most vitally important physiological systems can be potentially risky for a premature newborn . AlthougShort-term BPV is a result of complex regulation of cardiovascular system, including high-pressure baroreflex, sympathetic modulation of vasculature, regulation of cardiac activity, as well as changes in venous blood return  , 9. KnowThe aim of this study was to study developmental changes in BPV and BRS in preterm infants. We addressed also the hypothesis that baroreflex buffers the blood pressure oscillations and therefore in the next step we focused on the relation between BPV and BRS.A total of 33 children (15 boys and 18 girls) born in the 27th−36th gestational week with a birth weight of 820–2,730 g were recruited for the study. From this basic group, one child was classified as extremely preterm  and 14 were classified as very preterm . At the time of examination, the children had a postconceptional age  of 32.3–38.4 weeks. To analyze the influence of growth after birth and deviation of birth or current weight from average values for given age we found z-scores (distance from population mean expressed in standard deviations) for both birth and current weights. Growth after birth was quantified as a difference between z-scores for current and birth weights.Criteria for inclusion of newborns included postnatal age higher than 4 days and a wrist circumference of 45–75 mm. The infants at the time of examination were without any symptoms of respiratory or cardiovascular disorders and they did not take drugs that could affect the cardiorespiratory system. Only children who were calm during the examination were included in the study. The child's motor restlessness was one of the exclusion criteria. Other exclusion criteria included respiratory or cardiovascular disorders and chromosomal abnormalities. The infants requiring phototherapy due to hyperbilirubinemia or analgosedation at the time of measurement were also excluded from our study.The study was approved by the Ethics Committee of the Jessenius Faculty of Medicine, Comenius University in Martin (Slovakia). Written informed consent to the infant's participation in the study was given for each child by a parent or legal guardian.Examination of children and data recording were performed between 8 a.m. and 3 p.m, 1–2 h after feeding. The measurement conditions, including environmental, were standardized with a reduction of visual and acoustic stimuli, constant ambient temperature set according to the gestational age of the child in the incubator or on a warming mattress. During recordings the children were in the supine position.A Portapres instrument  was used for non-invasive and continuous peripheral blood pressure (BP) recording. BP registration was preceded by a selection of a cuff of the appropriate size according to the circumference of the newborn's wrist. After placing the cuff on the wrist of the right hand, which was supported and kept at heart level, the child was left at rest for at least 5 min. Subsequently, we recorded resting beat-to-beat BP values during 2–5 min. Recordings of blood pressure were stored in the device memory, transferred to a computer and processed by original FMS software. During each measurement, we recorded the child's behavior and the current oxygen saturation of blood with a pulse oximeter . The average value of oxygen saturation in the whole study group was 97% (range 93–100%). Respiratory rate was measured visually from chest and abdomen movements at 30 s intervals.Each child was connected to a monitor  for intermittent determination of systemic BP using oscillometric method. Two BP values were obtained before Portapres was used, two values after measurement by Portapres. For each infant, the oscillometrically measured BP was determined as an average of these four values.From each recording, a stationary part consisting of 250 continuous beat-to-beat values of systolic BP (SBP), diastolic BP (DBP), mean BP (MBP) values and pulse intervals were found. The mean values of SBP, DBP, MBP and heart rate  for each newborn were calculated. The spontaneous variability of SBP was analyzed by spectral analysis using fast Fourier transform (FFT) after resampling at 4 Hz and detrending. Window size was set at 256 resampled values. Total spectral power (TP) and spectral power in the low frequency band (LF: 0.04–0.15 Hz) and in the high frequency band (HF: 0.4–1.5 Hz) were calculated. Spectral bands for the neonatal population were defined according to Andriessen et al. , 11. WhiP = 0.01, it indicated that increase in systolic blood pressure was accompanied by an increase in pulse interval pointing toward an involvement of baroreflex in given window of recording. The delay giving the highest correlation was chosen and instantaneous BRS value was estimated as the slope of relation between systolic blood pressure and pulse interval. Mean BRS for each newborn was calculated as a mean of instantaneous BRS values . Data acquisition and processing are schematically presented in As the next step, BRS expressed in ms/mmHg was calculated using the cross-correlation sequence method (or xBRS method) using original software provided with Portapres device. In more details, 10 s windows of simultaneous systolic blood pressure and pulse interval changes were analyzed to find positive cross-correlation using time delays between blood pressure and pulse interval signal ranging from 0 to 5 s. When cross-correlation value was significant at t-test (for variables with Gaussian distribution) and non-parametric Mann-Whitney U-test  were used to test significant differences between two subgroups. To determine the correlations between variables, Spearman's correlation coefficient (rs) and P-value associated with the given coefficient were determined.Shapiro-Wilk normality test as a test of the normal Gaussian distribution of analyzed data was used prior to statistical analysis. Two-sample P-values below 0.05 as the statistically significant. The results are presented as mean and standard deviation (SD).For all statistics, we considered the s = −0.87) violating the possibility to analyze effects of postnatal age and gestational age separately.The study was originally intended to analyze separately the effect of gestational age and postnatal age on BPV and BRS measures. However, infants with lower gestational age had greater instability of the respiratory and cardiovascular systems at the beginning of neonatal period. These children were examined only after the stabilization of their vital functions. It caused that children with low gestational age were usually examined later after birth , while children with higher gestational age were examined earlier in their postnatal age. It caused strong negative correlation between gestational and postnatal age  was a group with higher gestational age and lower postnatal age and the second group (group 2) was characterized by a lower gestational age and higher postnatal age. Both groups had almost the same current weight at the time of measurement. The basic study group and subgroups characteristics are presented in −1).BP and HR values determined by the intermittent oscillometric method in the whole basic study group did not differ significantly from the values measured by Portapres presented in s = 0.537; p = 0.001) and MBP , BRS , and it correlated negatively with HR  and respiratory rate . Postconceptional age also significantly negatively correlated with total power in systolic blood pressure (TP SBP), spectral power in low frequency band (LF SBP) and in high frequency band (HF SBP)  .No correlation between z-scores of birth weight and current weight or of their difference with any analyzed cardiovascular measure was found.−1).Despite the similar postconceptional age and current weight, the group 1 in comparison to the group 2 had higher MBP (44.0 vs. 38.0 mmHg), DBP (35.3 vs. 28.0 mmHg) and lower HR .Correlations between BRS and HR and parameters of spectral analysis of SBP variability were calculated in the whole group of 33 infants. TP as well as spectral powers in LF and HF bands significantly negatively correlated with BRS . There wThe most important observations of our study include the following effects of postconceptional age and gestational age on cardiovascular control in premature newborns: a decrease of blood pressure variabiliy accompanied by an increase in baroreflex sensitivity, a decrease in heart rate together with an increase of diastolic and mean blood pressures and a significant correlation between baroreflex sensitivity and blood pressure variability magnitude.With the introduction of noninvasive method for beat-to-beat BP recording into clinical physiology, including its application to newborns, new insight into cardiovascular control emerged. Firstly, spontaneous oscillations of BP – BPV – could be analyzed providing information related to BP control. Secondly, from the analysis of heart rate  changes in relation to BP perturbations, cardiac chronotropic branch of high-pressure baroreflex characteristics including BRS can be estimated.The mechanisms behind spontaneous BPV are complex. Similarly to heart rate variability, the blood pressure changes from heart beat to heart beat. These spontaneous changes – BPV – are mostly composed of the slower (low-frequency – LF) and faster (high-frequency - HF) oscillations. Slower LF oscillations in BPV of systolic blood pressure were considered to reflect mostly sympathetic activity directed to blood vessels . HoweverSBP variability in the HF spectral band is mostly influenced by changes in cardiac contraction strength associated with ventilation . Cyclic We observed the negative correlation between postconceptional age and BPV  in the group of premature infants. It means that with a higher postconceptional age BPV in all assessed frequency bands decreases. Interestingly, when we analyzed two groups with the similar postconceptional age but different gestational and postnatal ages, we found statistically significantly lower values of TP SBP and HF SBP and a tendency toward lower LF SBP power. It indicates that the gestational age plays a dominant role in the gradual decrease of BPV in newborns.Our results point toward the fact that the intrauterine maturation  plays a dominant role in the stabilization of spontaneous short-term BPV, mostly in the HF band. Since blood pressure changes are mediated by multiple mechanisms partially explained above, several mechanisms could be responsible for this phenomenon:Firstly, the decrease in the baroreflex involvement in the origin of BPV oscillations mediated by sympathetic nerves directed to the vessels can be considered. However, we assume that this mechanism will affect mostly LF oscillations in BPV and we consider this mechanism as a less probable because in our study HF SBP was affected more prominently.Secondly, when we consider both LF and HF BPV oscillations, the changes in heart rate variability could be responsible for the changes in BPV via so called feedforward mechanism where changes in cardiac cycle length are transferred to SBP changes . HoweverThirdly, the activity and regulatory role of the autonomic nervous system is underdeveloped in premature infants making mechanical changes caused by respiration dominant in the origin of BP oscillations . A reducFourth important potential mechanism of observed BPV changes associated with postconceptional and gestational age include baroreflex acting as a buffer of BP oscillations . Wray etWe tried to confirm this hypothesis by the analysis of BRS from spontaneous HR and SBP oscillation. In agreement with previous studies –24, highWe observed a positive correlation of postconceptional age with MBP and DBP and negative correlation with heart and respiratory rate . In other words, the higher was the gestational age, the higher was the systemic DBP, MBP and lower HR and RR. These findings are consistent with previous results –29. SubgSeveral previous studies demonstrated that regardless of gestation week at birth where marked difference in BP values are observed, BP values become similar at the postconceptional age of 42 – 44 weeks , 32. In In contrast, growth rate expressed as a difference in z-scores between birth and current weights did not correlate with any analyzed measure and it did not differ between two groups. It indicates that potential effect of altered growth rate after birth did not contribute to the observed changes and relations.Method of the continuous non-invasive recordings of blood pressure by volume-clamp method in neonatology has great benefits but is relatively difficult and limited. The volume-clamp photoplethysmographic method  enables The first limit stems from the size of the cuffs supplied with the device . It limits the use of the device to newborns with a wrist circumference in the range of 45–75 mm, i.e., mostly to the premature newborns. A wrist circumference in our group of premature infants was in the range 49.5–74.2 mm. Using an inappropriate cuff size ].Relatively small number of examined subjects associated with complex measurement procedure did not enable to account for potential sex differences and it must be also considered as a study limitation.We conclude that maturation process is accompanied by a decrease in BPV and an increase of BRS reflecting buffering of BP changes by baroreflex. Gestational age plays a dominant role not only in BPV changes but also in BRS, MBP, DBP and HR changes. The results indicate changes related to parasympathetic heart rate control in relation to postconceptional and gestational age in preterm infants.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethical Committee of the Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.KJ, MZ, and MJ designed the study. KH and MZ arranged for the probands participation. KH performed the measurements. BC and KJ analyzed the data and prepared figures. KJ and MJ wrote the manuscript and have contributed equally to this paper and share first authorship. KJ, MJ and MZ contributed to the interpretation of the results. KJ and MZ helped to supervise the project. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The total amount of ultra-long-chain FAs containing 26 and more carbon atoms was significantly reduced . The desaturation index (18:1/18:0) increased after transplantation . The study showed a significant reduction in n-3 PUFAs in renal transplant recipients 3 months after transplantation, which may contribute to increased cardiovascular risk in this patient population.Epidemiological data indicate that metabolic disturbances and increased cardiovascular risk in renal transplant patients are a significant and common problem. Therefore, it is important to search for new solutions and, at the same time, counteract the negative effects of currently used therapies. In this study, we examined the effect of kidney transplantation on the serum levels of fatty acids (FAs) in order to assess the role of these compounds in the health of transplant patients. The FA profile was analyzed by gas chromatography-mass spectrometry in the serum of 35 kidney transplant recipients, just before transplantation and 3 months later. The content of total n-3 polyunsaturated FAs (PUFAs) decreased after transplantation (3.06 ± 0.13% vs. 2.66 ± 0.14%;  Despite advances in renal replacement therapy, the mortality rate in patients with chronic kidney disease (CKD) remains several times higher than in the general population. CKD is associated with an increased risk of cardiovascular disease (CVD) . DyslipiEnd-stage CKD requires renal replacement therapy (RRT), including dialysis, which keeps patients alive, yet at the same time, exposes them to many complications, including CVD. Kidney transplantation (KTx) either from a living donor (most often a family member) or from a deceased donor seems to be the RRT of choice for the majority of patients. The quality of life and life expectancy significantly improve after kidney transplantation; therefore, it is the optimal method of CKD treatment despite the fact that it is associated with the increased risk of obesity, post-transplant diabetes, arterial hypertension, and other adverse metabolic effects of immunosuppressive treatment. The risk of CVD decreases after KTx but still remains a major cause of morbidity and mortality among these patients .A major fraction of lipids, fatty acids (FAs) are a structural component of most complex lipids or can circulate in the blood in a free form . FAs build the phospho- and glycolipids of biological membranes and create fatty energy stores in the form of TG . The metCKD promotes FA disorders by metabolic alterations and dietary restrictions resulting from chronic intoxication. Previous research has shown changes in the proportion of individual serum FAs in CKD patients; in particular, the content of serum monounsaturated FAs (MUFAs) is increased , and theMost studies indicate that n-3 PUFAs may contribute to cardiovascular protection in the general population ,13. N-3 The dominant group of FAs are even-chain FAs . A smallKidney transplantation, like any therapy, has negative consequences. Basic lipid disorders are known to occur both in patients with end-stage kidney disease and in kidney transplant recipients.Only a few publications in the literature investigate the issue of the FA profile in kidney transplant recipients. Most of them assess the effect of n-3 PUFA supplementation on the kidney allograft function and lipid profile ,18.In our previous studies, we observed that despite normal kidney function after transplantation, the FA profile was still abnormal . Our recg, the serum sample was coded and stored at −80 °C until the FA analysis.The study included 35 CKD patients (19 men and 16 women) aged 22–70 years, evaluated before kidney transplantation from deceased donor and 3 months after the transplantation procedure. Unfortunately, we were not able to include in this study patients who had kidney transplantation from living donors due to the insufficient number of these transplantations in our center. In order to investigate the effect of transplantation on the FA profile, serum samples were collected at 2 time points from the same patients. The samples were collected just before transplantation and 3 months after the transplantation. The kidney transplant process begins when the deceased donor is qualified for organ donation. After tissue typing is performed, the recipient is selected from a nationwide list. The selected recipient is transported to the center that performs the procurement. Only recipients from the Pomeranian Region were included in the study, which allowed for further follow-up observations. The consent of the Independent Bioethics Committee of the Medical University of Gdansk was obtained (protocol no. NKBBN 151212019 of 4 September 2019) to perform this study. Written informed consent was obtained after the patient was admitted on the day of the transplant. After preliminary preparation and fasting, a blood sample was taken for analysis. After centrifugation at 3000× After a successful transplantation, the patients underwent further follow-up at the Nephrology Outpatient Clinic. Patients received dietary instructions in accordance with Polish guidelines . Three mv/v), according to the Folch et al. method [n-hexane. The organic phase was evaporated under a nitrogen stream. Extracts were then derivatized into FA methyl esters (FAMEs) with 10% BF3 in methanol solution for 1.5 h at 55 °C. Then, 1 mL of water was added, and FAMEs were extracted with 3 × 1 mL of n-hexane, dried under a nitrogen stream, and stored at −20 °C until the GC-MS analysis. The FAMEs were detected by a GC-EI-MS QP-2010SE spectrometer  with chromatographic separation on a Zebron ZB-5MSi capillary column, 30 m × 0.25 mm i.d. × 0.25-µm film thickness . Separation parameters were set as follows: column oven temperature was 60–300 °C (4 °C/min), total analysis run time was 60 min; helium was used as a carrier gas (column head pressure at 100 kPa). The MS analysis was conducted in full scan mode, with the mass scan range set at m/z 45–700. The electron impact source operated at 70 eV. FAs were identified using a reference standards mixture  and the reference library NIST 11. The internal standard was 19-methylarachidic acid.The FA profile was analyzed by gas chromatography with mass spectrometry (GC-MS), using the same method as in the previous work . Briefly. method . Next, at-test for parametric data. For nonparametric data, the Mann–Whitney U test was used. Normal distribution was assessed with the Shapiro–Wilk test. We assumed the significance of the differences at the level of p < 0.05. The results were presented as means together with the standard error of the mean (SEM). The Sigma Plot 14.5 program  was used for the calculations.In the analysis, the significance of changes was assessed using the two-tailed Student’s As expected, patients 3 months after kidney transplantation had significant improvements in renal function parameters . The C-reactive protein (CRP), which serves as an indicator of inflammation, was also significantly reduced .The total even-chain saturated FAs (ECFAs), OCFAs, BCFAs, and total SFAs did not change after transplantation A–D. Howep < 0.05). Among them, 26:0 was significantly decreased 3 months after kidney transplantation , whereas 28:0 and 30:0 tended to decrease  containing 26 and more carbon atoms was significantly reduced (decrease .p < 0.05).Among monounsaturated fatty acids (MUFAs), after transplantation, a statistically significant increase was found only for 20:1 , but theThe proportion of some n-6 PUFAs was significantly decreased 3 months after KTx, as was adrenic acid , dihomo-γ-linolenic acid , and arachidonic acid (ARA), whereas 18:2n-6 increased after transplantation .p <0.05), and most of them decreased statistically significantly  plays an important role in the synthesis of unsaturated acids. In the liver and adipose tissue, this enzyme catalyzes the process of biosynthesis of MUFAs, the major components of TG . The actAn interesting finding was a decrease in ULCFAs with 26 and longer carbon chains, which may be related to their increased degradation that occurs in the liver . We obseThe current study showed an alteration of patients’ FA profiles due to transplantation by comparing the serum FA profile in patients pre- and post- transplantation. This profile can be influenced by many factors. The fact that these patients were immunosuppressed may have had some impact. Similarly, other medications that patients were taking may have altered the lipid metabolism. Together with immunosuppression, each recipient took an average of 11 types of drugs after discharge from the hospital. We could not in any way eliminate or evaluate the influence of these substances on the examined FA profiles. The size of the study group and the large number of medications taken did not allow us to divide patients into groups depending on the type of medications taken. It should also be added that renal failure is usually associated with the presence of CVD and a multitude of complications of chronic toxemia in the course of CKD and hemodialysis . Diet isOur previous study  showed sAfter transplantation, recipients are particularly vulnerable to complications related to intensive immunosuppressive therapy, such as wound-healing disorders, infections, peptic ulcer disease, pancreatitis, and stroke. However, cardiovascular complications are the most common and the most important. Only over a long period of time are the greater benefits noticeable, i.e., the reduction of complications related to chronic dialysis and the prolongation of life .It is known that disturbances in the FA profile increase cardiovascular risk. Our research allowed us to observe exactly what changes occurred in the FA profile after kidney transplantation. The results suggest that decreased n-3 PUFAs may increase the cardiovascular risk in this group of patients. Moreover, the obtained results may suggest that the supplementation of appropriate FAs, especially n-3 PUFAs, alone or with dietary intervention, may reduce disorders in the FA profile and cardiovascular risk, but this should be confirmed in a properly designed clinical trial.Among the limitations of this study is the relatively small number of patients, which did not allow to perform a multivariable analysis to adjust the changes in various FA for potentially confounding variables, such as CHOL and TG. However, due to applying paired statistical tests, we were able to obtain conclusive results in this group of CKD patients.This study showed that kidney transplantation in patients suffering from CKD changes their FA profile over a 3-month follow-up period, and the most clear-cut changes concern a significant decrease in n-3 PUFAs. These results confirm our previous studies comparing transplant patients with healthy people, which also showed decreased levels of n-3 PUFAs in patients after kidney transplantation. Since such disorders may increase cardiovascular risk, it seems that further research with the use of nutritional intervention for supplementing the deficiencies shown is necessary.


Acute electrolyte and acid–base imbalance is experienced by many children following kidney transplantation. When severe, this can lead to complications including seizures, cerebral oedema and death. Relatively large volumes of intravenous fluid are administered to children perioperatively in order to establish perfusion to the donor kidney, the majority of which are from living and deceased adult donors. Hypotonic intravenous fluid is commonly used in the post-transplant period due to clinicians’ concerns about the sodium, chloride and potassium content of isotonic alternatives when administered in large volumes.Plasma-Lyte 148 is an isotonic, balanced intravenous fluid that contains sodium, chloride, potassium and magnesium with concentrations equivalent to those of plasma. There is a physiological basis to expect that Plasma-Lyte 148 will reduce the incidence of clinically significant electrolyte and acid–base abnormalities in children following kidney transplantation compared with current practice.The aim of the PLUTO trial is to determine whether the incidence of clinically significantly abnormal plasma electrolyte levels in paediatric kidney transplant recipients will be different with the use of Plasma-Lyte-148 compared to intravenous fluid currently administered.PLUTO is a pragmatic, open-label, randomised controlled trial comparing Plasma-Lyte 148 to current care in paediatric kidney transplant recipients, conducted in nine UK paediatric kidney transplant centres.A total of 144 children receiving kidney transplants will be randomised to receive either Plasma-Lyte 148 (the intervention) intraoperatively and postoperatively, or current fluid. Apart from intravenous fluid composition, all participants will receive standard clinical transplant care.The primary outcome measure is acute hyponatraemia in the first 72 hours post-transplant, defined as laboratory plasma sodium concentration of <135 mmol/L. Secondary outcomes include symptoms of acute hyponatraemia, other electrolyte and acid–base imbalances and transplant kidney function.The primary outcome will be analysed using a logistic regression model adjusting for donor type (living vs deceased donor), patient weight (<20 kg vs ≥20 kg pretransplant) and transplant centre as a random effect.The trial received Health Research Authority approval on 20 January 2020. Findings will be presented to academic groups via national and international conferences and peer-reviewed journals. The patient and public involvement group will play an important part in disseminating the study findings to the public domain.2019-003025-22 and 16586164. This is the first randomised controlled trial to evaluate balanced isotonic intravenous fluid in paediatric kidney transplant recipients.A process evaluation will be used to tailor the trial to optimise children and families’ experience of participating.Variation in current clinical practice between centres and clinicians makes standardisation of fluid administration in the control arm impractical, which could potentially affect the effect size.Blinding was not considered necessary due to the objective nature of outcome measures.Kidney transplantation is the treatment of choice for children with end-stage kidney disease.2Acute hyponatraemia is closely associated with clinical complications in children after transplant: cerebral oedema, seizures7 8Several factors predispose children to acute hyponatraemia following kidney transplant:First, relatively large volumes of intravenous fluid are administered perioperatively in order to establish and maintain perfusion to the adult donor kidney.8 10Children receiving isotonic fluid as opposed to hypotonic fluid for indications other than kidney transplant experience less hyponatraemia.Plasma-Lyte-148 is an isotonic, balanced intravenous fluid.A perceived risk of hyperkalaemia from the potassium content of Plasma-Lyte concerns some paediatric nephrologists, although a systematic review in adult kidney transplant recipients demonstrated less hyperkalaemia and acidosis with Plasma-Lyte compared with 0.9% sodium chloride.Currently, there is equipoise regarding use of balanced isotonic fluid versus hypotonic and chloride rich solutions for children undergoing kidney transplant.The aim of the Plasma-Lyte Usage and Assessment of Kidney Transplant Outcomes in Children (PLUTO) trial is to determine whether the incidence of abnormal and potentially dangerous plasma electrolyte levels in paediatric kidney transplant recipients will be different with the use of Plasma-Lyte-148 compared with current standard intravenous fluids.PLUTO is an open-label randomised controlled trial comparing Plasma-Lyte 148 (the intervention) to current intravenous fluids in paediatric kidney transplant recipients, conducted in nine UK paediatric kidney transplant centres plus three participant identification centres . The stuPlasma-Lyte 148 solution for infusion and Plasma-Lyte 148 and glucose 5% w/v solution for infusion are licensed in children and used in paediatric intensive care, surgical and general paediatric wards. They contain sodium 140 mmol/L, chloride 98 mmol/L, potassium 5 mmol/L, magnesium 1.5 mmol/L and gluconate/acetate buffer to maintain physiological pH .18 Both The comparator is the current paediatric kidney transplant intravenous fluid regimen; this varies by paediatric transplant centre and individual clinician. Many paediatric transplant centres use Hartmann’s fluid or 0.9% sodium chloride intraoperatively, followed by a combination of 0.45% sodium chloride and 0.9% sodium chloride with varying concentrations of glucose postoperatively. Some centres use 4.5% human albumin solution in addition.The primary outcome measure is acute hyponatraemia within the first 72 hours post-transplant, defined as laboratory plasma sodium concentration of <135 mmol/L confirmed on a concurrent blood gas sample where feasible.Secondary outcome measures are as follows:Symptoms of acute hyponatraemia  within the first 72 hours post-transplant.The degree of fluid overload experienced .Time to discharge from hospital (measured from transplant operation start time (‘knife to skin’) in days).Transplant kidney function at 1, 3, 7 and 90 days (estimated glomerular filtration rate (eGFR) calculated using creatinine-based univariate Schwartz formulaOther electrolyte abnormalities within the first 72 hours post-transplantation:Hypernatraemia (defined as plasma sodium concentration >145 mmol/L).Hyperkalaemia (defined as plasma potassium concentration >5.5 mmol/L).Hypokalaemia (defined as plasma potassium concentration <3.5 mmol/L).Non-anion-gap acidosis (defined as plasma bicarbonate <20 mmol/L and anion gap <20 mmol/L).Hyperglycaemia (defined as random blood glucose >5.5 mmol/L).Hypomagnesaemia (defined as plasma magnesium concentration <0.7 mmol/L).Hyperchloraemia (defined as plasma chloride concentration >107 mmol/L).Excessive rate of reduction in plasma sodium concentration (defined as >1 mmol/L/hour averaged over 6 hours).Excessive magnitude of reduction in plasma sodium concentration (defined as >10 mmol/L from pretransplant level).Maximum and minimum systolic blood pressure  sustained on three repeated values on each day, for 3 days post-transplant.Number of changes in intravenous fluid composition within the first 72 hours post-transplant.Patients under 18 years of age at the time of transplantation with valid patient/parental consent.Patients receiving a kidney-only transplant from either a living or a deceased donor, in a participating UK centre.Multiorgan transplant recipients.All patients <18 years old awaiting kidney transplantation, from either a deceased or living donor, will be screened for participation. The trial will be discussed during the process of preparation for kidney transplant in order to allow adequate time for families to consider participation. The potential benefits and risks of study participation are included in the study information sheets.In accordance with Clinical Trial Regulations, patients aged under 16 years are deemed to be ‘minors’ and an appropriate adult must give consent on behalf of the child. The wishes of the child must form part of the decision-making process and the child’s assent will be sought. For young people aged 16–18 years, their informed consent will be taken.Participants will be randomised 1:1 to the intervention or control groups via an online system.Participants randomised to the intervention arm will receive either Plasma-Lyte 148 or Plasma-Lyte 148 and glucose 5%, which can be administered interchangeably at the discretion of the clinical team, both intraoperatively and postoperatively . ParticiApart from intravenous fluid composition, all participants will receive routine clinical transplant care as summarised in the schedule of procedures .A process evaluation will explore patients’ and families’ perceptions of the participant information, recruitment and consent process and acceptability of the trial.At the time of initial approach for participation in PLUTO, families will be given a questionnaire , completBoth questionnaires include an option to opt-in to being contacted for a telephone interview. Interviews will explore experience of recruitment and consent, participant information, motivation for participation (or reasons for not participating) and reasons for changes in decision making.Baseline assessments comprise those undertaken as part of routine clinical care prior to kidney transplant:Eligibility checklist.Baseline form (pretransplant): details of the end stage-kidney disease , actual patient weight (kilogram), patient height (centimetre) and blood pressure.Baseline demographic data  will be obtained directly from the UK Transplant Registry (UKTR), held by NHS Blood and Transplant (NHSBT).Randomisation form (on day of transplant): randomisation date/time, randomisation ID number, treatment arm.Pretransplant blood test results .The 72 hour post-transplant period starts at the time of transplant operation ‘knife to skin’.Transplant operation form: operation start time, duration and graft placement.Fluids: all fluid input/output, and all patient weight measurements in the first 72 hours post-transplantBlood products: all blood products administered in the first 72 hours post-transplant.Medications: all inotropes, diuretics, immunosuppressives, insulin, antiemetics and electrolyte supplements administered in the first 72 hours post-transplant.Symptom assessment: daily symptom assessment for nausea, vomiting, headache, pain score and seizures. Pain is graded using an age-appropriate scale  or Wong-Baker).24 25Blood pressure: maximum and minimum systolic blood pressure sustained on three repeated values on each day, for 3 days post-transplant.Blood test results: all results to 72 hours post-transplant will be collected .Post-transplant form: need for dialysis post-transplant, creatinine at day 7 post-transplant (±1 day).Hospital discharge: date of discharge from hospital.No additional outpatient visits will be required for the research study. Plasma creatinine concentration at month 3 (±14 days) will be obtained directly from the UKTR held by NHSBT.The sample size required is 144 participants randomised. The baseline incidence was determined by analysis of 76 paediatric transplants performed at Great Ormond Street Hospital between 1 January 2015 and 31 March 2018, which showed that 45 children 59%) experienced hyponatraemia within the first 72 hours post-transplant when managed with 0.45% saline 5% glucose fluid.% experieA group sequential design with O’Brien-Fleming boundaries will inform early stopping of the trial in the case of strong evidence of harm or benefit, while preserving the overall 5% type I error rate. Two interim analyses to test for harm or benefit will be conducted after 70 and 100 participants have been recruited into the trial with primary outcome data. The stopping rules will be used as a guideline, alongside the other safety data available to the data monitoring committee (DMC), and used as part of their overall assessment of the trial.The analyses will be described in detail in a full statistical analysis plan. This section summarises the main issues.The population used for efficacy analyses will be a modified intention-to-treat analysis which will include all randomised participants who receive a transplant, as although unlikely it would be illogical to include any participant who did not receive a transplant after being randomised. This will be the primary analysis for the trial, though the primary outcome will also be analysed per protocol.Characteristics of all randomised patients will be tabulated by arm of the trial to describe the cohort. A Consolidated Standards of Reporting Trials diagram will be presented to show the flow of patients through the trial.This includes the proportion of patients who experience hyponatraemia (defined as plasma sodium concentration <135 mmol/L) within 72 hours post-transplant. This will be analysed using a logistic regression model adjusting for donor type (living vs deceased donor), patient weight (<20 kg vs ≥20 kg pretransplant) and transplant centre as a random effect. Subgroup and sensitivity analyses will be used to assess whether the treatment effect differs according to the fluid regimen used in the standard arm.The secondary outcomes which assess the incidence of other electrolyte and acid–base disturbance within 72 hours post transplantation  will all be analysed using the same model as the primary outcome. Exact logistic regression will be used to compare instances of nausea/vomiting, headache and seizures. Adjusted normal linear regression models will be used to assess differences in the continuous secondary outcomes, and an adjusted Cox proportional hazards model will be used to assess differences in time to discharge. The number of changes in intravenous fluid composition within the first 72 hours post-transplant will be summarised by treatment arm.Any missing primary and secondary outcome data will be summarised. Primary and secondary outcome measures will not be imputed, and these will be treated as missing data and excluded from the relevant analyses. If outcome data are missing for more than 25% of participants, outcomes will not be reported. To explore if missing values have an undue impact on the primary outcome result, a sensitivity analysis using multiple imputation will be performed if the primary outcome is missing in more than 5% of the participants included in the modified intention-to-treat analysis.A kidney transplant patient and her mother are coapplicants for the grant and members of the Trial Steering Committee (TSC). They make sure that the trial remains patient-centred throughout its delivery and will lead the dissemination of results to patients and families. The research plan was also shaped by a workshop with the Young Persons’ Advisory Group at Great Ormond Street Hospital, and involvement of five families with children awaiting kidney transplantation who advised on the burden of intervention.The investigator will ensure that this trial is conducted in accordance with the principles of the Declaration of Helsinki, ICH Good Clinical Practice Guidelines and in accordance with the terms and conditions of the ethical approval given to the trial. A favourable opinion has been given by a research ethics committee (HRA reference 19/LO/1866).Non-serious adverse events (SAEs) will not be reported. Plasma-Lyte 148 is a licensed product and therefore adverse reactions which are expected , pulmonary embolus and arteriovenous fistula).Transplant kidney arteriovenous fistula.Transplant nephrectomy.Haematuria.Cystoscopy for evacuation of haematoma or stent removal.Renal artery stenosis.Bowel injury, obstruction or ischaemia.Lymphocele/collection±drainage.Hernia.Urine leak.Nephrostomy.Infective complications.Viraemia (Epstein Barr Virus (EBV), cytomegalovirus (CMV), JC and BK viraemia).Bacteraemia.Fever.Immunological complications.Acute rejection.Transplant kidney biopsy.Medication-related complications.Calcineurin inhibitor nephrotoxicity and neurotoxicity.New-onset diabetes.Other.Delayed graft function/primary non-function.Thrombocytopenia/thrombotic microangiopathy.The Trial Management Group (TMG) will be responsible for the day-to-day running and management of the trial.The TSC will provide overall supervision for the trial and provide advice through its independent chair. The ultimate decision on continuation of the trial lies with the TSC.The DMC will be responsible for safety monitoring. Recommendations made by the DMC to alter the conduct of the study will be forwarded to the TSC for a final decision. The sponsor will forward such decisions to regulatory authorities, as appropriate. The DMC will be independent of the study team and will have no direct involvement in other aspects of the trial.The final study dataset will be analysed, and results will be published as soon as possible following completion of study follow-up, final data checks and database lock. The TMG will form the basis of the writing committee and will advise on the nature of publications.Study findings will be presented to academic and non-academic groups. The PPI group will play an important part in disseminating the study findings into the public domain. Dissemination to non-academic audiences including service users, commissioners, clinicians and service providers will be facilitated through the use of existing networks, for example, email lists and social media.All research teams and PPI members involved in the study will be invited to a close-out meeting to discuss the findings of the study.Open-access, peer-reviewed academic outputs and research reports, together with associated summaries and key findings, will be produced for funders, policy makers and NHS audiences and held on the study website.Any publications arising from this study will adhere to the National Institute for Health Research funding and support outputs guidance.


The esaxerenone dosage was increased to ≥2.5 mg/day in 100% (n = 33) and 93.1% (n = 54) of patients receiving monotherapy and add-on therapy, respectively. Reductions in sitting blood pressure from baseline to the end of treatment were similar . The antihypertensive effects of esaxerenone were consistent across patient subgroups. A serum K+ level ≥5.5 mEq/L was observed in seven patients (12.1%) receiving add-on therapy but in none receiving monotherapy. All increases in serum K+ levels were transient, and no patient met predefined serum K+ level criteria for dose reduction or therapy discontinuation. No patient discontinued treatment owing to kidney function decline. Esaxerenone was effective and well tolerated in hypertensive patients with moderate kidney dysfunction.Renin–angiotensin system inhibitors are recommended for treating hypertension with chronic kidney disease. The addition of a mineralocorticoid receptor blocker may be one option to achieve target blood pressure. We investigated the efficacy and safety of esaxerenone, a mineralocorticoid receptor blocker, in Japanese hypertensive patients with moderate kidney dysfunction. Two multicenter, open-label, nonrandomized dose escalation studies were conducted to investigate esaxerenone monotherapy and add-on therapy to renin–angiotensin system inhibitor treatment. Esaxerenone therapy was initiated at 1.25 mg/day and titrated to 2.5 and then 5 mg/day for a treatment duration of 12 weeks. Primary endpoints were changes from baseline in sitting systolic and diastolic blood pressure. Safety, pharmacokinetics, and urinary albumin-to-creatinine ratios were also assessed. Thirty-three patients received monotherapy, and 58 received add-on therapy; the mean baseline estimated glomerular filtration rates were 51.9 and 50.9 mL/min/1.73 m Both hypertension and chronic kidney disease (CKD) are important cardiovascular risk factors and form a vicious cycle –7. HowevSpironolactone and eplerenone are currently available mineralocorticoid receptor blockers , 12. HowEsaxerenone is a novel nonsteroidal oral mineralocorticoid receptor blocker that potently and specifically inhibits excessive mineralocorticoid receptor activity . The uri+ levels, and estimated glomerular filtration rate (eGFR) were measured. After these parameters were carefully evaluated, the add-on therapy study commenced.Two single-arm, open-label, nonrandomized, dose escalation studies were conducted in Japan: a monotherapy study (NCT02448628) at two centers from May to November 2015 and an add-on therapy study (NCT02807987) at 14 centers from June 2016 to May 2017. The monotherapy study was the first to administer esaxerenone to hypertensive patients with moderate kidney dysfunction. Therefore, at study initiation, all patients were admitted to hospital to ensure their safety, and their pharmacokinetics, BP, KEthical approval was obtained from all independent institutional review boards, and procedures were performed in accordance with the Declaration of Helsinki and Good Clinical Practice. All patients provided written informed consent.2. In the add-on therapy study, patients were also receiving a RAS inhibitor at a stable dose for ≥4 weeks prior to study drug administration. Patients with a serum K+ level <3.5 or ≥5.1 mEq/L were excluded from the monotherapy study, while those with a serum K+ level <3.5 or ≥4.8 mEq/L were excluded from the add-on therapy study. Patients were also excluded if they had been diagnosed with malignant or secondary hypertension  or if they had diabetes with albuminuria . Concomitant use of other antihypertensives was prohibited. The eGFR was calculated from serum creatinine using the following equation:Eligible patients were aged 20–80 years, had an average systolic BP between ≥140 and <180 mmHg based on two measurements in the observational period, an average diastolic BP between ≥80 and <110 mmHg (between-measurement difference ≤30/15 mmHg), and an eGFR between ≥30 and <60 mL/min/1.73 m−1.904 × age−0.287 (multiplied by 0.739 for women).eGFR = 194 × serum creatinineIn the monotherapy study, all antihypertensive agents were washed out during a 2-week washout period. In the add-on therapy study, all antihypertensive agents except for the RAS inhibitor were washed out during a 4-week washout period. Oral esaxerenone was started at a dose of 1.25 mg once daily for 4 weeks, followed by dose escalation and follow-up periods  or <4.8 (add-on therapy) mEq/L and when the eGFR reduction from baseline was <30% based on physician discretion to achieve a BP reduction of <130/80 mmHg.Dose escalation for both studies was considered when the serum K+ level was ≥6.0 mEq/L on one occasion or ≥5.5 mEq/L on two consecutive occasions in all monotherapy patients and in add-on therapy patients receiving 1.25 mg/day. For add-on therapy patients receiving 2.5 or 5 mg/day, the dose was reduced if the serum K+ level was ≥6.0 or ≥5.5 mEq/L on two consecutive measurements; if the serum K+ level remained ≥5.5 mEq/L after dose reduction, treatment was discontinued. Dose reductions were also made if severe hypotension developed or if deemed necessary by the investigator.Esaxerenone was discontinued if the serum KThe primary endpoints were changes in sitting systolic/diastolic BP from baseline  to the end of treatment . Secondary efficacy endpoints in both studies included changes over time in sitting systolic/diastolic BP and the proportion of patients achieving target BP (<140/90 mmHg). Additional exploratory endpoints in both studies were changes in the UACR from baseline to week 12. Plasma renin activity (PRA) was measured at baseline and every 4 weeks (monotherapy) or at baseline and week 12 (add-on therapy). Trough plasma esaxerenone concentrations were measured every 2 weeks (monotherapy) or every 4 weeks (add-on therapy). Changes in kidney injury biomarkers -glucosaminidase [NAG], β2 microglobulin [β2-MG], angiotensinogen [ATG], and 8-hydroxy-2′-deoxyguanosine [8-OhdG]) were also measured in the add-on therapy study.BP was measured just before the next esaxerenone dose using the same automated sphygmomanometer ; the mean of three measurements was calculated. In the monotherapy study, patients were hospitalized from the day before the date of esaxerenone therapy initiation to the day after initiation. BP was measured just before the first administration, and the trough BP level was determined 24 h after the first dose. The UACR was determined in the first morning urine sample. Urine was collected once for nondiabetic patients or twice for diabetic patients during the observation period and at week 12.+ levels ≥6.0 mEq/L or ≥5.5 mEq/L on two consecutive measurements were determined. In the monotherapy study, the serum K+ level and eGFR were measured on the day before treatment initiation, 24 h after the first dose, every week thereafter, and at the end of the follow-up period. In the add-on therapy study, the serum K+ level and eGFR were measured before, 1 and 2 weeks after treatment initiation, every 2 weeks thereafter, and at the end of the follow-up period. In addition, these parameters were measured 1 week after each dose escalation in individuals whose dose was increased.All adverse events were assessed; laboratory parameter assessments were performed centrally, but local values were used for dose-escalation decision-making. In addition, electrocardiogram findings, vital signs, and the proportion of patients with serum KBased on feasibility and the ability to clinically assess efficacy and safety endpoints, the planned sample sizes were 30 and 50 patients in the monotherapy and add-on therapy studies, respectively. The predefined full analysis set included patients who had taken ≥1 dose of the study drug and had ≥1 postbaseline measurement available. The safety analysis set included all patients who received ≥1 dose of the study drug.t-tests. The last observation carried forward method was used to impute missing BP data. The proportion of patients achieving target BP was assessed by the point estimate and corresponding exact 95% CI. For other exploratory endpoints, the geometric mean percent change from baseline and the 95% CI were calculated using log-transformed values and assessed using paired t-tests. Post hoc analyses of the change in BP over time were performed using paired t-tests. All reported P values and 95% CIs are two-sided, with a significance level of 5%, and were not adjusted for multiple testing. Analyses were performed using SAS System Version 9.2 or 9.3 .Regarding the primary endpoints, mean changes from baseline to the end of treatment and 95% confidence intervals (CI) were calculated and assessed using paired 2, respectively  and aged ≥65 years , and the mean eGFRs were 51.9 and 50.9 mL/min/1.73 mn = 30), the esaxerenone dosage was increased to 5 mg/day. In the add-on therapy group (n = 55), 4, 26 and 25 patients completed the study at dosages of 1.25, 2.5 and 5 mg/day, respectively  or not meeting the dose escalation criteria for serum K+ levels (n = 1). Reasons for not increasing the dose from 2.5 mg to 5 mg in 13 patients were as follows: not meeting the K+ criteria (n = 5), adequate BP control (n = 1), meeting both the K+ and BP control criteria (n = 1), and the doctor’s discretion (n = 6).Esaxerenone was increased to 2.5 mg/day in all patients in the monotherapy study and in 54/58 patients 93.1%) in the add-on therapy study, and to 5 mg/day in 30/33 patients (90.9%) in the monotherapy study and 25/58 patients (43.1%) in the add-on therapy study. No patients in either study had their esaxerenone dose reduced. In all patients in the monotherapy group who completed the study (% in the P < 0.001) and −17.8 /−8.1  mmHg  /−8.8 mmHg   and 28.6%  in the add-on therapy study (P < 0.001)  in the monotherapy study  and the add-on therapy group   experienced an adverse event (mostly of mild severity); the most common events were nasopharyngitis and arthropod sting (both 9.1%) , and drug-related adverse events occurred in 29.3% of patients (17/58)  and 0.4 ± 0.3 mEq/L  in the monotherapy and add-on therapy groups, respectively. In the add-on therapy group, the largest increase at one week after dose escalation  was observed in patients whose dosage was increased from 1.25 to 2.5 mg/day at week 6 (n = 7). There was no trend of a continuous increase in the serum K+ level over time  had transient serum K+ levels ≥5.5 mEq/L during treatment  in the monotherapy study and increased serum creatinine (n = 3) and an eGFR decrease (n = 3) in the add-on therapy study (Table Adverse events related to decreased kidney function were an eGFR decrease (dy Table . No pati2 was similar in the monotherapy (57.1% vs. 65.4%) and add-on (58.3% vs. 60.9%) studies. In the add-on therapy study, a serum K+ level increase to ≥5.5 mEq/L was not observed in any patient with an eGFR <45 mL/min/1.73 m2 and occurred in 15.2% of patients with an eGFR ≥45 mL/min/1.73 m2. Among the adverse events related to decreased kidney function, an increased serum creatinine level and a decreased eGFR occurred in 0.0% and 3.8% (monotherapy), and 25.0% and 6.5% (add-on therapy) of patients with an eGFR <45 mL/min/1.73 m2 and ≥45 mL/min/1.73 m2, respectively.The incidence of any adverse event in patients with a baseline eGFR <45 vs. ≥45 mL/min/1.73 m+ level (±SD) remained unchanged , and changes in the eGFR were not remarkable . There were no acute adverse events.In the monotherapy study, all patients were admitted to hospital to ensure their safety. The mean systolic/diastolic BP decreased from 150.5/91.2 mmHg before therapy initiation to 143.3/88.5 mmHg at 24 h after initial oral administration. The mean serum KHypertensive patients with moderate kidney dysfunction are at high cardiovascular risk, necessitating strict BP control. However, the RAS inhibitors recommended for these patients are often insufficient to achieve target BP, and the addition of ≥1 antihypertensive agent is required. We previously evaluated the antihypertensive effect of the novel mineralocorticoid receptor blocker esaxerenone in essential hypertensive patients , 23 and Notably, the BP-lowering effect of esaxerenone was quite rapid. In the monotherapy study, patients were hospitalized for the initiation of esaxerenone and systolic/diastolic BP decreased from 150.5/91.2 to 143.3/88.5 mmHg 24 h after the first administration; these values were similar to BP values observed after 1 week of treatment.Previous studies evaluating the antihypertensive effect of mineralocorticoid receptor blockers in patients with moderate kidney dysfunction are limited. Two retrospective studies of a small number of patients with difficult-to-control hypertension or resistant hypertension with stage 3/4 CKD were reported. In these studies, most patients who had received multiple antihypertensive drugs, including ARB and diuretics and add-on therapy with a mineralocorticoid receptor blocker (mostly spironolactone), showed a decrease in systolic BP by 10–24 mmHg and in diastolic BP by 3.4–13 mmHg , 27. Alt+ levels. The BP-lowering effects of esaxerenone were similar in patients with a final dosage of 1.25, 2.5 or 5 mg/day. This may suggest individual variations in BP responses to esaxerenone. Nevertheless, with close monitoring of patients, the esaxerenone dose can be adjusted to confer substantial BP-lowering benefits in various patient subgroups with moderate kidney dysfunction.In the add-on therapy study, 93.1% and 43.1% of patients had their esaxerenone dosage escalated to 2.5 and 5 mg/day, respectively. Reasons for not increasing the dose were a sufficient decrease in BP or not meeting the dose escalation criteria for serum KSignificant reductions in the UACR were observed even when esaxerenone was added to a RAS inhibitor, consistent with clinical studies on type 2 diabetes that demonstrated a dose-dependent reduction in the UACR , 25. How+ level were transient, and no patient met dose reduction or therapy discontinuation criteria, even when esaxerenone was added to a RAS inhibitor. In the add-on study, seven of 58 patients had transient serum K+ levels ≥5.5 mEq/L, which is comparable to the rate with low-dose spironolactone added to a RAS inhibitor in nondiabetic early-stage CKD patients (nine of 56 patients) [2 [2) showed a decrease of 15.1% [2: −8.56%), but the eGFR returned to baseline levels during the follow-up period. A transient eGFR decline has been reported with all mineralocorticoid receptor blockers, and this decline is thought to be due to the improvement in renal glomerular hyperfiltration [Esaxerenone was well tolerated in both studies. Sex hormone-related adverse events, which occur frequently with spironolactone , 30, 31,atients) . The saments) [2 , and anoof 15.1% . In the ltration . Thus, e2 than in those with a baseline eGFR ≥45 mL/min/1.73 m2, although all patients recovered without study drug discontinuation. Plasma concentrations of esaxerenone were not affected by the baseline eGFR in either study and were consistent with those reported in a phase 3 study of esaxerenone in patients with normal kidney function [2, especially when esaxerenone is added to a RAS inhibitor.The incidence of adverse events related to kidney function was higher in patients with a baseline eGFR <45 mL/min/1.73 mfunction . Therefo+ level, eGFR, and BP response may have contributed to the good tolerability observed in this study. The esaxerenone dosage was safely escalated to 2.5 mg/day in all patients receiving monotherapy and the majority (93.1%) of patients receiving add-on therapy. Further, the esaxerenone dosage was safely escalated to 5 mg/day in most patients (90.9%) in the monotherapy study and almost half of the patients (43.1%) in the add-on therapy study. In a previous study of eplerenone, dose escalation based on the BP response also appeared to minimize the risk of hyperkalemia compared with forced escalation [Starting esaxerenone from a low dosage (1.25 mg/day) and incrementally escalating the dose based on the serum Kcalation .The limitations of the present study were its nonrandomized design, small sample sizes, and relatively short study period. Furthermore, this study included only Japanese patients, so generalizability to other patient populations may be limited.+ elevation was manageable by titrating from a low starting dose.In conclusion, esaxerenone demonstrated sufficient antihypertensive effects and was well tolerated in hypertensive patients with moderate kidney dysfunction, both as monotherapy and add-on therapy to a RAS inhibitor. The magnitude of antihypertensive effects was comparable in hypertensive patients with normal kidney function. Serum KSupplementary Information


Vancomycin-associated acute kidney injury (AKI) remains a major challenge for patients and clinicians. This study aimed to construct a risk scoring system for vancomycin-associated AKI. We retrospectively reviewed medical records of patients who underwent therapeutic drug monitoring for vancomycin from June 2018 to July 2019. We selected possible risk factors for AKI by univariate and multivariable logistic regression analyses and developed a scoring system for vancomycin-associated AKI. Machine learning methods were utilized to predict risk factors for the occurrence of AKI. The incidence of vancomycin-associated AKI was 31.7% among 104 patients included in this study. A bodyweight ≤60 kg (two points), a Charlson comorbidity index ≥3 (two points), a vancomycin trough serum level >15 μg/ml (one point), and concomitant use of ≥6 nephrotoxic agents (two points) were included to construct a risk scoring system based on the coefficient from the logistic regression model. The area under the receiver operating characteristic curve (AUROC) ) across 10 random iterations using five-fold cross-validated multivariate logistic regression, elastic net, random forest, support vector machine (SVM)-linear kernel, and SVM-radial kernel models was 0.735 (0.638–0.833), 0.737 (0.638–0.835), 0.721 (0.610–0.833), 0.739 (0.648–0.829), and 0.733 (0.640–0.826), respectively. For total scores of 0–1, 2–3, 4–5, 6–7, the risk of vancomycin-associated AKI was 5, 25, 45, and 65%, respectively. Our scoring system can be applied to clinical settings in which several nephrotoxic agents are used along with vancomycin therapy. Vancomycin (VCM) is used for the treatment of severe infections such as sepsis, endocarditis, osteomyelitis, or meningitis caused by methicillin-resistant Staphylococcus aureus . To achiTo predict the AKI risk associated with VCM use, previous studies have identified risk factors for AKI associated with VCM use including sex, age, weight, height, race, renal function, and/or concomitant use of nephrotoxic agents . HoweverWe retrospectively reviewed the electronic medical records of patients who were admitted to a university hospital in South Korea from June 2018 to July 2019. The included patients were those who were treated with intravenous VCM for more than 2 days (48 h) or at least four times with adjustment in the VCM dose by TDM. Those who were younger than 18 years of age or who were admitted to the hospital for less than 48 h or for more than 6 months were excluded. This study was approved by the Institutional Review Board of Catholic Kwandong University International St. Mary’s Hospital  in accordance with the 1964 Helsinki declaration and its later amendments. The requirement for obtaining informed consent was waived by the Institutional Review Board of Catholic Kwandong University International St. Mary’s Hospital, due to the retrospective nature of this study. This study is registered at the Clinical Research Information Service .2 for 3 months or more (0–24h/minimum inhibitory concentration (MIC). MIC values of VCM were determined by the broth microdilution method. The serum trough levels of VCM were analyzed by chemiluminescent microparticle immunoassay methods using Architect i2000SR . As the first sampling of serum levels of VCM was performed after administration of at least four times of VCM, all trough levels of VCM were assumed to be at a steady state. For the repeated measurement of laboratory values, only the first serum level was included in the analysis.At the time of starting TDM, demographic data of patients including sex, age, weight, and height, diagnosis of chronic kidney disease (CKD) defined by glomerular filtration rate (GFR) < 60 ml/min/1.73 m or more , status  or more  receivedThe primary outcome was AKI as defined by the Acute Kidney Injury Network (AKIN) criteria . A nephrContinuous variables were compared with Student’s t-test. If the variables were not normally distributed as determined by one-sample Kolmogorov-Smirnov and Levene tests, the Mann-Whitney test was performed. The Chi-square test or Fisher’s exact test was used to compare categorical variables. The area under the receiver operator characteristic curve (AUROC) was plotted to determine the cut-off values for predicting AKI. Univariate and multivariate logistic regression analyses with the odds ratio (OR) and adjusted OR (AOR), respectively, were used to identify risk factors for AKI. Statistically significant features in the multivariate analysis were used for the machine learning analysis.Machine learning algorithms were developed to predict risk factors for AKI occurrence . Five-fop values <0.05 were considered statistically significant. The data were analyzed using Statistical Package for Social Sciences Version 20.0 for Windows . Machine learning algorithms were constructed using R software version 3.6.0 .All statistical tests were two-sided, and Data were obtained for 788 patients, of whom 684 were excluded; 335 did not have any TDM course, 215 had insufficient records, 35 had duplicate courses, 92 had a hospital length of stay <48 h, and 7 had no serum levels of VCM measured. Therefore, 104 patients were included in this study. The baseline demographic characteristics of the study patients are shown in In the univariate analysis, significant factors for AKI were a bodyweight of 60 kg or less, a CCI of three or higher, concomitant use of six or more nephrotoxic agents, and a serum trough level of VCM of higher than 15 μg/ml with OR values (95% CI) of 3.03 (1.28–7.14), 4.46 (1.85–10.75), 2.80 (1.17–6.74), and 2.37 (1.01–5.54), respectively . Among iUsing the significant features from the univariate analysis in addition to age and sex, we performed multivariate analysis and machine learning analysis. A bodyweight of 60 kg or less, a CCI of three or higher, and concomitant use of six or more nephrotoxic agents remained significant factors after the multivariate analysis with AOR values (95% CI) of 3.33 (1.25–8.84), 3.78 (1.44–9.92), and 3.18 (1.14–8.88), respectively . The AURp < 0.001).A risk scoring system was constructed with the selected features from the univariate analysis. Each coefficient from the logistic regression model was divided by the smallest one and rounded to the nearest integer. A bodyweight ≤60 kg (two points), a CCI ≥3 (two points), a VCM trough serum level >15 μg/ml (one point), and concomitant use of ≥6 nephrotoxic agents (two points) were incorporated into the risk scoring system for AKI. Patients with 0–1, 2–3, 4–5, and 6–7 points had about 4.5, 21.9, 44.4, and 64.3% risk of AKI . As showIn this study, the number of nephrotoxic agents used concomitantly with VCM, disease severity measured by the CCI, and actual patient bodyweight were significant risk factors associated with the occurrence of VCM-associated AKI.Known risk factors for VCM-associated AKI were patient demographics , VCM dose (>4 g/day), VCM treatment duration (>7 days), serum trough level (>15 μg/ml), comorbidities , and nephrotoxic agents  . To simpRegarding bodyweight, a bodyweight ≤60 kg was significantly associated with an increased incidence of AKI. When considering that higher exposure of VCM  was related to VCM-associated AKI , the lowThe serum trough levels of VCM were significantly associated with AKI in the univariate analysis; however, statistical significance was not found in the multivariate analysis. We included the serum trough level as a risk factor for the scoring system since higher serum trough levels of VCM were associated with an increased incidence of nephrotoxicity .The AUROC values indicated the favorable performance of these models, regardless of the machine learning method used in this study (higher than 0.7). The elastic net is a penalized linear regression model that combines the penalties of the lasso and ridge methods . RF is aThis study has several limitations. First, it has a small sample size with single-center cohort data and retrospective design. Second, we did not evaluate the severity and prognosis of AKI. Third, we did not perform the renal biopsy for identifying if it is a dose-independent acute tubulointerstitial nephritis or a dose-dependent renal tubular injury. Fourth, AKI was defined according to AKIN  rather tIn this study, we aimed to develop an optimal scoring system for predicting VCM-associated AKI using machine learning methods. To the best of our knowledge, this is the first study to propose a risk scoring system for VCM-associated AKI in Korean patients undergoing TDM with concomitant use of various nephrotoxic agents. Moreover, our studied patients had varied disease types such as sepsis, osteomyelitis, central nervous system infections, pneumonia, and CKD of various stages and were undergoing renal replacement therapies. Thus, our results can be used to develop guidelines or effective treatment strategies for VCM use in adult patients who are receiving nephrotoxic agents. Further studies using a larger population are needed to confirm our results.


Meta-analyses incorporating the Systolic Blood Pressure Intervention Trial (SPRINT) have shown a reduced incidence of dementia with blood pressure lowering. However, mechanistic explanations for this effect are lacking, apart from slowed progression of cerebral white matter lesions (WML). Here we examine possible biomarkers of angiogenesis related to small vessel brain disease including bFGF, FLT1, PLGF, TIE-2, VEGF, VEGF-C, and VEGF-D. The biomarkers were assayed in plasma at baseline and during follow-up (median follow-up = 3.8 years) in a subgroup of participants 60 to 89 years old from SPRINT (N=517). We modeled changes in each biomarker using robust linear mixed models accounting for treatment group, time since randomization, and kidney function. Participants were 69.8 ± 7.1 (standard deviation) years of age, 42.1% female, with a mean systolic blood pressure (SBP) of 138.2 ± 17.0 mm Hg. At baseline, none of the biomarkers were associated with WML lesion volume or total brain volumes adjusting for age , while FLT1, PLGF, and TIE-2 were negatively associated with frontal gray matter cerebral blood flow . For both intensive (target SBP<120 mm Hg) and standard (target SBP<140 m Hg) blood pressure control, mean levels for the majority of biomarkers increased during follow-up, with the exceptions of TIE-2 (decreased over follow-up) and VEGF-D (no change). We did not observe significant between-group differences for the change in these plasma biomarkers of angiogenesis comparing intensive to standard blood pressure treatment.