In multivariate regression analysis, an increase in FMD (p < 0.001) and a decrease in FPCS (p = 0.012) and TIS (p < 0.001) remained persistent findings when adjusted for age, systolic blood pressure (SBP), sodium, albumin, and diastolic blood pressure (DBP). LPD supplemented with KAs significantly preserves kidney function and provides additional benefits on endothelial function and protein-bound uremic toxins in patients with CKD.Studies have demonstrated that a low-protein diet supplemented with ketoanalogs (KAs) could significantly retard progression of renal function in patients with chronic kidney disease (CKD) stages 3–5. However, its effects on endothelial function and serum levels of protein-bound uremic toxins remain elusive. Therefore, this study explored whether a low-protein diet (LPD) supplemented with KAs affects kidney function, endothelial function, and serum uremic toxin levels in a CKD-based cohort. In this retrospective cohort, we enrolled 22 stable CKD stage 3b–4 patients on LPD (0.6–0.8 g/day). Patients were categorized into control (LPD only) and study groups (LPD + KAs 6 tab/day). Serum biochemistry, total/free indoxyl sulfate (TIS/FIS), total/free p-cresyl sulfate (TPCS/FPCS), and flow-mediated dilation (FMD) were measured before and after 6 months of KA supplementation. Before the trial, there were no significant differences in kidney function, FMD, or uremic toxin levels between the control and study groups. When compared with the control group, the paired  Globally, rapidly, and with increasing prevalence, chronic kidney disease (CKD) is becoming one of the leading public health problems, affecting 13.4% of the adult population .CKD patients are at a higher risk for developing cardiovascular disease (CVD), which, in turn, is associated with a more rapid progression of CKD . In compCKD is associated with significant morbidity and mortality; hence the management of this condition is crucial. This involves prioritizing key aspects such as mitigating decline in glomerular filtration rate, preventing cardiovascular diseases, and managing associated complications. Currently, there are a few strategies and treatments accessible for deterring CKD progression and minimizing cardiovascular incidents, including lifestyle adjustments, regulating blood pressure and blood sugar levels, employing RAS inhibitors, and more recently, incorporating SGLT2 inhibitors Despite optimal management, the risk of CKD progression remains , and novStudies have shown that PCS and IS have not only a positive association between each other in CKD patients, but also a correlation with CKD stages. As eGFR decreases, renal clearance of IS and PCS decreases, and total plasma levels rise in proportion to the eGFR ,21, reacAs previously mentioned, IS and PCS have been associated with the progression of CKD. Putative mechanisms include inflammatory and fibrotic pathways which induce renal toxicity , with enFurthermore, and as mentioned earlier, patients diagnosed with chronic kidney disease (CKD) are more susceptible to both traditional and nontraditional cardiovascular risk factors . The risThe majority of studies have demonstrated an inverse relationship between FMD and the likelihood of future cardiovascular events . In partThis study investigated whether adding KAs to CKD patients on an LPD could reduce the level of uremic toxins and result in reduced endothelial dysfunction (measured via FMD), thereby abating the progression of CKD.This was a single-center, retrospective cohort study, conducted for 6 months. Twenty-two stable patients with CKD stages 3b and 4, who had been on an LPD for the past 6 months, were enrolled from the outpatient department at Mackay Memorial Hospital. All of the patients were taking either ACE inhibitors (ACEI) or angiotensin receptor blockers (ARB) as their antihypertensive medications. Due to the restricted size of our cohort, individuals who were smokers or were with diabetes and iron deficiency anemia (IDA) were excluded to minimize the extent of confounding, particularly with regard to endothelial functions. Patients were classified into two groups at a ratio of 1:1, with and without using KAs. A control group of 11 patients was compared with the study group of 11 patients who took Ketosteril 6 tabs/day. Data were obtained before and after 6 months for both groups. The primary outcome was the level of uremic toxins (IS and PS), while the secondary outcome was FMD measurements. The study was conducted in accordance with the Declaration of Helsinki and approved by the ethics committee of the Mackay Memorial Hospital. All participants signed an informed consent approved by the Institutional Review Board  for studies involving humans.FMD of the brachial artery was performed using an ALOKA ultrasound machine  according to the guidelines set by the International Brachial Artery Reactivity Task Force. The brachial artery was longitudinally imaged above the elbow using an 11.3-MHz probe. After the image was recorded for 2 min, forearm ischemia was induced by the rapid deflation of a cuff that was inflated to 200 mmHg  below the elbow for 5 min. The resulting reactive hyperemia was recorded for an additional 2 min. A single trained investigator used Brachial Analyzer software  to analyze all FMDs.t-tests were performed between pre-test and post-test (after 6 months) for the control and study groups, where variables with a significant difference were identified. A t-test was then performed between the study and control groups to determine the variables with a significant difference after 6 months. Multivariate regression analysis was performed to determine whether the result persisted after adjusting for baseline covariates to determine the effects of KA (Ketosteril) on FMD and uremic toxins. Statistical significance was defined as a two-sided p-value of < 0.05. All statistical analyses were conducted using the SPSS software programs .Demographic data are expressed as mean ± SD, which was used to present the similarities between the study and control groups, and the value > 0.05 indicated insignificant differences in covariates between them. Paired p = 0.037), blood pressure (p < 0.001), Na (p = 0.02), hemoglobin (p = 0.046), and albumin (p = 0.044) were observed , eGFR (25.42 ± 11.28), and HCO3 (22.85 ± 1.59), with decreases in total PCS (9.73 ± 11.03) and total IS (8.15 ± 9.69) were noted with a significant difference between pre-and post-test .As for the control group, results revealed significant differences between the pre-test and post-test with a decrease in FMD (3.38 ± 0.43), GFR (16.69 ± 3.96), Ca (8.48 ± 0.38), albumin (3.79 ± 0.27), and HCO3 (18.73 ± 3.04), and an increase in FPCS (0.45 ± 0.34), TIS (6.32 ± 1.91), FIS (0.29 ± 0.13), BUN (59.60 ± 12.75), Cr (4.01 ± 1.11) and P (4.73 ± 0.54). .t-test showed a significant decrease in TIS, FIS, TPCS, FPCS, TG, and P, with a significant increase in FMD, eGFR, and HCO3  and decreases in FPCS  and TIS  remained consistent findings , and the hematocrit levels were within the normal range. Consequently, we considered the difference to be insignificant and excluded it as a covariate in our multivariate regression analysis.We would like to draw attention to the notable discrepancy in hemoglobin levels at baseline between the study and control groups. The disparity was only marginally significant  play a crucial role in transporting NO, synthesizing NO through nitrite reduction in hypoxic conditions, and generating NO via active endothelial nitric oxide synthase (eNOS) located within the RBC membrane during normoxia. Impaired eNOS has been identified as a significant factor contributing to RBC dysfunction in both anemic mice and patients with acute coronary syndrome .Research investigating the impact of anemia on endothelial function has primarily concentrated on sickle cell anemia and iron deficiency anemia (IDA). Studies have revealed that RBCs in IDA patients exhibit notable characteristics such as reduced size and increased stiffness. Computational simulations have demonstrated that these altered RBCs tend to accumulate near the vessel wall, resulting in aberrant shear forces that can adversely affect endothelial function . Thus, pErythropoiesis-stimulating agents (ESAs) have been demonstrated to influence endothelial function. A prospective study has shown that the administration of ESAs resulted in clinically improved endothelial dysfunction in anemic patients with chronic kidney disease (CKD), primarily through alleviating anemia . HoweverAs stated earlier, our study excluded smokers and individuals with diabetes. Diabetes is known to impact endothelial function, predominantly through prolonged exposure to hyperglycemia. The underlying mechanisms of endothelial dysfunction due to hyperglycemia are diverse and include: (1) increased formation of advanced glycation end products (AGEs) within cells; (2) activation of various protein kinase C (PKC) isoforms; and (3) induction of nuclear factor-κB (NFkB) . These mStudies on the dietary effect on CKD progression have shown that for patients with an eGFR < 30 who were on a VLPD, the addition of KAs has demonstrated retarding of renal progression and delaying of dialysis . MoreoveAs mentioned previously, the most widely explored uremic toxins are PCS and IS. Intestinal anaerobes generate IS during the partial breakdown of tyrosine and phenylalanine, while IS results from the breakdown of tryptophan . They arWhen we compared the study and control groups after 6 months, a significant difference was found in IS, PCS, FMD, GFR, Ca, P, and bicarbonate levels. A reduction in IS and PCS was foreseeable in the study group, most likely because of the use of KAs and the associated reduction in protein intake. The MEDIKA study showed that the levels of IS and PCS were reduced  with theWe also observed an increase in FMD in the study group compared with that in the control group. Endothelial dysfunction constitutes the first step of atherosclerosis and vascular calcification, it has shown not only contributing to the development of cardiovascular disease , but alsEndothelial dysfunction, induced by IS and PCS, are associated with nephrotoxicity. These substances compromise intercellular junctions by inducing the phosphorylation of vascular endothelium cadherin (VE-cadherin), which leads to disassembly and cell internalization . SubsequIn advanced CKD, IS and PCS impairment of endothelial-dependent vasodilatation is well established, with decreased expression of eNOS and reduction in the bioavailability of NO as the dominant pathophysiology . FurtherThe study group had a significantly higher eGFR after 6 months. Indeed, the impaired endothelial function has been associated with albuminuria and CKD progression independently of blood pressure and diabetes . TherefoFurthermore, IS and PCS manifest their nephrotoxic effects through multiple alternative mechanisms. IS and PCS are recognized for causing degradation of the remaining renal nephrons, particularly in the proximal tubular cells. This leads to the stimulation of glomerular sclerosis, renal fibrosis, and CKD progression. As a result, the expression of pro-a1 collagen, transforming growth factor b1 (TGF-b1), and tissue inhibitor of metalloproteinase 1 (TIMP-1) genes are increased, leading to a greater loss of nephrons. This, in turn, worsens the progression of CKD ,58. AddiThe improved mineral metabolism  was significantly increased after 6 months in the study group. This is likely due to the calcium content in the KAs which allows sufficient calcium content while mitigating the risks of hyperphosphatemia .Moreover, we also observed an increase in serum bicarbonate, which could be related to both a reduction in protein intake and a diet rich in fruit and vegetables, as well as the alkaline effect of calcium salt. Similar effects were demonstrated in multiple studies ,64.Although large observational studies have shown a reduced blood pressure in patients on VLPD/LPD + KAs , where aA reduction in triglyceride levels among the participants in the intervention group was also observed. Previous research on diabetic CKD patients has consistently demonstrated that the combination of low-protein diets (LPD) with ketogenic amino acid (KAs) supplementation leads to better fasting serum glucose levels when compared to LPD alone . HoweverAfter adjusting for baseline covariates with multivariate regression analysis, which included age, SBP, DBP, Na, and albumin, reduced IS and PCS with increased FMD persisted, which supports our hypothesis that the addition of KAs to LPD improves endothelial function and reduces IS and PCS in CKD stage 3b–4 patients.However, this study has several limitations. First, it was a single-center study with a limited sample size, which undermines its validity and power. Moreover, this study’s observational and retrospective nature has inherent limitations in attributing improved outcomes to KA supplementation. At the same time, we cannot decipher whether the improvement observed in FMD is due to improved kidney function, solely due to a reduction in uremic toxins, or both. Second, it should be noted that although all patients were being treated with either ACEI or ARBs, the use of alternative antihypertensive agents was not documented. Previous research has indicated that endothelial function is compromised as blood pressure rises, and the extent of dysfunction is directly correlated to the degree of blood pressure elevation ,69. AddiIn conclusion, our study indicates that by supplementing KAs to CKD stage 3b and 4 patients who were on LPD, a decrease in uremic toxin level and improvement in FMD and metabolic profiles was observed in 6 months. These may provide additional benefits, such as delayed CKD progression and decreased risk of cardiovascular disease, without compromising nutritional status. However, further prospective randomized controlled trials are warranted to consolidate this argument, possibly extending the study population to earlier CKD and End Stage Renal Diseases. Hopefully, this could serve as a pilot study for the ongoing investigation of the relationships between KAs, uremic toxins, and endothelial function.


Finding some convenient and economical indicators to initially screen overweight and obese patients at high risk of kidney stone recurrence can help them prevent stone recurrence with lower medical cost. The purpose of this article is to determine the clinical value of Ae index (Apo B × 1000/eGFR) as an independent predictor for kidney stone recurrence in overweight and obese populations.2 as the study population and divided the patients into stone recurrence group and non-recurrence group. Relevant parameters of routine blood and biochemical test, glycated serum protein (GSP), and history of hypertension and hyperglycemia were collected. Then the Chi-square test, independent samples t-test or Wilcoxon rank-sum test were used to calculate the differences between the two groups of data. Next, we performed univariate and multivariate logistic regression analysis to screen out the most significant variables Apo B and eGFR, and then we calculated the Ae index using the formula Apo B × 1000/eGFR, and analyzed the relationship between Ae index and kidney stone recurrence.We queried the electronic medical records of patients with kidney stone operated at our hospital from March 2016 to March 2022, and selected BMI ≥ 25 kg/mUnivariate analysis found that Apo B , Creatinine , Cystatin C, LDL-C , TC  were positively associated, eGFR  was negatively associated with kidney stone recurrence. And multivariate logistic regression analysis suggested that Apo B  and eGFR  were the most significant factors. Then we calculated Ae index and analyzed it, the sensitivity was 74.26% and the specificity was 60.00%, higher than either individual variable. Its smoothed curve revealed a non-linear relationship between them with the inflection point of 9.16. And the OR on the left side of the inflection point was 1.574 (95% CI: 1.228–2.018), whereas the OR on the right side of the inflection point was 1.088 (95% CI: 1.007–1.177).Ae index is an easily calculated and obtained index that has some predictive value for kidney stone recurrence in overweight and obese patients, which is of interest.The online version contains supplementary material available at 10.1186/s12894-023-01321-7. Kidney stone is a common disease in urology, which can cause urinary tract obstruction and affect kidney function in serious cases –4. CurreThere are many factors that influence the recurrence of kidney stone, both in relation to the patient's race, family history, age, and gender, but also in relation to obesity and lipid metabolism disorders –15. For One of the reasons for the high recurrence rate of kidney stone in obese or overweight patients is due to insufficient awareness of prevention. Therefore, it is very meaningful to find relevant indicators to make a preliminary prediction about whether patients are at high risk of recurrence, which can focus on strengthening health education and dietary intervention for high-risk patients, and better prevent recurrence of kidney stone. At present, there are few international studies on the risk indicators of kidney stone recurrence in overweight and obese patients. In this study, 301 overweight and obese patients hospitalized at the First Affiliated Hospital of Anhui Medical University from March 2016 to March 2022 were involved and divided into stone recurrence group and non-recurrence group, and relevant parameters were collected for statistical study to find statistically different indicators and to explore their predictive value.2 (overweight or obesity) as the study subjects [+), serum sodium (Na+), serum chloride (Cl−), serum calcium (Ca2+), serum phosphorus (P), serum magnesium (Mg2+), blood glucose (GLU), glycated serum protein (GSP), neutrophils (NE), lymphocytes (LYM), red blood cells (RBC), hemoglobin (Hb), platelets (PLT), and history of hypertension and hyperglycemia were collected.After the ethics committee of the First Affiliated Hospital of Anhui Medical University approval (Number: Quick-PJ2023-01–12), we retrospectively analyzed the clinical data of 768 patients with kidney stone who underwent surgical treatment in the department of urology, the First Affiliated Hospital of Anhui Medical University from March 2016 to March 2022. We calculated the BMI of these kidney stone patients and selected those with BMI ≥ 25 kg/m2; ② Patients with kidney stone; ③ Adults, who age ≥ 18 years old; Exclusion criteria: ① Patients with incomplete electronic medical record information; ② Patients with severe cardiovascular diseases, brain diseases, lung diseases, and malignancy history; ③ Patients younger than 18 years old and adult patients with a BMI < 25 kg/m2.Inclusion criteria: ① BMI ≥ 25 kg/mThe patient's blood parameters such as red blood cells (RBC), hemoglobin(Hb), platelets (PLT), neutrophils(NE), lymphocytes(LYM) were tested by a Automatic Flow Cytometer, and the albumin, globulin, direct bilirubin, indirect bilirubin, ALT, AST, urea, creatinine, cystatin C, eGFR, HDL-C, VLDL, LDL-C, Apo A, Apo B, lipoprotein, serum potassium, serum sodium, serum chloride, serum calcium, serum phosphorus, serum magnesium, blood glucose, glycated serum protein were tested by a Roche Cobas 6000 chemistry analyzer from venous blood drawn before the patient's hospitalization for surgery. We obtained the relevant data by reviewing the patient's previous inspection reports, and the patient's age, gender, hypertension, and hyperglycemia history were obtained by reviewing the patient's electronic medical record.We evaluated patients for stone recurrence by asking if they had a previous history of stones and by reviewing previous and current imaging data. We followed up the patients for six year and instructed them to complete KUB, CT, or abdominal ultrasound to determine whether they had a stone recurrence. Stone recurrence was defined as a new stone that was not previously present, and residual stones were excluded.2 in this study.Apo B is an apolipoprotein and eGFR is the estimated glomerular filtration rate, they were all tested by an automated biochemical analyzer. eGFR was calculated by CKD-EPI or modified CKD-EPI formula based on the creatinine level in venous blood combined with age, sex, body weight, and cystatin C level, it is a better indicator of the renal function status . Ae indehttps://cran.r-project.org/bin/windows/base/) and Empower software . Firstly, we used the Kolmogorov-Smirnova test to do the normality test for the measurement. For those conforming to normal distribution, we denoted it by x ± s and the differences between the two groups were used the independent samples t-test; those conforming to skewed distribution were expressed as M  and the differences between the two groups were used Wilcoxon rank-sum test. Then, we performed univariate and multivariate logistic regression analysis of the screened statistically significant parameters. Lastly, we used R software package “pROC” to plot the ROC curve to estimate the prediction accuracy of the selected parameters, and used a smooth curve to evaluate the relationship between Ae index and kidney stone recurrence [p < 0.05.Statistical analysis was performed using the R software  had recurrence of stones, including 61(60.4%) cases of male and 40(39.6%) cases of female. The routine blood, biochemical tests, and glycated serum protein lab reports of patients were queried, and related parameters of age, gender, BMI, ALB, GLOB, DBIT, IBIL, ALT, AST, urea, Cr, cystatin C, eGFR, HDL-C, VLDL, LDL-C, Apo A, Apo B, lipoprotein, K+, Na+, Cl−, Ca2+, P, Mg2+, GLU, GSP, NE, LYM, RBC, Hb, and PLT were collected. We divided the patients into kidney stone recurrence and non-recurrence groups and drew heat maps based on their clinical parameters , which reflects the expression level of LDL-C, and it is present on the surface of LDL, and cells generally take up LDL-C by recognizing Apo B . ElevateRecurrence of kidney stone is mainly caused by supersaturated precipitation of crystals in the urine in the kidney, which is closely related not only to the patient's personal basical disease, hypercalcemia, and race, but also to the patient's metabolic abnormalities , 24, 25.Ae index is closely related to Apo B and eGFR expression and is associated with the recurrence of kidney stone. The relationship between Ae index and kidney stone recurrence was detected by smoothed curve fitting, and a non-linear relationship was found between them with an inflection point was 9.16, and the increase in the risk of kidney stone recurrence slowed down as the Ae index increased after crossing the inflection point. Then we drew the ROC curve and found that its predictive accuracy was higher than that of Apo B and eGFR alone. The Ae index combines the advantages of Apo B and eGFR to improve the predictive ability of kidney stone recurrence, which is helpful to identify patients with high risk of stone recurrence. Then we focus on health education for them, reminding low salt and low protein diet, and instructing them to consume calcium, potassium, magnesium, and vit B6-rich vegetables and fruits in moderation, and increasing the frequency of review to reduce the possibility of recurrence.This study proposes a new index named Ae index and it can predict the probability of stone recurrence in overweight or obese people. Its advantages are shown in the following two aspects: Firstly, the index is simple to calculate, and the Apo B and eGFR parameters involved can be obtained by biochemical assays, it can be tested in most primary care hospitals at a lower medical cost, convenient and economical, saves patient time and reduces medical burden. Secondly, the ROC curve analysis suggested that people with Ae index higher than 8.72 were at high risk of kidney stone recurrence, and smoothed curve revealed the risk of kidney stone recurrence increased by 8.8% for each unit increase when the index across the inflection point of 9.16. We used the Ae index to briefly assess postoperative stone patient, and for those at high risk, we need to focus on strengthening health education, enhancing diet guidance, and increasing the frequency of follow-up to reduce the probability of recurrence. At the same time, this study has the following shortcomings: Firstly, this study is a retrospective study, the number of included study subjects are small, some information data are missing, there is a certain selection bias, and the sample size needs to be further expanded in the future. Secondly, although the specificity and sensitivity of the Ae index was higher than any other univariate, it was still not particularly significant, and collection of more parameters to construct predictive models to improve the sensitivity and specificity of the prediction of kidney stone recurrence could be considered in the future. Thirdly, the index is currently limited to overweight and obese people with kidney stone, and further studies are needed to expand the participating population. Fourthly, this study is a single-center study, and further multicenter studies are needed in the future.This study proposes a new Ae index to assess the risk of stone recurrence in overweight and obese kidney stone patients, which has a non-linear relationship with kidney stone recurrence. Patients with Ae index over 8.72 are at high risk for stone recurrence, and the risk of kidney stone recurrence increased by about 8.8% for each unit increase in Ae index.Additional file 1: Table S1. Univariate analysis of patient data of overweight and obesity stone recurrence.


This study aimed to investigate a variety of machine learning (ML) methods to predict the association between cardiovascular risk factors and coronary artery disease-reporting and data system (CAD-RADS) scores.This is a retrospective cohort study. Demographical, cardiovascular risk factors and coronary CT angiography (CCTA) characteristics of the patients were obtained. Coronary artery disease (CAD) was evaluated using CAD-RADS score. The stenosis severity component of the CAD-RADS was stratified into two groups: CAD-RADS score 0-2 group and CAD-RADS score 3–5 group. CAD-RADS scores were predicted with random forest (RF), k-nearest neighbors (KNN), support vector machines (SVM), neural network (NN), decision tree classification (DTC) and linear discriminant analysis (LDA). Prediction sensitivity, specificity, accuracy and area under the curve (AUC) were calculated. Feature importance analysis was utilized to find the most important predictors.p < 0.001), and high-density lipoprotein (HDL-C) lower (p < 0.001) in CAD-RADS score 3–5 group compared to the CAD-RADS score 0–2 group. Nineteen features were chosen to train the models. RF (AUC = 0.832) and LDA (AUC = 0.81) outperformed SVM (AUC = 0.772), NN (AUC = 0.773), DTC (AUC = 0.682), KNN (AUC = 0.707). Feature importance analysis indicated that plasma fibrinogen, age and DM contributed most to CAD-RADS scores.A total of 442 CAD patients with CCTA examinations were included in this study. 234 (52.9%) subjects were CAD-RADS score 0–2 group and 208 (47.1%) were CAD-RADS score 3–5 group. CAD-RADS score 3-5 group had a high prevalence of hypertension (66.8%), hyperlipidemia (50%) and diabetes mellitus (DM) (35.1%). Age, systolic blood pressure (SBP), mean arterial pressure, pulse pressure, pulse pressure index, plasma fibrinogen, uric acid and blood urea nitrogen were significantly higher (ML algorithms are capable of predicting the correlation between cardiovascular risk factors and CAD-RADS scores with high accuracy. CAD is the leading cause of morbidity and mortality worldwide  and is oMachine learning (ML) have been developed to predict outcomes in cardiovascular disease and have the potential to provide useful insights for cardiovascular medicine systems . ML accon = 45), incomplete basic clinical information (n = 38), and a history of bypass surgery or percutaneous coronary intervention (PCI) (n = 54)  . The stu(n = 54) .Demographic variables and traditional CAD risk factors included age, gender, SBP, diastolic blood pressure, mean arterial pressure, pulse pressure, pulse pressure index, hypertension, DM, smoking status, hyperlipidemia, total cholesterol, triglycerides, HDL-C, low-density lipoprotein cholesterol (LDL-C), uric acid, plasma fibrinogen, blood creatinine, and blood urea nitrogen. Patients who were smokers at the time of analysis were classified as current smokers. Hypertension is defined as SBP values ≥140 mmHg and/or diastolic blood pressure values ≥90 mmHg or use of antihypertensive medication . DM was All CCTA scans were performed using two 256-slice multidetector CT scanners (Brilliance iCT 256 from Philips and SOMATOM Definition Flash CT from Siemens). The scanning parameters were as follows: tube voltage of 120 kV, 800 mAs, slices/collimation of 128/0.625 mm, gantry rotation time of 330 ms, pitch of 0.2, effective slice thickness of 0.9 mm, and reconstruction increment of 0.45 mm. Patients with a heart rate > 80 beats/min were given oral beta-blockers 1 h prior to the examination. All patients received 0.5 mg of sublingual nitroglycerin for coronary vasodilatation. A bolus of 1.5 ml/kg of iodinated contrast medium was administered intravenously at a rate of 5 ml/s, followed by 40 ml of saline injected at the same rate. After acquisition, the images were processed using artificial intelligence (AI) software .(1) Coronary stenosis severity was scored as follows: CAD-RADS 0 indicated no visible stenosis, with a degree of maximal coronary stenosis of 0%; CAD-RADS 1 indicated minimal stenosis of 1–24%; CAD-RADS 2 indicated mild stenosis of 25–49%; CAD-RADS 3 indicated moderate stenosis of 50–69%; CAD-RADS 4 indicated severe stenosis, including two groups: CAD-RADS 4A-70–99%; CAD-RADS 4B-Left main > 50% or 3-vessel obstructive disease; and CAD-RADS 5 indicated 100% total occlusion .(2) The stenosis severity component of CAD-RADS was stratified into two groups for uniformity and sample size based on previously published methods: CAD-RADS score 0-2 group and CAD-RADS score 3–5 group . The CADThe study population was randomly assigned to the training cohort, which comprised 70% of the patients, and the test cohort, which comprised 30% of the sample, in order to validate the predictive models . The traTo develop predictive models, we used six ML methods: random forest (RF), support vector machine (SVM), neural network (NN), k-nearest neighbor (KNN), decision tree classification (DTC) and linear discriminant analysis (LDA).k = 10) cross-validation. We tuned the parameters for each model using the grid search method to increase the prediction accuracy. The training set was used to learn the ML parameters, while the test set was used for standard evaluation metrics. Each model was trained and tested for CAD-RADS scores.All models were implemented using the statistical software package R and JASP and designed using k-fold  sensitivity, (2) specificity, (3) accuracy of prediction, (4) area under the receiver operating characteristics curve (ROC-AUC), which plots true positive against false positive rate . As AUC t-test. Prior to analysis, we assessed the normality of data distributions and homogeneity of continuous variables.Whenever the distribution of continuous data was not normal, the Mann–Whitney U-test was used for comparison, and results were presented as median . A p value< 0.05 was considered statistically significant. Six models were employed to utilize the statistical software package R and JASP, and their performance was subsequently compared to determine the optimal selection classifier for identifying high risk factors in predicting CAD-RADS scores.Statistical analysis was performed using the SSPS software . Baseline characteristics are presented as mean ± standard deviation (SD) or frequencies and percentages. Categorical variables were compared using the chi-square or Fisher’s exact tests, while continuous variables were analyzed with independent samples p < 0.001), and HDL-C lower (p < 0.001) in the CAD-RADS score 3-5 group compared to the CAD-RADS score 0-2 group (p = 0.052), total cholesterol (p = 0.265), LDL-C (p = 0.572) and different CAD-RADS scores. A total of 442 CAD patients were included in this cohort, with 268 (60.6%) males and 174 (39.4%) females. The median age was 63 years, with the lowest and highest ages being 18 and 88 years, respectively. Among the entire cohort, there was a high prevalence of patients with hypertension (51.6%) and hyperlipidemia (42.8%). One hundred and forty-two (32.1%) people had a history of smoking and 91 (20.6%) had DM. All subjects were divided into two groups based on CAD-RADS scores: 234 (52.9%) subjects were CAD-RADS score 0–2 group and 208 (47.1%) were CAD-RADS score 3–5 group. The CAD-RADS score 3–5 group had a higher prevalence of hypertension (66.8%), hyperlipidemia (50%), and DM (35.1%). Age, SBP, mean arterial pressure, pulse pressure, pulse pressure index, plasma fibrinogen, uric acid, and blood urea nitrogen were significantly higher . We employed the RF prediction model to rank all features based on their significance in test data, using k-fold cross-validation . These findings highlight the potential benefits of monitoring blood plasma fibrinogen concentrations in preventing CAD.Plasma fibrinogen, as a coagulation index, was the most important feature based on our feature selector, and it was independently associated with coronary severity and complexity in patients with CAD. Plasma fibrinogen, a marker of inflammation and coagulation, may stimulate coagulation, platelet aggregation, and vascular endothelial dysfunction, mediate the transportation of adhesion molecules on the surface of the endothelium and their further migration to the intima, trigger proliferation and migration of smooth-muscle cells to increase coronary plaque vulnerability , and is In our study, age was the second most important risk predictor for CAD-RADS scores. Similar findings have been reported that age was the second most important risk factor for 5-year mortality in CAD patients undergoing PCI . Sun et In summary, our findings suggested that elevated plasma fibrinogen levels, advanced age, and DM were significant predictors of CAD-RADS 3–5 scores. Monitoring plasma fibrinogen and blood glucose levels may offer additional information for the prevention of CAD in clinical practice. Individuals with elevated level of plasma fibrinogen, blood glucose or advanced age should receive increased attention in the CAD prevention efforts. In addition to plasma fibrinogen, age and DM, other variables such as pulse pressure, HDL-C, pulse pressure index, mean arterial pressure, SBP and smoking are also relatively significant in stratifying a patient’s risk for CAD. These risk factors seldom occur independently but rather tend to cluster together with other cardiovascular risk factors. Modifying these risk factors may be effective in preventing CAD progression and reducing CAD-RADS scores. Further research with a larger sample size of Chinese patients with CAD is necessary to provide more conclusive evidence regarding these associations.This study has both strengths and limitations: Firstly, there are still some disadvantages to using ML in cardiovascular practice. There are many unmeasured or unknown important variables, and different classifiers for the same dataset may not all be equally robust . Data avThis study indicated that RF outperformed other models in predicting CAD-RADS scores among CAD patients, making it a recommended predictive model for identifying high-risk patients with CAD-RADS 3–5 scores. The most significant feature selection were plasma fibrinogen, age and DM, indicating that combined strategies targeting these factors may be effective in preventing the burden of CAD. We hope this study can serve as a valuable resource for future research on this topic.10.7717/peerj.15797/supp-1Supplemental Information 1Click here for additional data file.


Among the complications related to chronic kidney disease (CKD), those of a neurological nature stand out, and for a better quality of life for patients, the diagnosis and treatment of these complications is fundamental.This study aimed to assess the effect of hemodialysis on intracranial pressure waveform (ICPw) in patients with chronic kidney disease undergoing hemodialysis and those who are not yet undergoing substitutive therapy.An observational study was conducted in two stages at a kidney replacement therapy center in Brazil. The first was a longitudinal study and the second was a cross-sectional study.Forty-two patients on hemodialysis were included in the first stage of the study. In the second stage, 226 participants were included. Of these, 186 were individuals with chronic kidney disease (who were not undergoing substitutive therapy), and 40 did not have the disease (control group). The participants’ intracranial compliance was assessed using the non-invasive Brain4care method, and the results were compared between the groups.There was a significant difference between the hemodialysis and non-hemodialysis groups, with the former having better ICPw conditions.Hemodialysis influenced the improvement in ICPw, probably due to the decrease in the patients’ extra-and intracellular volumes. Furthermore, ICPw monitoring can be a new parameter to consider when defining the moment to start substitutive therapy. The classification of the progression of this disease is based mainly on the GFR, and five stages have been established, as shown in  The consequences of the illness, besides the loss of kidney function, include cardiovascular disease and premature death, in which the risk of death due to a cardiovascular event is higher than that of requiring hemodialysis or a transplant. Approximately 4 million people worldwide depend on kidney replacement therapy, of which 89% undergo hemodialysis. The complications related to hemodialysis are common. Some are even expected due to the hemodialysis process itself, in which the patient bears hours of extracorporeal blood flow, forced ultrafiltration, and exposure to large quantities of dialysate. Unexpected complications include infectious diseases, mineral metabolism disorders, and neurological complications, such as hemodialysis imbalance syndrome.Kidney disease has become a public health concern due to its increasing prevalence and high treatment costs for the public. In clinical terms, kidney disease is characterized the loss of kidney function occurs over time. Diagnosis is based on the mean glomerular filtration rate (GFR)  monitoring tool was developed by the Brazilian company Brain4care Inc. . This novel approach to studying neurological disturbances has already been applied in hemodialysis patients. The technology is based on capturing small variations in the skull caused by ICP alterations through a voltage sensor in contact with the lateral region of the sagittal suture, providing real-time ICPw data. This ICPw is composed of three peaks , and fro Kt/V is a formula used to measure dialysis adequacy, in which K is urea clearance by the dialyzer, t is the time of treatment, and V is the volume of urea distribution in the patient. The recommended Kt/V is maintained above 1.2 during hemodialysis. A subsequent follow-up study evaluated the intracranial compliance (by means of the ratio between the peaks P2/P1) pre-dialysis and post-dialysis, demonstrating that the P2/P1 ratio was less than that observed before the dialysis was done, reinforcing the previous finding that hemodialysis generates a positive effect on intracranial compliance.A first cross-sectional study using this technology in patients with ESKD undergoing hemodialysis indicated that these patients frequently experience alterations in intracranial compliance and that high-quality hemodialysis (according to Kt/V) might be effective in normalizing intracranial compliance.2, but dialysis is usually indicated when the GFR is < 10 mL/min/1.73 m2.Based on these results, the need to investigate alterations in intracranial compliance in the initial stages of CKD as well as in those patients in stage 5 who do not undergo dialysis is required. Patients with CKD enter stage 5 when their GFR is < 15 mL/min/1.73 m and a control group.The aim of this study was to analyze intracranial compliance in different CKD stages  compared with the results obtained in patients undergoing dialysisThis study was conducted in two stages at a substitutive kidney therapy center (KTC) of a hospital in southern Brazil. Both protocols were approved by the Research Ethics Committee of Universidade Estadual de Ponta Grossa  and the study followed the STROBE. The study started in January 2017 and ended in August 2018. The second stage was an observational, cross-sectional study that included 226 participants. Of those, 186 were patients with CKD in stages 1–5 but who still did not undergo any kind of substitutive kidney therapy, and 40 did not present with CKD and were classified as the control group. The choice of control group participants was randomized, including individuals of similar age groups as those in the CKD group. The second stage began in October 2019 and ended in October 2021. During both stages, the sampling was convenient because this was an unprecedented study according to the number of patients admitted at the KTC.The participants were patients with chronic kidney disease from the southern region of the state of Paraná, most of whom have diabetes and high blood pressure and were being treated by the Unified Health System . The first stage was an observational, longitudinal, prospective study of 42 patients with terminal kidney disease who underwent hemodialysis periodically, three times a week, for six months.Every participant received information about the study and willingly participated after signing the two-part form of the Consent Term (Termo de Consentimento Livre e Esclarecido). As inclusion criteria, it was established that participants should be ≥ 18 years and considered legally capable. The clinical characteristics of patients were obtained using questionnaires and consultations with online medical records from the KTC. The study was conducted in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki). safe, and detects micrometric deformation of the cranial bones through a mechanical extensometer attached to a sensor. This sensor is fixed to a band and coupled to the lateral position of the patient’s head, approximately 2 cm above the ear. The detected deformations were transformed into electrical signals and displayed on a monitor. The amplification stage then occurs in which the equipment filters, amplifies, digitizes, and records the signals. The monitor displays are saved and sent to the Brain4care Analytics software, which provides us with a report of each display in which the wave morphology of the ICP and the amplitude of its peaks can be observed. The equipment used was properly calibrated by Brain4care.Intracranial compliance was monitored using non-invasive equipment provided by the company Brain4care. Two examiners participated in the research, one for each stage, and they underwent previous training provided by the company. This method is innovative, validated,At the moment of monitoring, the individuals stood still, sat down, and were monitored for approximately 3–5 min. The patients in the first stage, who underwent hemodialysis, were monitored pre- and post-dialysis in every session during the 6-month period in which they were assessed. Patients in the second stage underwent one monitoring session.Two comparison models were created for the P2/P1 ratio. The first included three groups: 1) individuals without CKD; 2) individuals with CKD who did not undergo substitutive treatment; and 3) individuals who underwent hemodialysis. The second model differs from the first because it includes three levels of CKD severity among patients with the disease who did not undergo hemodialysis. The levels of severity were: mild, which includes individuals at stages 1 and 2; moderate, which includes individuals at stages 3a and 3b; and severe, which includes individuals at stages 4 and 5. In this way, Model 2 included five groups: 1) individuals without CKD; 2) individuals with CKD in the mild form; 3) individuals with CKD the moderate form; 4) individuals with CKD in the severe form; and 5) individuals undergoing hemodialysis.The average P2/P1 ratio of each patient undergoing hemodialysis was calculated pre- and post-dialysis monitoring. Pre-dialysis values were selected for a more reliable analysis, as post-dialysis values could be affected by all dialysis procedures.Analysis of the quantitative value of the ICPw P2/P1 ratio in both models utilized an analysis of variance (ANOVA) with Tukey’s post-hoc test. We conducted the Shapiro-Wilk test to verify the normality of the data (P >0.05).To assess the discriminative power of ICPw in CKD patients undergoing enhanced hemodialysis compared with those who still required it, we generated a receiver operating characteristic (ROC) curve using the P2/P1 ratio as a factor. The ROC curve plots the sensitivity (true positive rate) against 1-specificity  for different cut-off values of the P2/P1 ratio, displaying the relationship between sensitivity and specificity across a range of cut-off values. We calculated the area under the curve (AUC) to evaluate the overall diagnostic accuracy of non-invasive intracranial pressure measurements. The optimal cut-off value was determined by maximizing the Youden index, which combines sensitivity and specificity to measure the overall diagnostic accuracy. By comparing the ROC curves of patients with CKD not undergoing hemodialysis with those of patients with CKD undergoing hemodialysis, we assessed the discriminative power of non-invasive intracranial pressure measurements between the two groups. Statistical significance was set at a significance level of 5% (P < 0.05). All calculations were performed using GraphPad Prism version 9.00 Windows .The clinical parameters of the patients included in this study are shown in There was a significant difference between the analyzed groups ; the patThe graph ahead  brings aThe mild, moderate, and severe CKD groups had similar P2/P1 ratios. However, there was a significant difference between the CKD groups without hemodialysis and patients undergoing hemodialysis. The healthy patients had similar results to the patients in the groups “mild,” “moderate,” and “severe,” undergoing hemodialysis.An ROC curve was generated for the P2/P1 ratio to assess its diagnostic performance in patients with CKD in both the hemodialysis and non-hemodialysis groups. The P2/P1 ratio demonstrated discriminative power, with an AUC value of 0.728 (P < 0.0001). Hence, the P2/P1 ratio serves as a good marker for distinguishing between hemodialysis and non-hemodialysis patients with CKD . One of the pathological mechanisms is brain edema, which can be due to the accumulation of uremic toxins and increase in extracellular fluid, progressing as the GFR decreases, causing ICP elevation. Patients who undergo hemodialysis are in the terminal stage of the disease and present a very low GFR. In addition, the ICP in these patients was better, probably because of the decrease in fluid volume due to hemodialysis. This aligns with our results of the ICPw comparison pre- and post-dialysis, indicating improvement after the procedure. Therefore, hemodialysis plays an important role in the improvement of ICPw. The mild, moderate, and severe CKD groups exhibited similar P2/P1 ratios. The hypothesis for this result is the administration of adequate treatment for these patients and the differences in the protocols for each stage. As CKD progresses, the disease management protocol becomes more complex and rigid, requiring better control of laboratory parameters and administration of medications.In this study, we demonstrated that the group of individuals undergoing hemodialysis presented better intracranial compliance than the group of individuals with CKD who did not undergo substitutive kidney therapy. One of the most affected organs by CKD is the brain, and varied neurological damages are commonly observed in kidney patients, such as cognitive deterioration, encephalopathy, convulsions, and strokes. Hence, our findings suggest that the P2/P1 ratio serves as a reliable marker for distinguishing between the two groups.An additional interesting finding of this study was the distinction between the groups of patients with CKD who underwent hemodialysis and those who did not. Using the ROC curve, we determined a cut-off point of 1.245 for the P2/P1 parameter, with an AUC value of 0.728 and a sensitivity of 98%. AUC is a widely used performance measure for assessing the accuracy of a binary classification model. AUC values close to 1.0 indicate excellent performance in correctly classifying true categories; values between 0.7 and 0.9 are considered indicative of moderate to good performance; and AUC values between 0.5 and 0.7 are deemed poor to moderate performance. In the early stages, the main symptoms reported are: difficulty focusing, lack of attention, emotional unbalance, depression, and recent memory impairment. In the more advanced stages, the accumulation of organic waste and toxins causes loss of consciousness, convulsions, and coma. Although the neurological symptoms become more evident in the terminal stage of the disease, their identification and adequate management in the early stages delay the progression and effects of these complications. Usually, initiating dialysis in patients with chronic kidney disease is determined based on the presentation of typical symptoms of kidney insufficiency, which often occur with a GFR 5–10 mL/min/1.73 m, and include mental confusion and loss of consciousness. In this context, the monitoring of the ICPw might aid in investigating neurological disturbances at every stage of CKD. In summary, the ICPw follow-up in the last CKD stage might be one of the determining factors in initiating substitutive renal therapy. Hemodialysis has demonstrated efficient ICPw improvement in these patients, reducing the symptoms and improving the quality of life.Neurological manifestations may appear in any CKD stage, with higher chances in the late stages. and its limits are an average arterial pressure between 60 and 160 mmHg for healthy adults. Furthermore, thickening of the internal basal membrane of the brain microvasculature and an increase in the P2 peak in mice with diabetes was observed. The hypothesis is that the damage to the brain microvasculature in diabetes mellitus compromises intracranial compliance. In addition, diabetic ketoacidosis, a complication of diabetes, may lead to brain edema, which may cause intracranial hypertension. Moreover, many authors associate obesity with the development of idiopathic intracranial hypertension. Idiopathic intracranial hypertension is characterized by increased intracranial pressure of uncertain etiology, primarily affecting obese women of reproductive age. Although its pathophysiological mechanism is unknown, the risk of developing idiopathic intracranial hypertension intensifies according to the body mass index. Notwithstanding, overweight and obesity are factors that increase the probability of cerebrovascular diseases, which may lead to intracranial hypertension. Other possibilities for the ICPw alteration in patients of the control group could include undiagnosed medical conditions that may affect intracranial compliance and arterial hypertension, which may exceed the brain’s self-regulation limit. Although these data are noteworthy, they are not the focus of this study, and more studies are being conducted with the objective of clarifying the behavior of the ICPw and related variables.In the control group, a large number of individuals presented with alterations in ICPw. This may be attributed to the presence of diseases such as arterial hypertension, diabetes, and obesity observed in some of these patients, which may interfere with brain self-regulation. Brain self-regulation corresponds to the capacity of the brain to maintain adequate blood flow through variations in arterial pressure,This research has some limitations, such as convenience sampling of only one KTC, which may generate biased selection. Furthermore, in the second stage, only one monitoring of each patient was performed, providing accurate data without the possibility of following up. Additionally, both stages were not performed concurrently, with the possibility of protocol changes between the years of the study.Despite its limitations, this study demonstrates the relevance of monitoring ICPw in patients with CKD from the early stages until the terminal stage. The incorporation of the non-invasive monitoring method of the ICPw in the follow-up of patients with chronic renal diseases aids in their treatment, resulting in an improved quality of life and preventing complications such as strokes, which are common in these individuals. In patients in the terminal stage, ICPw monitoring may be an auxiliary tool in the decision to initiate hemodialysis, as it influences ICPw improvement.In conclusion, hemodialysis influences ICPw control in patients with CKD at the terminal stage. In addition, we suggest non-invasive monitoring using ICPw as a new parameter in deciding the moment at which the patient with CKD must initiate substitutive kidney therapy, with the objective of minimizing the risks to the brain and improving the patient’s quality of life.


Activity and chronicity of kidney involvement in ANCA-associated vasculitis (AAV) can be currently reliably evaluated only by kidney biopsy. In this study, we measured a panel of serum and urinary biomarkers collected at the time of kidney biopsy and hypothesized that they could reflect specific histopathological parameters in the biopsy and help to predict prognosis.We examined a cohort of 45 patients with AAV and 10 healthy controls. Biomarker levels  were measured in this study by ELISA. Biopsies were scored with a scoring system for AAV  and interstitial fibrosis was quantified.Levels of urinary DKK-3, CD163, EGF, PRO-C6 and C3M significantly differed among biopsy classes in AAV, with urinary DKK-3 and PRO-C6 levels being highest in the sclerotic class and lowest in the focal class, urinary CD163 levels highest in the crescentic class and urinary C3M levels highest in the focal class. Moreover, the urinary biomarkers were able to discriminate focal biopsy class from the other classes. Urinary DKK-3, EGF, PRO-C6 and C3M levels measured at the time of biopsy were also significantly related to the extent of fibrosis and to the final kidney function at the end of follow-up.This small pilot study suggests that selected urinary biomarkers of fibrosis and inflammation may reflect changes in the kidney biopsy and be prognostic of kidney outcome in patients with AAV. HoweverKidney fibrosis is a typical feature of chronic kidney disease (CKD) present also in patients with AAV. It is caused by an imbalance in turnover of extracellular matrix (ECM) components. ECM biomarkers describing the morphological changes in the kidney tissue are detectable in serum and urine, potentially even in patients with still preserved kidney function .Novel serum and, especially, urinary biomarkers able to assess the type, extent and potentially prognosis of kidney disease in AAV are needed. In this study, we aimed to assess the potential value of a panel of fibrosis, kidney tissue injury and inflammation biomarkers to diagnose and assess kidney disease in AAV.Several biomarkers of the morphological changes in the kidney tissue have been already described. DKK-3 (Dickkopf-related protein 3), a stress-induced tubular epithelia-derived profibrotic glycoprotein, was shown to be prognostic for risk of short-term eGFR loss regardless of the cause of kidney injury and specifically correlated with the extent of tubular atrophy and interstitial fibrosis –8. High PRO-C6 and C3M are two markers of collagen turnover that have been previously shown to strongly correlate with kidney function and associate with adverse kidney- and cardiovascular-related outcomes in patients with CKD of different aetiology –17. IncrThe aim of this study was to investigate the association of DKK-3, CD163, EGF, PRO-C6 and C3M measured in urine with the histological changes in kidney biopsies , as well as their prognostic potential for kidney function in patients with AAV. To our knowledge, this is the first time these biomarkers have been studied together in a cohort of AAV patients.22.1The cohort consisted of 45 patients with AAV  years, type of ANCA PR3 (proteinase - 3)/MPO (myeloperoxidase)/double 20/23/2) sampled on the day of kidney biopsy, and 10 healthy controls  years). All patients were recruited from Department of Nephrology of the General University Hospital in Prague, Czech Republic. Follow-up clinical data were available at 1 year in 44 patients and at 3 years in 32 patients. Two mentioned biomarkers (DKK3 and PRO-C6) were measured in the same cohort of patients in our previous research study . One year after diagnosis, all patients were still treated with maintenance immunosuppressive therapy, and after 3 years the immunosuppressive therapy was completely withdrawn in 6% of the patients.The study was conducted in accordance with the World Medical Association’s Declaration of Helsinki. The participants provided their written informed consent to participate in this study and the study was reviewed and approved by the Ethics Committee of General University Hospital in Prague.2.2Basic clinical and laboratory data were obtained from routine patients’ visits  at the time of diagnosis and during follow-up . Serum and urine samples were collected and stored in the Biobank at -80°C. According to the median of serum creatinine (156 µmol/l) at the end of follow-up, we divided patients into two groups – the favourable prognosis group with the last available serum creatinine below 156 µmol/l and the unfavourable prognosis group with the last serum creatinine above 156 µmol/l .2.3The selected biomarkers were measured in paired serum and urine samples using commercially available enzyme-linked immunosorbent assay (ELISA). DKK-3 was measured in serum and urine with the human ELISA kit by Sigma-Aldrich. CD163 and EGF were measured in urine with ELISA kits by R&D systems. All of them were measured in the laboratories of the General University Hospital in Prague. PRO-C6 and C3M levels were measured in serum and urine with ELISA kits by Nordic Bioscience, Denmark. Serum and urinary samples used for measurement of these biomarkers were not available for all 45 patients. Finally, we had 45 samples in AAV group measured for the basic comparison with healthy controls, 40 samples for measuring biomarkers in particular biopsy classes used in most subanalyses, and 38 samples for measuring renal outcome. Urinary marker levels were normalized to urinary creatinine measured by standard measurement method in the Institute of Medical Biochemistry and Laboratory Diagnostics in the General University Hospital in Prague.2.4Ultrasound-guided kidney biopsies were performed at the time of diagnosis of AAV at the General University Hospital in Prague.The glomerular morphology in the biopsies was classified according to Berden’s scoring system for AAV as focal , crescentic (> 50% of glomeruli with cellular crescents), sclerotic  or mixed (meeting none of the above criteria) .2.5All biomarkers were measured in both serum and urine samples but only urine biomarkers were kept in the final statistical analyses for their non-invasive character.For the comparison of various groups, the non-parametric tests were used. Two groups may be compared by Mann-Whitney test, for more than two groups the Kruskal-Wallis test was used.The p-value is obtained using the asymptotic approximation of the distribution of the statistic. The estimation of p-values is included in software XLSTAT.Linear discriminant analysis was used for the calculation of ROC only. All results were confirmed by the Logistic regression.Linear discriminant analysis predicts a membership in a group or category based on observed values of several continuous variables . Specifii. The most common functions used to link probability p to the explanatory variables, xi , are the logistic function (the Logit model). XLSTAT uses the Newton-Raphson algorithm to iteratively find a solution. All statistical analysis were performed by XLSTAT software.Logistic regression is a frequently used method, as it enables binary variables, the sum of binary variables, polytomous variables (variables with more than two categories), or ordinal variables  to be modeled. The principle of the logistic regression model is to link the occurrence or non-occurrence of an event to explanatory variables. For logistic regression, the dependent variable (y), also called the response variable, follows a Bernoulli distribution for parameter p (p is the mean probability that an event will occur) when the experiment is repeated once. The probability parameter p is here a linear combination of explanatory variables, x33.1The demographic, clinical and laboratory data on participants are summarized in 3.2Using discrimination analysis, a combination of 5 urinary markers  could significantly differentiate patients with AAV from healthy controls with 100% accuracy of discrimination. Urinary DKK-3, CD163 and PRO-C6 levels were higher and urinary EGF and C3M levels were lower in patients with AAV as compared with healthy controls. The medians and I. and III. quartile of biomarkers levels in patients with AAV and healthy controls are summarized in 3.3Kidney biopsies were classified as focal, crescentic, sclerotic and mixed class. Urinary DKK-3, CD163, EGF, PRO-C6 and C3M significantly differed in patients with different biopsy classes. These 5 urinary biomarkers were able to discriminate the focal class from the other classes  with 90% accuracy , urinary EGF and C3M levels were highest in patients with less than 25% renal fibrosis (ci0+ci1) according to the Banff schema .Simultaneously, we were able to describe the association between the renal biopsy class and extent of renal fibrosis at the time of diagnosis. Unsurprisingly, while most patients with the focal and crescentic class had an interstitial fibrosis percentage less than 25% (Banff ci0+ci1), the sclerotic class displayed interstitial fibrosis of more than 25% (in the majority even more than 50% - Banff ci3) . The median of final serum creatinine was 156 (range 69-800) µmol/l in the whole cohort and 8 patients (18%) reached end-stage renal disease. Five urinary biomarkers  collected at the time of diagnosis AAV were able to differentiate between patients with better or worse final renal function (favourable and unfavourable prognosis) at the end of follow-up with 88.9% accuracy , as a fully non-invasive method, to distinguish respective biopsy classes. Although, the accuracy of discrimination with only urinary biomarkers was not as high as with serum and urinary biomarkers (data not shown), still the accuracy and sensitivity were high enough (80% and more). While the discrimination between the focal and the sclerotic class, and between the focal and the crescentic class reached 100% sensitivity and more than 90% specificity, distinguishing the crescentic from the sclerotic class proved to be less specific. We think that this might be caused by a high serum creatinine levels in both classes and found CD163 to be the most useful biomarker for this discrimination. In order to achieve higher accuracy and specificity, one would perhaps need to find yet another biomarker in the future. Furthermore, only the urinary DKK-3, EGF and PRO-C6 levels were significantly related to the extent of renal fibrosis.As regards to ANCA levels in various biopsy classes, we observed higher ANCA PR3 levels in the focal class and higher ANCA MPO levels in the other biopsy classes, mainly in the sclerotic class. These findings could be explained by different manifestation of AAV with ANCA MPO and PR3. While ANCA MPO AAV is mostly connected with more gradual renal impairment and AAV is usually diagnosed later with more advanced histological changes, ANCA PR3 AAV is often diagnosed earlier due to extrarenal manifestation when renal impairment is not so advanced yet. We did not find any statistically significant differences in comparison between the biomarker levels and the PR-3 and MPO-ANCA positive patients.We have also investigated the association of biomarker levels at the time of diagnosis and renal outcome at the end of follow-up. The 5 selected urinary biomarkers  significantly differed favourable and unfavourable group of patients. Urinary DKK-3 and PRO-C6 levels at the time of diagnosis were higher in patients with the worse renal function at the end of follow-up. On the contrary, urinary EGF and C3M levels were higher in patients with better renal function at the end of follow-up. Our findings support various studies in different renal diseases in which similar results had been observed , 15, 28.The limitations of this study include the inclusion of a relatively low number of patients in a single-center cohort, and a possible selection bias in the recruitment of the patients, as some of the patients were not included due to the lack of renal biopsy because of life-threatening disease symptoms, requiring acute hemodialysis or plasma exchange. Due to the design of the study and low number of patients, we were not able to confirm the results in a validation cohort, but plan to do that in the future. Moreover, we do not have any data on longitudinal biomarkers measurements that would elucidate the exact relationship of the markers to vasculitis activity, impact of treatment and kidney fibrosis ongoing development.The strength of this study is that we have used biomarkers that can be easily assessed in biological fluids. Moreover, the urinary biomarkers identified in this study could be used as a non-invasive tool for monitoring histological and functional changes of kidney.One day, with further investigation and systematic assessment, the urinary biomarkers potentially can replace the renal biopsy, especially, they might be preferentially used where the biopsy was considered risky or could not be done due to aggressive disease course, or used for activity/chronicity assessment in cases with a suboptimal size of the biopsy samples, etc.In conclusion, this small study demonstrated that non-invasive biomarkers of fibrosis, inflammation and kidney tissue injury were associated with severity of renal involvement and prognosis of kidney disease progression in patients with AAV.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 Ethics committee of General University Hospital in Prague. The patients/participants provided their written informed consent to participate in this study.ZH, VT, FG, NS and VS designed the study. MS performed the statistical analysis, made the figures and tables. VS drafted the paper. LB, EH, MK provided renal biopsy data. FG, NS, MA, HK provided laboratory data. VS, DF, RR, VB, ZH provided clinical data. ZH, VT, FG provided supervision. All authors contributed to the article and approved the submitted version.


Hypertension is a well-established cardiovascular risk factor in patients with diabetes, chronic kidney disease, obesity, heart failure and stroke. Among the modifiable risk factors, particularly diabetes together with sedentary lifestyle, smoking and obesity greatly influences cardiovascular risk in patients with hypertension.In South Asia, the prevalence of diabetes, hypertension and atherosclerotic cardiovascular disease is on the rise.2In a recent issue of Pakistan Journal of Medical Science (PJMS), Adnan et al.This is an important study investigating the burden of hypertension and BP control in patients with diabetes and adds useful information to the existing literature. Although the overall prevalence of hypertension was not low in the study, including 24-hour ambulatory BP (ABPM) recording could yield even higher prevalence of true hypertension, including so-called masked hypertension. In fact, 24-hour ABPM measurement not only identifies hypertension subtypes and evaluates treatment response , but can4Furthermore, BP control was assessed by office/clinic BP – threshold of 140/90 mmHg. However, for patients with diabetes, chronic kidney disease, and coronary artery disease , which all are defined as high-risk patients, the recommended therapeutic target by most guidelines is towards 135/80 mmHg or 130/80 mmHg in younger patients.Further, the authors showed that modifiable factors such as lack of education, sedentary lifestyle, and unhealthy diet not only contribute to hypertension, but also increase the risk of undetected hypertension and masked untreated hypertension.Orthostatic hypotension, which is common in patients with diabetes, was not discussed as it probably was not the aim of the study. However, orthostatic hypotension defined as a reduction in systolic BP of at least 20 mmHg or in diastolic BP of at least 10 mmHg within three minutes of standing, is associated with an increased risk of mortality and cardiovascular events.Finally, although the classes of antihypertensive medications were accounted for, the information about statin use was missing. Patients with hypertension, and Type-2 diabetes often have unfavourable lipid profile  and may benefit from a statin, which should be added to the patient’s antihypertensive treatment.Despite the usual prescribed antihypertensive medications with maximal tolerable doses, many patients fail to achieve the recommended BP targets. The novel antidiabetic agents, sodium-glucose cotransporter-2 inhibitors (SGLT2i), can reduce office and ambulatory BP by several mmHg on top of conventional antihypertensive drugsDiabetes can contribute to subclinical LV dysfunction (diabetic cardiomyopathy) by both the direct effect on the LV myocardium through a load-independent impairment of systolic function, and by arterial stiffening increasing LV afterload.Furthermore, Type-2 diabetes is associated with arterial stiffening and abnormal pulsatile arterial hemodynamics in patients with heart failure and preserved ejection fraction.The findings that modifiable factors such as lack of education, sedentary lifestyle and unhealthy diet contribute to hypertension and treatment resistance, as well as increase the risk of undetected hypertension, are important and highlight the need of formal usage, patient education, improving compliance and tackling therapeutic inertia by the physician.Studies have shown that diabetes is a predictor of resistant hypertension. Other predictors are older age, male gender, black African origin, obesity, established atherosclerotic cardiovascular disease and chronic kidney disease.The opinion expressed in the present expert commentary is the view of the authors and does not necessarily reflect the view of the institutions the authors belong to.SS wrote the first draft of the article which was revised by AMA, MAM and PMN.All authors approved the final submission.


Telomeres are dynamic DNA nucleoprotein structures located at the end of chromosomes where they maintain genomic stability. Due to the end replication problem, telomeres shorten with each cell division. Critically short telomeres trigger cellular senescence, which contributes to various degenerative and age-related diseases, including chronic kidney diseases (CKDs). Additionally, other factors such as oxidative stress may also contribute to accelerated telomere shortening. Indeed, telomeres are highly susceptible to oxidative damage due to their high guanine content. Here, we provide a comprehensive review of studies examining telomere length (TL) in CKDs to highlight the association between TL and the development and progression of CKDs in humans. We then focus on studies investigating TL in patients receiving kidney replacement therapy. The mechanisms of the relationship between TL and CKD are not fully understood, but a shorter TL has been associated with decreased kidney function and the progression of nephropathy. Interestingly, telomere lengthening has been observed in some patients in longitudinal studies. Hemodialysis has been shown to accelerate telomere erosion, whereas the uremic milieu is not reversed even in kidney transplantation patients. Overall, this review aims to provide insights into the biological significance of telomere attrition in the pathophysiology of kidney disease, which may contribute to the development of new strategies for the management of patients with CKDs. Chronic kidney diseases (CKDs) are a heterogeneous group of disorders that represent a global public health problem. They affect more than 750 million people worldwide, and this number is expected to increase due to the ageing population . Age-relOxidative stress is a hallmark of CKDs and contributes to accelerated telomere attrition. Here, we provide a comprehensive review of studies investigating TL in CKDs and highlight the association between TL shortening and the development and progression of CKDs. We then focus on studies investigating TL in patients who are receiving kidney replacement therapy. Overall, this review provides insights into the biological significance of telomere shortening in the pathophysiology of CKDs, which may contribute to the development of new strategies for managing patients with CKD.Telomeres are nucleoprotein structures that cap the ends of eukaryotic chromosomes. In humans, telomeres consist of non-coding tandem TTAGGG DNA sequences, which are bound by six telomere-specific proteins called shelterin . TelomerIn the ageing kidney, telomere shortening is faster in the renal cortex than in the medulla and it may contribute to glomerulosclerosis. The differences are greater in younger kidneys and decrease with age . StudiesThe prevalence of CKD is highest in the elderly population. Because TL has been proposed as a marker of biological age, many studies have investigated the association between TL and kidney function, the progression of nephropathy, and the duration of CKDs. These studies are listed in Conflicting results have been published for the relation between TL and kidney function, but most studies reported an association between shorter TL and kidney dysfunction. In the United States National Health and Nutrition Examination Survey, which included more than 10,000 patients, short leukocyte TL was cross-sectionally associated with decreased eGFR and increased UACR . On the Several studies have demonstrated an association between TL and the progression of CKD. In a prospective study of Chinese patients with type 2 diabetes, a one-unit decrease in leukocyte TL was associated with a 1.2-fold increased risk of end-stage kidney disease (ESKD), independent of the traditional risk factors including age, duration of diabetes, metabolic control, and complications at baseline . In contInteresting results were reported in the German Chronic Disease Study, which included 4802 CKD patients. They found a U-shaped relationship between TL and CKD duration. Namely, the shortest telomeres were found in CKD patients with a reported CKD duration of less than 6 months, followed by patients with a CKD duration of more than 5 years. Patients with a duration between 6 months and 5 years had the shortest telomeres . The lenPatients with CKD have increased morbidity and mortality. Indeed, a shorter TL increased the risk of death in CKD patients ,39. MoreAlthough premature death is more common in CKD patients than a progression to ESKD , the numHD contributes to an inflammatory response beyond that associated with CKD itself . IncreasTLs of leukocytes and PBMCs were found to be inversely related to the duration of HD ,53,58,60KTx patients usually have a better quality of life and better long-term outcomes than HD patients . A recenOxidative stress occurs when the formation of reactive oxygen and nitrogen species (RONS) exceeds the endogenous antioxidant capacity . RONS caCellular replication is the main cause of telomere shortening, but other factors may also influence the rate of telomere shortening. Several in vitro and in vivo studies have shown that oxidative stress significantly accelerates telomere attrition ,69. The Telomeres are repaired less effectively than the rest of the genome . A studyLong non-coding RNAs, known as telomeric repeat-containing RNAs (TERRA), can be transcribed from subtelomeric regions toward chromosome ends and are actively involved in mechanisms regulating telomere maintenance and chromosome end protection . TERRA cTelomere shortening is a complex process influenced by genetic, environmental, and lifestyle factors, as illustrated in In addition to modifiable factors affecting TL, TL has been shown to be a highly heritable trait (36–86%). Several genome-wide association studies have been performed and most identified SNPs harboring genes encoding proteins with known functions in telomere biology ,102,103.CKDs are a serious global health problem. As discussed in this review, the accumulating data suggest that telomere shortening is associated with CKDs. Apart from some conflicting results, most studies have shown that telomere shortening is associated with a decline in kidney function and the progression of CKD. During disease progression, TL elongation has been observed in some individuals. HD accelerates TL shortening, whereas KTx is unlikely to reverse the uremic milieu.postmortem tissue samples, has shown that leukocyte TL is a surrogate for TL in the renal cortex [Nevertheless, there are still many gaps that need to be addressed in the future. In most studies, TL is measured in blood samples (leukocytes or PBMCs). Studies on kidney samples would be desirable, but a kidney biopsy is an invasive procedure and therefore, it is rarely performed. Although TL varies from tissue to tissue, the Genotype Tissue Expression Project (GTEx), which analyzed l cortex .Maintenance of TL is a complex process that is influenced by genetic, epigenetic, and environmental factors. As mentioned above, oxidative stress accelerates the shortening of telomeres . AdditioResearch designs must be carefully planned and use robust and reproducible methodologies because many technical parameters such as storage conditions and DNA isolation can affect the results ,111. TheIn conclusion, although TL is associated with the development and progression of CKDs, TL alone provides only a crude estimate of the rate of ageing and, thus, can hardly be considered a clinically important biomarker. However, together with biomarkers of oxidative stress and genetic factors, it may help identify patients who are at an increased risk of developing CKD and the rapid progression to kidney failure. In addition, studies on patients with different etiologies of nephropathy are needed to clarify the extent to which telomere shortening contributes to the development and progression of CKDs. Further studies are needed to translate these findings into clinical practice, which could improve the management of CKD patients.


Although alcohol flushing syndrome (AFS) has been associated with various diseases, its association with intracranial aneurysm rupture (IAR) is unclear. We aimed to examine this association in the Chinese Han population.We retrospectively reviewed Chinese Han patients with intracranial aneurysms who were evaluated and treated at our institution between January 2020 and December 2021. AFS was determined using a semi-structured telephone interview. Clinical data and aneurysm characteristics were assessed. Univariate and multivariate logistic regression were conducted to determine independent factors associated with aneurysmal rupture.p < 0.001). Meanwhile, there was a significantly difference between the AFS and non-AFS group in habitual alcohol consumption . In the univariate analyses, AFS  was significantly associated with IAR. In the multivariate analysis, AFS was an independent predictor of IAR . Multivariate analysis revealed that AFS was an independent predictor of IAR in both habitual  and non-habitual drinkers .A total of 1,170 patients with 1,059 unruptured and 236 ruptured aneurysms were included. The incidence of aneurysm rupture was significantly higher in patients without AFS (Alcohol flushing syndrome may be a novel clinical marker to assess the risk of IAR. The association between AFS and IAR exists independently of alcohol consumption. Further single nucleotide polymorphism testing and molecular biology studies are warranted. The estimated prevalence of unruptured intracranial aneurysms (UIAs) ranges between 3 and 7%  and apprYang et al.  recentlyWe retrospectively reviewed all Chinese Han patients with intracranial aneurysms who were evaluated or treated at Beijing Tiantan Hospital between January 2020 and December 2021. All aneurysms were diagnosed using digital subtraction angiography (DSA). Intracranial aneurysm rupture (IAR) was diagnosed based on computed tomography (CT) evidence of subarachnoid hemorrhage. Institutional review board approval was obtained. Among the 3,514 patients who were evaluated or treated, 1,170 patients harboring 1,059 UIAs and 236 ruptured intracranial aneurysms (RIAs) were included for analysis after applying our exclusion criteria. A semi-structured telephone interview  was perfTwo experienced neurointerventionalists evaluated the morphological features of aneurysms using three-dimensional rotational digital subtraction angiography (DSA). The aneurysm size, neck size, and parent artery diameter were measured, and aneurysm shape and location were documented. The maximum cross-sectional diameter, vertical distance between the aneurysm dome and neck, and maximum horizontal diameter were defined as aneurysm size, height, and width, respectively. Aspect ratio (AR) was calculated as the ratio of aneurysm height to neck diameter. Height/width ratio (HWR) was calculated as the ratio of aneurysm height to aneurysm width. Size ratio (SR) was calculated as the ratio of aneurysm size to parent artery diameter. Additionally, the mean vessel diameter was determined by averaging the diameters of two vessel segments upstream of the aneurysm , . A bifurp-value less than 0.05.Continuous variables were analyzed using appropriate statistical tests based on their distribution, such as means with standard deviation for normally distributed variables and median with interquartile range for non-normally distributed variables. Categorical variables were presented as numbers with frequency and compared using chi-square or Fisher’s exact test as appropriate. To assess the relationship between clinical and aneurysm characteristics and aneurysmal rupture, univariate and multivariate logistic regression analyses were performed to calculate odds ratios (ORs) with 95% confidence intervals (CIs). SPSS software version 25  was used for all statistical analyses. Statistical significance was considered at a Patient characteristics are shown in Aneurysm characteristics overall and according to rupture status are summarized in p < 0.001). Meanwhile, there was a significantly difference between the AFS and non-AFS group in habitual alcohol consumption . Among habitual drinkers, the prevalence of IAR in the AFS and no AFS subgroups was 11.6 and 33.8%, respectively, and the odds of IAR were also significantly higher in those without AFS . At an arterial bifurcation, the arterial wall is constantly in a weakened state because of high hemodynamic pressure and high blood flow, which explains the higher risk of rupture at these locations . In addiInterestingly, history of ischemic stroke was associated with lower odds of aneurysmal rupture. Statins and antiplatelet agents are commonly used for prevention of stroke in patients with hyperlipidemia and those with a previous ischemic stroke. Several recent studies have emphasized the potential protective effect of these agents for aneurysmal rupture . Potentivia questionnaires alone. Several studies have shown the presence of the alcohol dehydrogenase 2*2 allele in East Asians, which encodes a hyperactive form of alcohol dehydrogenase 2 that presents with AFS because acetaldehyde accumulates faster than ALDH2 can metabolize it  and Natural Science Foundation of Hebei Province of China (grant no. F2020202053) supported this study.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 reviewer BJ declared a shared affiliation with the author(s) to the handling editor at the time of review.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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