P = 0.007) in the subcohort without proteinuria. The interaction between febuxostat treatment and presence of proteinuria in terms of eGFR slope was significant (P for interaction = 0.019). When cross-classified by the presence of proteinuria and serum creatinine level, the mean eGFR slopes significantly differed between the febuxostat and placebo groups (P = 0.040) in cross-classified subcohorts without proteinuria and with serum creatinine level ≥ median, but not in the cross-classified subcohorts with proteinuria and serum creatinine level < median. Febuxostat mitigated the decline in kidney function among stage 3 CKD patients with asymptomatic hyperuricemia without proteinuria.Attribute-based medicine is essential for patient-centered medicine. To date, the groups of patients with chronic kidney disease (CKD) requiring urate-lowering therapy are clinically unknown. Herein, we evaluated the efficacy of febuxostat using a cross-classification, attribute-based research approach. We performed post hoc analysis of multicenter, randomized, double-blind, placebo-controlled trial data for 395 patients with stage 3 CKD and asymptomatic hyperuricemia. Participants were divided into febuxostat or placebo groups and subcohorts stratified and cross-classified by proteinuria and serum creatinine concentrations. In patients stratified based on proteinuria, the mean eGFR slopes were significantly higher in the febuxostat group than in the placebo group ( However, some controversies remain in CKD research3, including the effects of nephrosclerosis4 and urate-lowering therapy for CKD5. Although urate-lowering therapy is not generally approved for patients with asymptomatic hyperuricemia6, pharmacological treatment of hyperuricemia in patients with CKD is recommended in Japan7.The definition of chronic kidney disease (CKD) has been widely disseminated and generally accepted4, and the number of patients with end-stage kidney disease due to nephrosclerosis is increasing with the aging population6. Interestingly, hyperuricemia in patients with CKD has gained attention owing to the global spread of arteriosclerosis8 and is associated with kidney arteriolopathy10. Animal studies have reported a direct negative effect of uric acid on endothelial11 and smooth muscle cells13 in kidney arterial/arteriolar vessels. The observation period of several clinical trials was short because of the associated expenses, making it difficult to detect the outcomes of CKD involving slowly progressive nephrosclerotic kidney diseases.As risk factors and pathological conditions for CKD progression differ with the etiology and patient attributes, studies are needed to consider these factors. Nephrosclerosis is characterized by the absence of or minimal proteinuria associated with slowly progressing kidney diseaseP = 0.005) or a serum creatinine level lower than the median (P = 0.009) after febuxostat treatment14.The Febuxostat Versus Placebo Randomized Controlled Trial Regarding Reduced Renal Function in Patients With Hyperuricemia Complicated by Chronic Kidney Disease Stage 3 (FEATHER) study  failed to confirm that febuxostat alleviated the decline in the estimated glomerular filtration rate (eGFR) in stage 3 CKD patients with hyperuricemia without gout in the entire cohort. However, the FEATHER study reported substantial suppression of eGFR decline in patients without proteinuria 16 have recently garnered attention. Although randomized controlled trials (RCTs) are the cornerstone of EBM with the highest-quality evidence when setting clinical guidelines and policies for patient care17, ingenuity in adapting RCT results to individual patients is required18. Although subgroup analyses of the heterogeneity of treatment effects will provide valuable information for patient care15 and can lead to personalized EBM19, the characteristics of patients may influence the efficacy of therapy; thus, conventional subgroup analyses are typically not informative20. This is because RCT results are generally examined through conventional subgroup analyses, contrasting effects in groups of patients, and defining one variable or attribute at a time21. Such single-attribute comparisons intrinsically result in subcohorts that are more similar to the total cohort because of the averaging of the multiple characteristics of patients in cohorts comprising heterogeneous patients20. Thus, conventional subgroup (one-attribute-at-a-time) analyses under-represent heterogeneity among patients who differ in several variables16.Patient-centered medicine23. In cross-classified models, the main diagonal elements are responsible for direct effects and off-diagonal elements are responsible for indirect effects, which are important for discriminating subcohorts24. As shown in Fig. 24. The primary outcome in an RCT can be influenced by baseline prognostic factors such as disease severity, referred to as chance bias25. Chance bias can be eliminated by stratified randomization or minimization25 and by adjusting the imbalance in baseline variables20. Notably, proteinuria and decreased kidney function are precise indices of the severity of CKD1 and major risk factors for kidney disease progression26, which should be adequately adjusted in RCTs in patients with CKD. However, the prognostic factors that affected the efficacy of febuxostat in the FEATHER study are unclear. Furthermore, the need for a plausible hypothesis for treatment heterogeneity between patients with and without proteinuria in urate-lowering therapy for CKD has been increasing27. Therefore, it is necessary to identify a precise subcohort suitable for febuxostat therapy. We hypothesized that the efficacy of febuxostat is affected by proteinuria, and febuxostat is more useful for populations without proteinuria, comprising patients with atherosclerosis. To overcome the limitations of the conventional one-attribute-at-a-time subgroup analysis and to adjust two major and interactive risk factors in CKD simultaneously, we performed novel cross-classification subgroup analyses of patients in the FEATHER study. We aimed to investigate whether proteinuria or kidney function affects the efficacy of febuxostat.Two-attributes-at-a-time subgroup analysis (cross-classification approach) is frequently used in research for marketing and has expanded to various fields2) were treated with febuxostat (203 patients) or placebo (192 patients). The study groups were well-matched regarding eGFR, sex, age, proteinuria, and diabetes mellitus, with no significant differences in the baseline characteristics from those of the entire cohort. Patients without proteinuria were significantly older  and had significantly higher eGFR  than those with proteinuria. Supplementary Table The baseline characteristics of the patients are presented in Table 2/year; P = 0.76). However, when stratified by proteinuria, the mean eGFR slope values significantly differed between the febuxostat and placebo groups  in the subcohort without proteinuria. The interaction between febuxostat treatment and the presence of proteinuria in terms of eGFR slope was significant (P for interaction = 0.02). When stratified by serum creatinine level, a similar tendency was observed: the mean eGFR slopes differed between the febuxostat and placebo groups  in the subcohort with serum creatinine level < median.The eGFR slope analysis results are presented in Table 2/year; P = 0.04) in the cross-classified subcohorts without proteinuria and with the serum creatinine level ≥ median, but not in the cross-classified subcohorts with proteinuria and serum creatinine level < median , indicating that the presence of proteinuria exhibited an association stronger than a high serum creatinine level with febuxostat efficacy .When cross-classified by proteinuria and serum creatinine level, the mean eGFR slopes significantly differed between the febuxostat and placebo groups , eGFR (45.2 vs. 31.7 mL/min/1.73 m2), eGFR slope in the placebo group (− 0.31 vs. − 3.33 mL/min/1.73 m2/year), urinary albumin-to-creatinine ratio (117.0 vs. 716.9 mg/g), proportion of patients with diabetes (29% vs. 45%), ethnicity of the participants (100% Asian vs. 5% Asian), and the agent used . The major reason for the difference in efficacy of urate-lowering agents for patients with CKD is unknown, but may involve the presence or absence of proteinuria.Recently, an RCT in patients with stage 3–4 CKD  failed to confirm the benefits of allopurinol on kidney outcomes26. However, in clinical settings, patients without proteinuria show progressive kidney diseases30 and develop end-stage renal disease. Most of these patients are clinically considered to have nephrosclerosis, which shows a slow progression of kidney dysfunction and is referred to as benign nephrosclerosis31. However, it has been recently shown that patients with nephrosclerosis have a poor long-term prognosis32. Nephrosclerosis is pathologically characterized as arterionephrosclerosis and subsequent tubulointerstitial inflammation/fibrosis. Arterionephrosclerosis is considered associated with systemic atherosclerosis. It arises because of various risk factors, including obesity, oxidative stress, and chronic inflammation, and has two pathological populations31. One is interstitial inflammatory fibrosis caused by ischemia/hypoxia/oxidative stress33 and the other is glomerular hypertrophy caused by losing autoregulation of renal blood flow resulting from an impairment of the afferent arteriole myogenic response34.Proteinuria is an important risk factor for kidney diseases, and several patients with glomerulonephritis and diabetic nephropathy present with proteinuria10 and animal36 studies. Experimental studies of serum and intracellular hyperuricemic models have found that hyperuricemia causes renal arterionephrosclerosis/arteriolopathy owing to the activation of the renin–angiotensin–aldosterone system37 and decreased nitric oxide bioavailability37. This results in ischemic injury with tubulointerstitial inflammation/fibrosis37 caused by impaired renal ischemia/hypoxia/intrarenal oxidative stress, leading to glomerular hypertrophy38. Thus, hyperuricemia is considered to directly and indirectly cause nephrosclerosis.Notably, hyperuricemia has been associated with arteriosclerosis and arterionephrosclerosis/arteriolopathy in human39. Xanthine oxide (XO) and XOR, both sources of reactive oxygen species, are associated with arteriolopathy and tubulointerstitial inflammation/fibrosis40. In animal models, febuxostat has been found to attenuate kidney injuries caused by impaired renal ischemia/hypoxia/intrarenal oxidative stress41, such as renal arterionephrosclerosis/arteriolopathy42, tubulointerstitial inflammation/fibrosis42, and glomerular hypertrophy12. Thus, hyperuricemia and increased XO and XOR activities in animal models result in arteriolopathy and tubulointerstitial inflammation/fibrosis, which is sometimes associated with arteriosclerosis-related diseases without excessive proteinuria; these data are consistent with the findings of human observational studies43. Therefore, febuxostat is expected to be effective for such conditions in humans44, and to the best of our knowledge, the present study is the first to show the effects of febuxostat in patients without proteinuria after six months. The reason for the lack of a febuxostat effect in less than six months is unclear, but may be related to variable glomerular size46. There are two types of nephrosclerosis, glomerular collapse and glomerular hypertrophy31, and the response to febuxostat may differ at individual nephron levels. Some glomeruli may increase the single-nephron GFR by improving ischemia and some glomeruli may decrease it by improving glomerular hyperfiltration/hypertrophy. Because of this difference, it may take six months for the average renoprotective effect of febuxostat to be detected. Furthermore, improvements in chronic tubular interstitial injury due to renal ischemia/hypoxia/intrarenal oxidative stress may require a long recovery time to restore the tissue damage47.Febuxostat, a non-purine selective inhibitor of xanthine oxidoreductase (XOR), inhibits both the reduced and oxidized forms of XOR and has been reported to attenuate experimental atherosclerosis in mice25; therefore, we consider that the analysis should be adjusted for baseline attributes25. Patient-centered medicine and research have recently attracted attention15. In patient-centered research, it is important to evaluate a homogeneous patient group to overcome individual heterogeneity in human studies. Attribute-based studies of homogeneous patient groups are essential for patient-centered medicine, and the two-attributes-at-a-time subgroup analysis (cross-classification approach) can harmonize with RCTs in patients with CKD. Thus, the cross-classification approach will expand and contribute to subgroup analyses in future RCTs.In RCTs for CKD, substantial and identifiable heterogeneity of risk in the trial population is pathophysiologically anticipated owing to the nature of the kidney disease, which can cause a chance bias14, patients with stage 4 or 5 CKD were excluded. The number of patients was relatively low, and there were more male participants than female participants . Since we adjusted the baseline characteristics using proteinuria and the serum creatinine level , the attributes for which interaction had not been confirmed, including diuretics, were not completely adjusted. The proportion of patients using diuretics in this study was 18%, which is considered to have little effect on the results. However, the effect of diuretic-related hyperuricemia on kidney outcome remains to be studied. Patients without proteinuria were likely to have clinical nephrosclerosis; however, those who participated in this study were not diagnosed by kidney biopsy. Finally, the association between hyperuricemia and kidney outcomes may not be generalizable to other populations, as all participants were Japanese.This study had limitations. As described in a previous studyIn conclusion, the cross-classification approach revealed that the presence or absence of proteinuria rather than the level of serum creatinine affects febuxostat efficacy. Compared with the placebo, febuxostat mitigated the decline in kidney function among patients with stage 3 CKD asymptomatic hyperuricemia without proteinuria.48. The study protocol was approved by the ethics committee of each participating medical institution , and the study was conducted in accordance with the tenets of the Declaration of Helsinki. The pre-specified subgroups were based on the level of kidney function (median serum creatinine level determined in the primary FEATHER study) and presence or absence of proteinuria.We conducted a post hoc analysis of the results of the FEATHER study, which was a multicenter, randomized, double-blind, parallel-group, placebo-controlled, prospective cohort study in Japan. Patients were enrolled between November 2012 and January 2014, and their last visits were between March 2013 and February 2016. The FEATHER study was registered at the University Hospital Medical Information Network Clinical Trials Registry under UMIN000008343. The design and methods of the FEATHER study have been published previously48. In brief, the major inclusion criteria were age > 20 years, hyperuricemia (uric acid concentration > 7.0–10.0 mg/dL), stage 3 CKD, no history of gout, and patients agreed to provide written informed consent. The major exclusion criteria were uncontrolled diabetes mellitus or blood pressure and ≥ 50% variation in serum creatinine concentration within 12 weeks before eligibility confirmation. After screening in the primary FEATHER study, 443 patients from 55 nephrology centers were randomly assigned to the febuxostat or placebo group, and the data of 441 eligible patients were analyzed14. In this study, to adjust for an imbalance in the follow-up, 46 individuals who were observed for < 1 year and < 4 timepoints were excluded from the study cohort by the enrollment center . The data of the remaining 395 patients were distributed to an independent statistical expert for analyses  or annual change in the eGFR calculated using a linear mixed-effects model with repeated GFR estimates over time for each patient. Mean values and their standard errors for eGFR were also examined from baseline to week 108 to test the trend using a mixed model.The primary endpoint was the eGFR slope  performed statistical analyses using SAS ver. 9.4 software .Data are presented as the mean ± standard deviation, median with interquartile range, or proportion. Group differences were evaluated using unpaired Student’s Supplementary Information.


Background: Anthropometric measures  have been used as prediction factors for incident hypertension. However, whether any of these measures is superior to another in the matter of accuracy in predicting hypertension in diabetic patients has been controversial. The present prospective study aimed to determine whether WHtR is a more accurate tool for predicting hypertension than WHR and BMI in patients with type 2 diabetes.Methods: The study population consisted of 1,685 normotensive patients with type 2 diabetes. BMI, WHR, and WHtR were assessed at baseline and followed up for hypertension incidence for a mean of 4.8 years. A cox regression analysis was performed to assess the association between anthropometric measures  and incident hypertension during the follow-up period. The area under the ROC curve analysis was performed and optimal cutoff values were calculated for each anthropometric measure for hypertension prediction.Results: WHtR and BMI were significantly associated with an increased incidence of hypertension (HR = 3.296 (0.936–12.857), P < 0.001, and HR = 1.050 (1.030–1.070), P < 0.001, respectively). The discriminative powers for each anthropometric index for hypertension were 0.571 (0.540–0.602) for BMI, 0.518 (0.486–0.550) for WHR, and 0.609 (0.578–0.639) for WHtR. The optimal cutoff points for predicting hypertension in patients with type 2 diabetes were 26.94  for BMI, 0.90  for WHR, and 0.59  for WHtR.Conclusion: WHtR was a more accurate tool for predicting hypertension compared to WHR and BMI in patients with type 2 diabetes. Diabetes mellitus is among the most common diseases worldwide that significantly affects the cardiovascular system. The main cause of death among patients with diabetes is cardiovascular diseases (CVD) –3. DiabeSince obesity, particularly abdominal obesity, plays a significant role in the etiology of hypertension, using anthropometric indicators of adiposity may help screen patients who are at a higher risk for developing hypertension. The identified individuals could be referred to health centers with better hypertension monitoring systems earlier, and therefore, the early diagnosis of hypertension optimizes the opportunity for secondary prevention measures .Body mass index (BMI), the standard general obesity measure, is the most commonly used indicator in hypertension prediction and screening. The adipose tissue distribution is a significant factor in developing cardiovascular diseases compared to total body fat. Thus, several measures that consider the distribution of adipose tissue, including WHR (waist-to-hip ratio) and WHtR (waist-to-height ratio) have been developed . ResearcN = 2,362), the ones who failed to attend monthly follow-up, or had missing data on systolic blood pressure, weight, height, or waist circumference (N = 8), the final study population consisted of 1,685 normotensive patients with T2DM , self-reported health conditions (use of antihypertensive medications), and objective measures (only blood pressure). In this study, current smokers were defined as individuals who had smoked a minimum of 100 cigarettes in their lifetime and continued smoking during the follow-up period. A team of trained and closely observed researchers using standard equipment was responsible for data collection at all times.2). The BMI values were categorized according to the World Health Organization (WHO)'s classification: <18.5 kg/m2 (underweight), 18.5 to 24.9 kg/m2 , 25 to 29.9 kg/m2 (overweight) and ≥30 kg/m2 (obese). Waist circumference (WC) was measured at the end of a normal expiration. The tape was positioned horizontally at the midway between the iliac crest and the inferior border of the last rib according to standard WHO protocol  was calculated as weight (kilograms) divided by squared height . Then, the extracted serum was used for laboratory evaluations. Enzymatic calorimetric methods using the glucose oxidase test were implemented to measure the fasting plasma glucose (FPG) and 2 h post-prandial glucose (2 hPPG). Glycated hemoglobin (HbA1c) was measured using high-performance liquid chromatography. By using enzymatic methods, the serum concentrations of triglycerides, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and total cholesterol were determined. The commercially-available kits, distributed by the central reference laboratory , have passed all the quality control procedures.Blood pressure (BP) was measured on the left arm by using a mercury sphygmomanometer  with an appropriate cuff size according to the subjects' arm circumference. The procedure was performed in the sitting position after a 10-min resting period, and all the subjects were asked not to smoke or consume caffeine 30 min preceding the procedure commencement. BP was measured twice, with a 10-min interval between the two measurements. During this interval, the patients were asked to remain seated with their left hand placed at the heart level and their palm in the upward-facing position. The mean of the two measured values were considered as the patient's BP. Auscultated systolic blood pressure (SBP) was defined as the first Korotkoff sound heard during the cuff deflation, while diastolic blood pressure (DBP) was marked by the disappearance of the last Korotkoff sound. Patients using antihypertensive drugs or subjects with an SBP higher than 140 mmHg or a DBP higher than 90 mmHg were classified as hypertensive .t-test and chi-square, respectively. The data were reported as mean ± standard deviation (SD) for continuous variables and as proportions for categorical variables. Cox regression analysis was performed to assess the association between anthropometric measures  and incident hypertension during the follow-up period. Hazard ratios (HR) were adjusted for the confounding variables , SBP, DBP, FPG, and family history of hypertension). The Cox regression analysis was also used to calculate HRs of hypertension and their 95% CIs with reference to a normal BMI and the first quartile of WHR and WHtR. The adjustment was performed for age, gender, history of CAD, SBP, DBP, FPG, history of CAD, and family history of hypertension. The discriminative powers of BMI, WHR, and WHtR were assessed by the area under the ROC curve analysis in the group with incident hypertension. The area under the ROC curve of the baseline BMI, WHR, WHtR, and their 95% confidence intervals (CIs) were reported. Optimal cutoff values were calculated for each aforementioned anthropometric measure for the diagnosis of hypertension. Youden index was employed for calculating the optimal cutoff value. The sensitivity and specificity of each of the anthropometric measures were determined based on the calculated cutoff values. The risk of incident hypertension was compared among the BMI categories  and the quartiles of WHR and WHtR. A two-sided p-value < 0.05 was considered necessary to reject the null hypothesis.SPSS version 24.0  was employed for statistical analysis. We used Kolmogorov–Smirnov and Shapiro-Wilk normality tests, P-P plot, and histogram to test the normality of our study population. The null hypothesis was rejected for all the variables; thus, they were normal. To assess the association between different variables and incident hypertension, uni-variable analysis of potential continuous and categorical risk factors was performed using A total of 1,685 participants were enrolled in this study. The mean follow-up period was 4.8 years, and throughout this period, 426 participants (25.3%) developed hypertension. P < 0.001, and HR = 1.050, 95%CI: 1.030–1.070, P < 0.001, respectively). However, this association was not significant for WHR . Studies have shown that patients with the same BMI may have different waist circumferences. Since, people with abdominal obesity are more prone to cardiovascular diseases and hypertension , it is cHsieh et al. argued that among the Japanese men in the third quartile of WC (84.5 - 89 cm), shorter individuals were more prone to hypertension than the taller individuals . FurtherThe current study had several strengths. Firstly, to the best of our knowledge, this is the first prospective cohort study comparing obesity anthropometric indices in patients with diabetes. Secondly, it used a prospective cohort design as well as a large population-based sample. Thus, there is a clear causality between incident hypertension and obesity anthropometric indices. Thirdly, professional interviewers performed several interviews. Anthropometric data were recorded through repeated measurements in accordance with a standard protocol. Such procedures helped to reduce bias. This study had several limitations. Firstly, since our study population was limited to the Iranian ethnicity, caution should be taken when extrapolating the results to other ethnicities. Secondly, since the participant's diet details were not available, we couldn't adjust for hypertension-related covariates, such as salt and fat intake. Thirdly, repeated measures of the anthropometric indices and other variables measured at baseline, were not available for all the patients, so we could not analyze the role of time-varying indices and adjust for the time-varying confounders.The present prospective study showed that WHtR is a more accurate screening tool for HTN than WHR and BMI in patients with type 2 diabetes. Our data reinforce the significance of including the most accurate anthropometric indices in the public health strategies to prevent and control the obesity epidemic and address the risk of developing hypertension. Therefore, WHtR could be recommended as a useful and accurate screening tool to predict hypertension due to its high discriminative power.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.The studies involving human participants were reviewed and approved by the Ethics Committee of Tehran University of Medical Sciences. The patients/participants provided their written informed consent to participate in this study.All participants voluntarily agreed to participate in this research study.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.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. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


BackgroundHelicobacter pylori (HP) is a common bacterium that globally infects humans. The significance of HP infection and eradication of kidney impairment remain ambiguous. Moreover, little is known about whether elimination of the bacteria has any consequence on kidney function. This study aimed to explore the relationship between HP eradication and kidney function in patients with chronic gastritis (CG).MethodologyWe retrospectively reviewed the records of all CG patients with eradicated HP at King Abdulaziz University Hospital between June 2002 and June 2021. All patients older than 18 years, diagnosed with CG in whom HP had been eradicated, were included. Out of 1,936 patients’ records, only 46 met the criteria.ResultsThe mean age of the study sample was 48 years; in addition, 58.7% of the patients were obese. There was no significant difference in serum creatinine, blood urea nitrogen, and glomerular filtration rate after HP eradication .ConclusionsWe found no relationship between the eradication of HP and improvement in renal function. However, prospective population-based studies must be conducted to assess an association between HP eradication and renal function, as well the future risk of nephropathy with the persistence of HP. As such, we recommend a multicenter study that includes a representative sample size. Helicobacter pylori (HP) is a spiral-shaped, microaerophilic Gram-negative flagellated bacterium that usually lives in the gastric mucosa [c mucosa -3. HP inc mucosa .Chronic gastritis (CG) is a long-standing inflammation of the gastric mucosa, combined with different degrees of damage of superficial and glandular epithelia. The causes of CG are exogenous (mainly HP) and endogenous .Blood tests for blood urea nitrogen (BUN) and creatinine are the easiest way to monitor kidney function. These are normal metabolic waste products excreted by the kidneys. BUN is an indirect and rough measurement of renal and liver function measuring the amount of urea nitrogen in the blood. BUN is related to the excretory function of the kidney . Serum cHowever, the importance of HP infection and renal function remains unclear. HP is an etiological factor in endothelial dysfunction and may be involved in causing proteinuria by this mechanism. Little is known about whether eradicating the bacteria would have any impact on renal function . Future In their study, Pan et al. indicated that in patients with peptic ulcer disease, HP infection is probably a risk factor associated with renal injury. Moreover, HP eradication may decrease the risk of renal damage and prevent chronic kidney disease (CKD) .To our knowledge, there are no studies addressing this issue, considering different population traits with other studied populations. We hypothesize that HP eradication has a positive impact on kidney function, demonstrated by estimated GFR. We identified CG at King Abdulaziz University Hospital (KAUH), which may be a new HP eradication goal if proven.This is a retrospective record review study of all CG patients infected with HP, who underwent treatment and eradication at KAUH between June 2002 and June 2021. Medical records of 1,936 adult patients were reviewed, with a total of 46 records meeting the criteria. Ethical approval was obtained from the Research Ethics Committee Board, KAUH, College of Medicine (reference no. 162-21).In collaboration with the Pathology Department at KAUH, all record numbers for patients diagnosed between 2002 and 2021 (with HP-induced CG based on histopathology results) were retrieved. Medical records with 1,936 patients were subsequently reviewed. In addition, patient data collected through the official KAUH medical record database (Phoenix) between June and August 2021 for eligibility, based on pre-specified inclusion and exclusion criteria, were assessed. To reiterate, 46 records were recruited for analysis.H. pylori eradication testWe used the urea breath test (UBT), histopathology reports, or HP stool antigens to confirm the diagnosis, as well as the eradication of HP infection.Population and data collectionAll patients 18 years or older, diagnosed with HP-induced CG, followed by treatment and eradication, were included in the study. Patients who were aged <18 years or had a history of malignancy, renal impairment, or missing data were excluded. Data from KAUH included pertinent demographics: age, gender, nationality, height, weight, pre- and post-eradication SC, and BUN during 2021. Reference ranges are listed in Table Estimated GFR was calculated using a four-variable MDRD Study Equation : GFR = 1Statistical analysisMicrosoft Excel 2019 was used for data entry, with statistical analysis performed using SPSS Statistics version 21 . Continuous variables are displayed using means and standard deviations, whereas categorical variables are depicted with frequencies and percentages. Analysis of variance and the paired sample t-test were used in the analysis. P-values of <0.05 were considered statistically significant.There were 46 CG patients with eradicated HP. In addition, 56.5% were female, 58.7% were obese, and 63% were Saudi nationals. Table Descriptive statistics were calculated for all lab tests that reflect kidney function Table . The meaA paired sample t-test was performed for SC, BUN, GFR, and pre- and post-HP eradication, with p-values of 0.414, 0.112, and 0.300, respectively. There was no significant difference in SC, BUN, and GFR after HP eradication , and noting HP stool sample antigens with the UBT could have helped.We found no association between HP eradication and improvement in renal function. Yet, prospective population-based studies must be conducted to assess an association between HP eradication and renal function, especially if there is a risk of nephropathy with HP persistence. We recommend a multicenter study design that would be a representative sample size.


Observational studies have suggested a close but controversial relationship between blood pressure (BP) and amyotrophic lateral sclerosis (ALS). It remains unclear whether this association is causal. The authors employed a bidirectional two-sample Mendelian randomization (MR) approach to evaluate the causal relationship between BP and ALS. Genetic proxies for systolic blood pressure (SBP), diastolic blood pressure (DBP), antihypertensive drugs (AHDs), ALS, and their corresponding genome-wide association study (GWAS) summary datasets were obtained from the most recent studies with the largest sample sizes. The inverse variance weighted (IVW) method was adopted as the main approach to examine the effect of BP on ALS and four other MR methods were used for sensitivity analyses. To exclude the interference between SBP and DBP, a multivariable MR approach was used.P = 0.017) and that increased SBP was an independent risk factor for ALS , which is supported by sensitivity analyses. The use of calcium channel blocker (CCB) showed a causal relationship with ALS . No evidence was revealed that ALS caused changes in BP.We found that genetically determined increased DBP was a protective factor for ALS (OR = 0.978, 95% CI 0.960–0.996, This study provides genetic support for a causal effect of BP and ALS that increased DBP has a protective effect on ALS, and increased SBP is a risk factor for ALS, which may be related to sympathetic excitability. Blood pressure management is essential in ALS, and CCB may be a promising candidate.The online version contains supplementary material available at 10.1186/s13023-022-02212-0. Amyotrophic lateral sclerosis (ALS) is a rare fatal neurodegenerative disorder with particularly severe loss of motor neurons and consequent muscle weakness and wasting . The medHypertension is one of the critical risk factors for cardiovascular events and chronic kidney disease, contributing to the global disease burden most significantly . HyperteMendelian randomization (MR) is a novel statistical approach for assessing the causal relationship between an exposure and an outcome depending on genetic variances as instrumental variables (IVs) . By simuTo assess blood pressure comprehensively and enhance statistical power, we regarded blood pressure as a continuous variable instead of a binary variable that considered the presence or absence of hypertension . Systolihttps://www.drugbank.ca/) and GeneCards (https://www.genecards.org/).We attempted to study the influence of antihypertensive drugs on ALS. Proxies for common antihypertensive drugs (including angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), β-blocker (BB), and calcium channel blocker (CCB)) were determined by DrugBank  associated with blood pressure at the genome-wide significance level (P < 5E−8) were strictly selected as IVs, and IVs for antihypertensive drugs were all significantly associated with SBP (P < 5E−8) and in relatively modest linkage disequilibrium (LD) (r2 < 0.4), both as described previously [Single-nucleotide polymorphisms (SNPs) independently  by searching the publicly available online tool SNiPA (http://snipa.helmholtz-muenchen.de/snipa3/). Those without reported proxies were excluded from downstream MR analysis. Due to the requirements of MR approaches, the exposure would be removed when its available IVs were less than two. Altogether, 400 SNPs were identified as IVs for SBP, 397 SNPs were identified as IVs for DBP, 47 SNPs were identified as IVs for CCB, and 5 SNPs were identified as IVs for ALS. An additional table showed this in more detail  approach was adopted to diminish the interference between them. Specifically, the causal association between SBP and ALS was estimated regarding DBP as a covariate, and the association between DBP and ALS was estimated with SBP as a covariate. In addition, reverse causation between blood pressure and ALS was assessed by bidirectional MR analysis, which made ALS the exposure and blood pressure the outcome. The process is shown in Fig. We implemented the multiplicative random effects inverse variance weighted (IVW) method as the main approach to examine the overall causal relationship between exposure and ALS based on the effect of IVs on exposure and the effect of IVs on ALS . To valiP values less than 0.05/3 were considered significant with Bonferroni correction, and a P value between 0.017 and 0.05 was regarded as a suggestive significance level. All analyses were carried out in R software version 3.6.3 by the "TwoSampleMR" package (version 0.5.6) [n 0.5.6)  and the n 0.5.6) .In our study, proxies related to SBP, DBP, CCB, and ALS were utilized to investigate the relationship between blood pressure and ALS using five MR methods. The detailed results are displayed in Tables P = 0.074) (Table P = 0.178) and the MR Egger method  generated similar results with wider CIs and less precision. No influence of outliers was detected. The MR PRESSO global test provided suggestive horizontal pleiotropy for IVs (P = 0.042), which was not supported by the MR Egger intercept . The heterogeneity of IVs was observed by Cochran's Q test . When we adjusted SBP, the effect of DBP on ALS was enhanced. The risk of ALS was alleviated by 2.2%  with a per genetically predicted SD increase in DBP (approximately 11 mmHg). In the bidirectional causal relationship exploration, no evidence was found that ALS caused changed DBP values   = 0.991, 95% confidence interval (CI) 0.982–1.001, P = 0.397) (Table P = 0.246). No instrument outliers existed, and Cochran's Q test detected no heterogeneity. After DBP was adjusted, we observed a significant risk effect of SBP on ALS, which elevated ALS risk by 1.4% per genetically predicted unit increase . No modifying role of ALS on SBP values was manifested   Table . SensitiP = 0.049), which was not verified by additional MR analyses. No influence of the outliers, heterogeneity, or horizontal pleiotropy were detected  seem to be a promising target for ALS management. Nevertheless, caution should be taken when explaining the MR results into expected pharmacologic efficacy attributed to the difference between genetically predicted lifelong exposure to a biomarker and short-term intervention. Ca2+ is an essential mediator of cell communication and signal transduction, and calcium channels are widely expressed. Basal intracellular calcium levels were elevated in motor neurons with mutant transactive response DNA-binding protein 43 (TDP43), suggesting altered Ca2+ homeostasis in ALS [2+ levels cause functional defects in lysosomes and autophagic flux, hinder the removal of misfolded toxic proteins, and result in further disease development [2+ from neurons.Interventions relevant to calcium ions (Cas in ALS . Aberranelopment , 41. TheOur study is the first to shed light on the interventive effect of blood pressure management in ALS. All the analyses are performed with the largest European-based GWASs. Reliable data sources and study design provide sufficient statistical power. Nevertheless, there are still some shortcomings in this study. The limitations of the methodology have been reviewed elsewhere . Some SNThis study provides genetic support for a causal effect of BP and ALS that increased DBP has a protective effect on ALS, and increased SBP is a risk factor for ALS, which may be related to sympathetic excitability. Blood pressure management is essential in ALS, and CCB may be a promising candidate.Additional file 1: Supplementary Table 1. Information of Instrumental Variables.


Coronary artery diseases (CAD) are big health problem in both developed and developing countries. It is considered one of the main causes of death in the world. Dyslipidemia increases the risk of CAD incidences. It is aimed in this worktop study the impact of 3'APOBVNTRgene on CAD incidences.Eighty CAD patients and ninety-three healthy volunteers are enrolled in this study. Lipid parameters were estimated in both groups and PCR technique has been performed to analyze 3'APOB-VNTR gene polymorphism.The genotypes 31/31, 31/37, 37/37 and 31/44 are more predominant in both groups. The frequency of 24/31 in CAD patients is (0.137) while it is completely absent in the control group. Our results show that there is an increase in the frequency of various genotypes  in the control group compared to theca patients group.3'APOB-VNTR gene could probably be considered a risk factor for CAD incidences and may help to early diagnose them. Cardiovascular diseases are a collection of heart- and blood vessels-related diseases that are globally common. Among them are coronary artery diseases that are considered one of the main causes of mortality on the globe Apolipoprotein B (ApoB) is an important component of lipoproteins (LDL- and VLDL-cholesterol) The present work aims to study the impact of 3'APOB-VNTRon the incidence of CAD in Egyptian population.Eighty CAD patients with mean (±standard deviation) age 53.5 (±9.0) years and ninety-three healthy participants, whose mean (±standard deviation) age is 45.1 (±7.1) years, were included in the present study. Subjects having either hepatitis B or hepatitis C virus were excluded from the study. None of the control subjects had any signs or symptoms suggesting CAD. Based on medical history and CAD questionnaire, all control subjects were free from any other diseases.Blood samples. The local Ethics Committee approved the study and informed consent was obtained from each participant. Fasting whole blood samples (5 mL) were collected from the subjects under investigation (patients and controls). The blood sample was divided into two parts, one part delivered to plain tubes and allowed to clot for 10 min, centrifuged and the separated serum was used to analyze the levels of cholesterol, triglycerides and HDL-cholesterol. The second part of the whole blood was taken in EDTA coated tubes for DNA extraction. PCR technique on these DNA samples was applied.Biochemical analyses. Total cholesterol Determination of genotypes. Genomic DNA was extracted from whole blood using Qiagenspin columns.Determination of 3'APOB-VNTR. The amplification of 3'APOB-VNTRby PCR was carried out using a forward and reverse primer. The forward primer sequence was 5'-ATGGAAACGGAGAAATTATG-3', while the reverse primer sequence was the 5'-CCTTCTCACTTGGCAAATAC-3'. Each reaction was done with 100 ng of genomic DNA, 1.0 μL of each primer (20 pmol), 5 μL of 10x buffer solution, 4 μL dNTP and 1.0 μL (2 U) Taq polymerase in a total volume of 50 μL. The PCR program for the amplification has been executed according to that described in Ruixing et al. Genotyping of the 3'APOB-VNTR polymorphism. 15 μL of amplified DNA were run on agarose gel to separate the 3' VNTR alleles. The gel was stained with ethidium bromide and visualized using UV. The formula used in the calculation of the number of tandem repeats is: repeat number= (fragment length (bp)-138 bp)/15 bp Statistical analysis. Statistical analysis was performed with the statistical discovery software JMP 9. Quantitative data were presented as mean and SD. Qualitative data were presented as frequencies. Oneway analysis of variance (ANOVA) test was used to compare variables with a normal distribution and significance was accepted at P<0.05.The frequency of ApoB genotypes in both groups (patients and controls) is shown in CAD is a common health problem all over the world Our results show the levels of cholesterol, triglycerides, LDL-cholesterol and VLDL-cholesterol and the atherogenic index are significantly high in CAD patients compared to the control group. This finding is in line with many previous studies Our finding has some similarities with the results reported by Sajib et al. There is a highly significant increase in the frequencies of some alleles  in ApoB gene in CAD patients group when compared to their correspondences in the control group. These results may support the idea that the accumulation of bad cholesterol particles in blood may attitude to genetic factors such as ApoB gene and the priority to control the blood lipids levels by different ways such as control the diet, doing physical exercises and finally administration of some drugs, which may help reduce fat particles in blood.Acknowledgements. The author would like to thank the anonymous referees as well as the editor for their invaluable comments that helped to improve the paper.3’APOB-VNTRgene might be considered a risk factor in CAD incidence and might help to early diagnose CAD.All the authors declare that they have no conflict of interest in this work.


Background: Arterial stiffness and phase angle (PhA) have gained importance as a diagnostic and prognostic parameter in the management of cardiovascular disease. There are few studies regarding the differences in arterial stiffness and body composition between renal transplant recipients (RTRs) receiving belatacept (BELA) vs. calcineurin inhibitors (CNI). Therefore, we investigated the differences in arterial stiffness and body composition between RTRs treated with different immunosuppressants, including BELA. Methods: In total, 325 RTRs were enrolled in the study . Arterial stiffness was determined with an automated oscillometric device. All body composition parameters were assessed, based on bioelectrical impedance analysis (BIA), and laboratory parameters were obtained from the medical files of the patients. Results: We did not detect any significant difference in terms of arterial stiffness and PhA in RTRs undergoing different immunosuppressive regimens, based on CsA, Tac, or BELA. Age was an essential risk factor for greater arterial stiffness. The PhA was associated with age, BMI, time of dialysis before transplantation, and kidney graft function. Conclusion: No significant differences in arterial stiffness and PhA were observed in RTRs under different immunosuppressive regimens. While our data provide additional evidence for arterial stiffness and PhA in RTRs, more research is needed to fully explore these cardiovascular risk factors and the impact of different immunosuppressive regimens. Kidney transplantation (KTX) is associated with a superior cardiovascular outcome, compared to other renal replacement therapies . HoweverArterial stiffness has gained in importance as a diagnostic and prognostic parameter in the management of cardiovascular disease among RTRs . It is rMoreover, the assessment of body composition has taken on a significant role in the cardiovascular evaluation of patients with chronic kidney disease (CKD). CKD can lead to extracellular volume overload and chronic uremia can cause perturbations in the electrolyte balance, as well as alterations of body composition and nutritional status ,13,14. SAlthough kidney function increases after transplantation, RTRs still demonstrate higher pulse wave velocities compared to healthy adults . Studiesp < 0.001) . De. De32]. ® . The patients were requested to lie flat on their backs, with arms and legs spread to the sides, for at least five minutes before starting the measurement. After correct positioning of the cuffs, systolic and diastolic blood pressure  was measured on both arms  and legs (1–2 cm above the ankles). In addition, ABI  and brachial-ankle pulse wave velocity (baPWV) (in m/s) were acquired. Carotid-femoral pulse wave velocity (cfPWV) (in m/s) and pulse pressure (PP) were calculated by the device. The following reference values were defined as physiological: RR ≤ 130/80 mmHg, PP < 50 mmHg, ABI > 0.9, baPWV < 12 m/s, cfPWV < 10 m/s [The assessment of arterial stiffness via oscillometric PWV-measurement was performed using an ankle-brachial index (ABI) device produced by boso< 10 m/s .® device . With an alternating current at a power of 80 microamperes (µA) ± 10 µA, 30 impedance measurements at six different frequencies were conducted at each of the five segments . The patients were assigned to step on the BIA scales and stand on foot electrodes for about one minute, with their arms abducted, holding two thumb electrodes. They were asked to refrain from moving or speaking. The body composition measurement comprised body water content and lean and fat mass analyses. Among other parameters, body mass index ), muscle (in kg) and fat mass (in kg), protein and mineral content , as well as skeletal body mass (in kg) and PhA , were calculated. The skeletal muscle index  was calculated from body height (in m) and skeletal muscle mass. The following reference value for PhA was predefined: PhA: ≥5.5° (women), ≥6.0° (men).The body composition parameters were acquired via direct segmental multi-frequency BIA, using the InBody7702). By use of an electro-chemiluminescent immunoassay (ECLIA), troponin T (in nanograms per liter (ng/L)) and NT-proBNP  were measured in the serum or heparin plasma. According to the official statements of Labor Berlin, the following reference values were determined: HbA1c: <6%, CRP: <5 mg/dL, LDL cholesterol: <130 mg/dL, creatinine: ≥0.51–≤0.95 mg/dL (women), ≥0.67–≤1.17 mg/dL (men), eGFR: 95–160 mL/min/1.73 m2 (women), 98–156 mL/min/1.73 m2 (men), troponin T: <50 ng/L, NT-proBNP: depending on age, between <94 ng/L (<44 years) and <526 ng/L (>74 years).All patients had fasted before giving blood samples on the examination day. Labor Berlin was responsible for the analysis of all laboratory values. Using high-performance liquid chromatography, HbA1c (in %) was determined in EDTA (ethylenediaminetetraacetic acid) blood. In addition, the C-reactive protein ), low-density lipoprotein (LDL) cholesterol (in milligrams per deciliter (mg/dL) and creatinine (in mg/dL) levels were measured in the serum. The estimated glomerular filtration rate (eGFR) was calculated from the CKD-EPI formula  were conducted. The medians were compared using a Kruskal–Wallis test. Through linear regression analysis, associations between dependent and independent continuous variables could be detected. The standardized regression coefficient was calculated, to compare the effects of independent variables on the dependent variable. By the calculation of Cohen’s d and the correlation coefficient r, the effect size of the t-tests could be determined. Multiple linear regression analysis allowed us to adjust for confounders and detect those variables that have an independent association with the endogenous variable.Results are expressed as mean ± standard deviation for normally distributed variables or median and interquartile range (25th–75th percentile) and natural logarithm, respectively, for non-normally distributed values. Frequencies of the categorical entities were expressed as a percentage (%) and compared via a chi-square test. To analyze the differences between mean values, unpaired ® . Probability values of <0.05 were considered statistically significant.In addition, propensity score (PS) matching was performed. The PS can be understood as the probability with which a patient receives an investigated therapy. At first, PS was calculated by multiple regression analysis, taking predefined patient characteristics into account. In a second step, a so-called 1:1-matching was conducted. Therefore, each patient from one group  was assigned to another patient from another group , with a similar PS. In this study, PS matching was performed three times . Within the matched collective, the parameters of interest were compared between the groups. All statistical analyses were performed using the program IBM SPSS Statistics 25Out of 325 included patients, 122 (37.5%) were female and 203 (62.5%) were male . The pat2. Their average HbA1c was 5.5 ± 0.6% and the concentration of LDL cholesterol amounted to 123.2 ± 37.9 mg/dl. Median values for troponin T and NT-proBNP were 12 (7–22) and 288 (112–731) ng/L, respectively.On the examination day, the average creatinine level was 1.7 ± 0.8 mg/dL, and the patients’ mean eGFR was 50.2 ± 20 mL/min/1.73 mAmong the study population, 211 (64.9%) patients were undergoing therapy with Tac, 73 (22.5%) patients were being treated with CsA, and 41 (12.6%) with BELA . Prior tThe mean systolic and diastolic blood pressure was 140.8 ± 17.6 mmHg and 85.8 ± 10.2 mmHg, respectively. The average ABI amounted to 1.08 ± 0.1 on the right and 1.12 ± 0.5 on the left side. The baPWV was 12.3 ± 2.3 m/s on the right and 12.3 ± 2.5 m/s on the left, respectively. The measurement of the cfPWV could be accomplished in 294 of the patients. On average, the patients’ cfPWV was 8.3 ± 2.3 m/s. Using ANOVA, no statistically significant differences in any of the abovementioned parameters were found between the groups .2 and the body fat percentage was 27.1 ± 9.5%, on average. The ECW/WBW ratio amounted to 0.39 ± 0.01, and the SMI was 7.67 ± 1.3 kg/m2, respectively. PhA could be measured in 321 of the patients and was 4.9 ± 0.9°, on average. The mean values of the mentioned parameters were comparable among the three groups. Only the ECW/WBW ratio (p = 0.084) showed differences, which were, however, not significant (The mean BMI was 25.5 ± 4.7 kg/mnificant .p = 0.720). Age (p < 0.01) and the type of kidney donation  showed a significant, independent association with the cfPWV using an ANCOVA. Only 28.5% of the variance could be explained by this model (r2 = 0.285).After adjusting for the covariates of age, sex, BMI, logarithmical dialysis time, logarithmical time since transplantation, type of kidney donation (living-donor/deceased-donor donation), and prevalence of diabetes and creatinine levels in the serum, no significant differences in cfPWV could be found among the three therapy groups , after adjusting for the covariates. However, a significant, independent association was found among PhA and age (p < 0.01), sex (p < 0.01), BMI (p < 0.01), dialysis time (p = 0.01) and creatinine levels (p < 0.01). Only, 50.1% of the variance could be explained by this model (r2 = 0.501).In addition, no significant differences in PhA could be detected between the groups  and the PS was calculated for each patient. Matching was performed three times in total  and resulted in acceptable and comparable characteristics of predefined variables .p = 0.287). Additionally, no difference in PhA could be found between the groups (p = 0.931).At first, 30 patients undergoing Tac-therapy were matched with 30 patients undergoing BELA therapy. Mean cfPWV in the Tac- and BELA groups amounted to 9.2 ± 3.1 m/s and 8.4 ± 2.4 m/s, respectively. The difference was, however, not statistically significant (p = 0.446). In addition, the mean PhA was similar between the groups (p = 0.729).In a second step, 29 patients undergoing CsA therapy were matched with 29 patients undergoing BELA therapy. Again, the mean cfPWV was 0.7 m/s higher in the CNI-based therapy group compared to the BELA group, but no statistically significant differences could be detected .Finally, 57 patients undergoing CsA therapy were matched with 57 patients from the Tac group. The mean cfPWV and PhA were comparable and no statistically significant differences could be found between the groups . Therefore, the older age and CV history influence the value of PWV significantly.It was confirmed by Kolonko et al. and Kim et al. in the RTRs population and in ESRD  patients on the waiting list for kidney transplantation ,40. AddiIt is worth underlining that in our study, the PWV and PhA in BELA-treated patients were not better or worse in comparison to CNI. It is important to mention that prior to conversion to BELA, the patients in the BELA group had been treated with CNI for 3.4 (1.8–6) years on average. Many of those patients were converted because of CNI toxicity and had inferior renal function ,37. At tStróżecki et al. showed that CNI increased PWV significantly, compared to the non-CNI-regimen  patients. Moreover, CsA influenced PWV more strongly than Tac . In anotThere is not much data regarding the evaluation of PhA in patients after kidney transplantation. Wong et al. and Saxena et al. showed more extracellular water and lower PhA in RTRs, in comparison to healthy controls ,42. On tp = 0.07). Finally, the mean eGFR of our patients was relatively high, at 54.1 mL/min (compatible with stage 3A chronic kidney disease), but patients on BELA have a significantly lower eGFR compared to the CNI groups. Future studies should be designed as a prospective, ideally randomized trial, with at least two measurements for each immunosuppressive regimen, to detect any differences over time in each of the groups. However, currently, no such randomized study is possible for BELA due to its limited availability.In our study, the PhA value was slightly higher compared to that reported by Wong et al. and Saxena et al. This could be associated with the better nutritional status of RTRs. Secondly, we observed a tendency for a negative correlation between PhA and extracellular water (r = −0.17; There are several limitations of this study that should be considered when interpreting our conclusions. First of all, this is a single-center study. The sample size was relatively small, and the study population was a heterogeneous group with different comorbidities, including cardiovascular disease, diabetes, and heart failure, different dialysis vintage, and a different time after renal transplantation. Additionally, there is obviously an important selection bias since BELA patients had received CNI for several years and had significantly lower eGFR compared to the CNI groups. We aimed to compensate for these relevant limitations by propensity score-matching, which did not reveal any statistical differences with regard to some potential confounders . HoweverHowever, despite these limitations, this study highlights some important information for RTRs in terms of arterial stiffness and PhA in this population. Hence, we cannot exclude the possibility of residual confounding. To obtain a definite answer on the effect of an immunosuppressive regimen on PWV and PhA, further studies are needed. Due to the abovementioned limitations and the limited availability of BELA, no prospective study was possible, and firm conclusions can only be drawn in a prospective randomized trial. Our data are hypothesis-generating and are important for the design of future trials in the field.In our observational study, we did not observe any significant differences in arterial stiffness and PhA in RTRs under different immunosuppressive regimens. Due to the outlined limitations and a potential selection bias, further, prospective studies are necessary to definitively assess the relationship between arterial stiffness, PhA, and immunosuppressive regimen. Our data provide additional evidence to the literature on PWV and PhA in RTR and may provide the basis for future research on cardiovascular risk factors.


Chronic heart failure (CHF) refers to a state of persistent heart failure that can be stable, deteriorated, or decompensated. The mechanism and pathogenesis of myocardial remodeling remain unknown. Based on 16S rDNA sequencing and metabolomics technology, this study analyzed the gut microbiota and serum metabolome in elderly patients with CHF to provide new insights into the microbiota and metabolic phenotypes of CHF.  Blood and fecal samples were collected from 25 elderly patients with CHF and 25 healthy subjects. The expression of inflammatory factors in blood was detected by ELISA. 16S rDNA sequencing was used to analyze the changes in microorganisms in the samples. The changes of small molecular metabolites in serum samples were analyzed by LC-MS/MS. Spearman correlation coefficients were used to analyze the correlation between gut microbiota and serum metabolites. α levels were significantly increased, and the IL-10 level was significantly decreased in the elderly patients with CHF compared with the healthy subjects. The diversity of the gut microbiota was decreased in the elderly patients with CHF. Moreover, Escherichia Shigella was negatively correlated with biocytin and RIBOFLAVIN. Haemophilus was negatively correlated with alpha-lactose, cellobiose, isomaltose, lactose, melibiose, sucrose, trehalose, and turanose. Klebsiella was positively correlated with bilirubin and ethylsalicylate. Klebsiella was negatively correlated with citramalate, hexanoylcarnitine, inosine, isovalerylcarnitine, methylmalonate, and riboflavin.  Our results showed that the IL-6, IL-8, and TNF- The gut microbiota is simplified by the disease, and serum small-molecule metabolites evidently change in elderly patients with CHF. Serum and fecal biomarkers could be used for elderly patients with CHF screening. Although there are many therapies that are currently used, CHF remains a disease with high morbidity and high mortality. CHF affects not only the heart and blood circulation but also the musculoskeletal, neuroendocrine, metabolic, and immune systems. CHF is associated with altered gut function, including intestinal morphology, permeability, and absorption capacity . Increasal rates , 3. In fammation . The excammation . ChronicIn addition, recent studies have reported that the gut and the heart are an axis of mutual regulation, and the blood is the bridge between the two interactions , 7. Afteα (HIF-1α), which inhibits pyruvate dehydrogenase (PDH) and promotes cardiac glycolysis without activating glucose oxidation, leading to an increase in the circulating levels of pyruvate and lactic acid and is a prognostic indicator of death [The imbalance of gut microbial metabolites leads to intestinal malnutrition, heart dysfunction, and other diseases in CHF patients. There are at least 6,500 low-molecular-weight metabolites in humans, in addition to proteins and genes, that play important roles in biological systems . The latof death , 16. MetAs the global population ages, chronic diseases are placing an increasing burden on public health systems. Studies have shown one to two in every 100 adults in the general population, and more than one in 10 people aged over 70 years are diagnosed with heart failure . At presTwenty-five CHF patients (H group) and 25 healthy subjects (C group) participated in the experiments. According to current guidelines, the diagnosis of CHF is based on symptoms, clinical signs, and recorded left ventricular dysfunction during exercise. All patients were clinically stable (according to the New York Heart Association (NYHA) functional rating) and had received constant medication for at least 4 weeks prior to evaluation. The study sequentially collected information on medications taken by CHF patients and on the NYHA classification of the disease. All healthy subjects did not take any drugs. The study excluded subjects who had infection, rheumatoid arthritis, renal failure, major valvular heart disease, intestinal disease, cancer, or autoimmune disease. None of the subjects had any known immune system diseases, and none had received immunomodulatory therapy. The clinical data of subjects in different groups are shown in https://www.microbiomeanalyst.ca/) was used for bioinformatics analysis.Fecal samples were collected from 20 healthy subjects and 22 CHF patients by using stool sampling cups. All the fecal samples were stored at -80°C. Microbial genomic DNA was extracted from each fecal sample at 200 mg using the QIAamp ® Fast DNA Stool Mini Kit (Qiagen) according to the manufacturer's protocol. An Agilent 4200 Tapestation Kit (Agilent Technologies) was used to determine the quality of the extracted DNA, and then, the Nextera XT DNA Sample Prep Kit (Illumina) was used to generate sequencing libraries. The bacterial V3/V4 region (F: CCTACGGGNGGCWGCAG and R: GACTACHVGGGTATCTAATCC) was amplified. An Agilent 4200 Tapestation was used to confirm the quality of the libraries, and targeted sequencing of the samples was performed on the HiSeq 2500 platform (Illumina). FastQC (0.11.9) was used for quality control of the original high throughput sequence data. Trim-galore (0.6.5) and CutAdapt (2.8) were used to perform low-quality filtering and joint removal. Cluster analysis was performed with 97% similarity after obtaining effective sequences, and each cluster was called an operational taxonomic unit (OTU). QIIME 2 (2020-2) software and a 16S rDNA sequence database (SILVA-132-99) were used to perform taxonomic annotation and quantitative statistics for the representative sequences of each OTU. A rank abundance curve was used to explain the two aspects of species abundance and species evenness. Qiime 2 software was used to calculate the alpha diversity index (Chao1 index) of each sample and to draw the ranked abundance curve based on ASV and the dilution curve based on alpha diversity. R software was used to draw a boxplot of differences in alpha diversity (R phyloseq package) between groups for the Wilcoxon test (between two groups) method. The MicrobiomeAnalyst platform , 19 (httμL) into a labeled test tube and stored at -80°C before preparation for metabolomics analysis. Each aliquot (100 μL) was mixed with 300 μL of cold acetonitrile and then vortexed for 30 s before analysis. The mixture was deproteinized by centrifugation at 4°C , and 1 μL of supernatant was injected into a UPLC instrument. After each operation, the needle was cleaned for 5 s. An HPLC system  and a UPLC BEH Amide column  combined with a TripleTOF 6600  and a QTOF 6550 were used for LC-MS/MS analysis. The mobile phases consisted of 25 mM NH4OAc and 25 mM NH4OH (pH = 9.75) (A) and acetonitrile (B) in water. The elution gradient was as follows: 0 min 95% B; 7 min, 65% B; 9 min, 40% B; 9.1 min, 95% B; 12 min, 95% B, delivered at a rate of 0.5 mL/min. The injection volume was 2 μL. In this mode, the acquisition software  continuously evaluates the full-scan survey MS data and triggers the acquisition of MS/MS spectra based on preselected criteria. In each cycle, 12 precursor ions with an intensity greater than 100 were selected and fragmented with collision energy (CE) of 30 V . ESI source conditions were set as follows: ion source gas 1 was 60 psi, ion source gas 2 was 60 psi, curtain gas was 35 psi, source temperature was 650°C, ion spray voltage floating (ISVF) was 5000 V, and positive and negative voltages were 4000 V. The raw data were converted to MZXML format using ProteoWizard and processed using an internal program, which was developed by R software and based on XCMS for peak detection, extraction, alignment, and integration. Then, the internal MS2 database (BiotreeDB) was applied for metabolite annotation. The critical value of the annotation was set to 0.3. QC samples were used to demonstrate the stability of the LC-MS system. MetaboAnalyst [https://www.metaboanalyst.ca/) and Kyoto Encyclopedia of Genes and Genomes [https://www.kegg.jp/) were used for bioinformatics analysis.Blood samples from 25 healthy subjects and 25 CHF patients were used for metabolomic analysis. The blood from all participants was centrifuged at 1150 × g and 4°C for 10 min in a centrifuge tube coated with heparin. The supernatant was then aliquoted  in the blood samples was determined by ELISA kit according to the manufacturer's instructions, and all samples analyses were repeated three times.Blood samples were collected from 20 healthy subjects and 22 CHF patients. The level of IL-6 , IL-8 , IL-10 , and TNF-t tests. A P value < 0.05 was considered to be statistically significant. Analysis of similarities (ANOSIM) is a nonparametric test method based on permutation tests and rank-sum tests and is used to test whether the difference between groups is significantly greater than that within groups, so as to judge whether the grouping is meaningful. LDA effect size  robustly identifies microbes that are significantly different among biological classes, and additional tests were performed to assess these differences with the LDA value and P < 0.05. Spearman correlation coefficients (P < 0.05) and heatmaps were used to analyze the correlation among gut microbiota, serum metabolomic, and inflammatory factors by Graph prism (8.0) software.Statistical analysis of the data was performed using SPSS 21.0  and Graphpad prism 8.0 statistical software. The Gpower software  was used to calculate the experimental validity when selecting samples. All the data are presented as the means ± standard deviations (SDs). Statistical significance between two groups within experiments was determined by unpaired two-tailed Student's α in the CHF group were significantly higher, while the expression of IL-10 was significantly lower , Escherichia Shigella , Ruminococcaceae UCG 005 , Ruminococcaceae UCG 002 , Lactobacillus , Atopobium , Romboutsia , Streptococcus , Haemophilus , and Klebsiella  were significantly enriched in the feces of CHF patients, suggesting that they may be fecal biomarkers for CHF . The cluster of QC samples in the PCA score plot demonstrated satisfactory stability and repeatability of the metabolic profiling method . As demoP < 0.05 and log2(FC) > 1.0, including 27 and 23 metabolites that were enriched in the CHF and healthy groups, respectively  and ethylsalicylate , N-monomethylarginine, and methyllysine have shown that elevated levels of methylated arginine metabolites (demmethyllysine) are associated with left ventricular diastolic dysfunction, and elevated levels of ADMA were associated with later right ventricular systolic dysfunction . Heart fcontrols . The CRPcontrols . Our stuCampylobacter, Salmonella, Escherichia Shigella, Yersinia enterocolitica, and Candida species [Candida, Campylobacter, and Shigella species [Enterobacter, Megasphaera, Oscillibacter, and Desulfovibrio, and fewer commensal or beneficial genera including Bacteroides, Prevotella, and Faecalibacterium [Eubacterium rectale and Dorea longicatena were less abundant in the HF patients than in that of healthy subjects [Faecalibacterium was depleted, while Lactobacillus was enriched in the gut of older HF patients [Escherichia Shigella, Ruminococcaceae, Lactobacillus, Atopobium, Romboutsia, Streptococcus, Haemophilus, and Klebsiella were significantly enriched in the feces of CHF patients. Our study found that the more potential pathogenic bacteria and less beneficial bacteria enriched in the gut microbiota of CHF patients. Whether these reduced beneficial bacteria have a potential effect on chronic heart failure remains to be seen. We will further explore the potential role of probiotics or prebiotics in chronic heart failure in animal models, with a view to developing new treatments for chronic heart failure based on the “heart-gut axis” or “gut-heart axis” theory.Recently, studies have shown that the gut microbiota can affect the cardiovascular system, and that arrhythmias can aggravate the development of HF . The imb species . Compare species . Artery acterium . Eubactesubjects . Comparepatients . The LDAVeillonella, Coprobacillus, and Streptococcus, while plasma-reduced metabolite ricinoleic acid was positively correlated with Butyricicoccus enriched in healthy [Escherichia Shigella was negatively correlated with serum biocytin and riboflavin. Haemophilus was negatively correlated with serum alpha-lactose, cellobiose, isomaltose, lactose, melibiose, sucrose, trehalose, and turanose. Klebsiella was positively correlated with serum bilirubin (bilirubin) and ethylsalicylate, while negatively correlated with serum citramalate, hexanoylcarnitine, inosine, isovalerylcarnitine, methylmalonate, and riboflavin. There were some studies of plasma metabolite in HF disease. Lysophosphatidylcholine 18 : 2, cholesteryl ester 18 : 1, alanine, choline, and fructose were correlated with B-type natriuretic peptide or left ventricular ejection fractions [Metabolites derived from the intestinal tract and gut microbiota are nutrients that are directly or indirectly digested, absorbed, and utilized by the host , 32. The healthy . Our sturactions . Orotic ractions . Norvaliractions . StudiesFunctional prediction of gut microbiota showed amino acid metabolism, metabolism of cofactors and vitamins, energy metabolism, replication and repair, and metabolism of terpenoids and polyketides pathways were significantly enriched in the healthy group, and membrane transport and signal transduction pathways were significantly enriched in CHF group at L2 pathways. At L3 pathways, ABC transporters, beta lactam resistance , and bacterial secretion system pathways were significantly enriched in the healthy group, and thiamine metabolism, NOD-like receptor signaling pathway, and beta alanine metabolism pathways were significantly enriched in the CHF group. Studies have shown that skeletal muscle mass and strength are extremely low in 20% of patients with CHF . SupplemIn conclusion, our study found that the diversity and quantity of gut microbiota in elderly patients with CHF were reduced, the potential pathogenic bacteria were enriched, the beneficial bacteria were depleted, and the changes of serum metabolic map were accompanied. Our study may provide insignificance for the treatment of elderly patients with CHF, but it uncovers the relationship between gut microbiota and serum metabolites in elderly patients with CHF.The diversity of the gut microbiota in CHF patients was decreased, and the disease tended to reduce the complexity of microbiota. Imbalance of the gut microbiota and serum metabolites profiles was the basic characteristics in elderly patients with CHF.


Despite decades of research and established treatment strategies, hypertension remains a prevalent and intractable problem at the population level. Yoga, a lifestyle-based practice, has demonstrated antihypertensive effects in clinical trial settings, but little is known about its effectiveness in the real world. Here, we use electronic health records to investigate the antihypertensive effects of yoga as used by patients in their daily lives.A retrospective, observational case-control study of 1815 records among 1355 yoga exposed patients and 40,326 records among 8682 yoga non-exposed patients collected between 2006 and 2016 from a regional academic health system. Linear mixed-effects models were used to estimate the average treatment effect of yoga on systolic and diastolic blood pressures. Mixed effects logistic regression models were used to calculate odds ratios for yoga use and four blood pressure categories: normal, elevated, stage I, and stage II hypertension.p < .001) and diastolic  blood pressures. Patients using yoga have 85% increased odds  of having normal blood pressure relative to yoga non-exposed patients. Patients aged 40–59 years have 67% decreased odds  of having stage II hypertension. All effect sizes are age-dependent.Yoga patients are predominantly white (88.0%) and female (87.8%) with median age 46 years (IQR 32–57) who use yoga one time per week (62.3%). Yoga is associated with lower systolic (− 2.8 mmHg, standard error 0.6; Yoga, as used by patients in their daily lives, may be an effective strategy for blood pressure control and the prevention of hypertension at the population level.The online version contains supplementary material available at 10.1186/s12889-022-12569-3. Hypertension is the leading modifiable risk factor for cardiovascular disease and related mortality in populations around the world . AdverseAn individual’s risk of developing hypertension and/or coronary artery disease has a genetic component, but lifestyle, as an independent risk factor, plays an outsized role. A favorable lifestyle, defined as a healthy diet, regular physical exercise, absence of current cigarette smoking, and absence of obesity, can mitigate the effects of a high risk genetic profile , 8. LikeYoga, a lifestyle-based practice that incorporates physical postures, breath control and/or meditation, has antihypertensive effects in clinical trial settings. Systematic reviews and meta-analyses have demonstrated that yoga reduces blood pressure relative to usual care, in both healthy patients and patients with hypertension or other risk factors for cardiovascular disease –11. In tIn 2017, an estimated 46.5 million adults in the US reported using yoga in the prior 12 months . But litHere, we leveraged the electronic health record (EHR) as a source of real-world, observational data on patient lifestyle, blood pressures, and prescribed medications and used mixed effects modeling to assess the antihypertensive effects of yoga as used by patients in their daily lives.We designed an observational, retrospective case control study using EHRs from the University of Pennsylvania Health System, a large, regional health care system comprised of six hospitals and hundreds of outpatient centers in southeast Pennsylvania. The data were sourced from a data warehouse containing repositories of structured and unstructured EHR data maintained by and accessed through the Data Analytics Center at the Perelman School of Medicine at the University of Pennsylvania.During the study period there were approximately 1.2 million patients in the database, 2–3% of which had at least one clinical chart note containing the word “yoga” . AvailabYoga notes were manually annotated and associated patient encounters were only included if the patient had a regular yoga practice, defined here as at least one yoga session per week, at the time of the clinical encounter . Yoga patient encounters were excluded if the note indicated yoga was used less frequently than one time per week  or if there was no indication of frequency . Otherwise, notes were annotated by the number of times a patient reported using yoga each week.Because we do not have direct access to the EHR data, we requested a preliminary data set from the Data Analytics Center that was generated by doing a keyword search for “yoga” in the patient chart notes to identify a potential yoga exposed group (see Yoga Annotation subsection), and a yoga non-exposed group; the latter had no mention of “yoga” in their charts and were matched at random to the yoga exposed group on age, sex, and race. A 3:1 non-exposed to exposed ratio was used to capture unmeasured and unknown confounders . This prCovariates were chosen to represent biological, behavioral, environmental, and social factors that may affect blood pressure or use of yoga including: age, sex, race, ethnicity, BMI, insurance status, zip code at home address, alcohol use disorder, smoking status, comorbidities common to hypertension, and prescriptions for blood pressure lowering drugs.Comorbidities are the chronic condition dyads that included hypertension from the Centers for Medicaid and Medicare Services. The list includes: diabetes, hyperlipidemia, chronic kidney disease, heart failure, heart failure and chronic kidney disease, and coronary artery disease A list of ICD codes can be found in Additional File Missing data were imputed only within a patient’s own records. Height was imputed as the median across all encounters. Weight was imputed as weight recorded at the nearest encounter within 365 days.  Race and ethnicity were imputed as multiracial or Hispanic if more than one race or ethnicity was reported across the entire record. Insurance status and zip code were imputed as the values recorded at the nearest encounter. Comorbidities, smoking status, alcohol misuse disorder, and blood pressure lowering drugs were assigned to an encounter when documented within the prior 12 months.Inclusion criteria at the patient level required 3 years of clinical history. There were no set exclusion criteria at the patient level, but all encounters for one patient were excluded because they had an equal number of visits as male and female.Inclusion criteria at the encounter level required encounters to be with primary care providers and that the providers had seen patients in both the yoga exposed and yoga non-exposed groups, the recorded age of the patient had to be between 18 and 79 years for the encounter to be retained, and blood pressure had to have been recorded at the encounter.Exclusion criteria at the encounter level were applied after imputation and included: a diagnostic code for pregnancy or end-stage renal disease, weight below the first percentile or above the 99th percentile (< 101 lb. or > 322 lb), missing BMI, or systolic blood pressures greater than 220 mmHg or less than 60 mmHg and diastolic blood pressures greater than 140 mmHg or less than 40 mmHg (ranges indicative of a hypertensive or hypotensive crisis).All data used in this study were collected during routine care at outpatient visits between November 15, 2006 – November 16, 2016.2) was coarsened to five categories: underweight (< 18), normal weight (18 < = BMI < 24.9), overweight (24.9 < = BMI < 29.9), obese (29.9 < = BMI < 34.9), and severely obese (> = 34.9), and the remaining covariates were already categorical. CEM generates a weight for each observation as a normalized ratio of cases to controls within each strata, these weights were used in all statistical models. In the context of this study, the yoga exposed are “cases”, and yoga non-exposed are “controls”.We used the coarsened exact matching (CEM) package in R to balance the data set by the measured covariates (listed above) . CEM strp < 0.05.To calculate the effect of yoga on blood pressure, we fit linear mixed effects models with systolic or diastolic blood pressure as the dependent variable. The statistical units in this study are the encounters. Patients may be represented in the data set more than once; each encounter with the health care system that met the inclusion criteria was retained. An encounter is considered a yoga exposure if the clinical chart notes indicate yoga was being used at least one time per week at the time of the encounter (see Yoga Annotation). We included in the model as covariates: age, sex, race, ethnicity, BMI, frequency of yoga practice, insurance status, zip code at home address, diagnostic codes retained after matching , and prescriptions for antihypertensives, beta blockers, calcium channel blockers, and diuretics. A random effect term was included for the patient identifiers to create a shared random intercept across all encounters for each individual patient. Each observation was weighted based on the CEM output. To test for age dependent effects, we repeated the analysis within three age groups, 18–39 years, 40–59 years, and 60–79 years. Beta coefficients are presented as effect sizes and statistical significance was set at and diastolic less than 80 mmHg), elevated (systolic between 120 and 129 and diastolic less than 80 mmHg), stage I hypertension (systolic between 130 and 139 or diastolic between 80 and 89), and stage II hypertension (systolic at least 140 or diastolic at least 90 mmHg) [p < 0.05.To quantify the association between regular use of yoga and four blood pressure categories, defined in the 2017 ACA/AHA blood pressure guidelines, we fit mixed effects logistic regression models with blood pressure category as the dependent variable. Blood pressure categories are: normal , white (88.0%), females (87.8%), with a median age of 46 years (IQR 32–57 years), who reported using yoga one time per week (62.3%) Table .2 and 23.7 kg/m2) and blood pressures , 72 (IQR 68–80) and 115 (IQR 108–122), 72 (IQR 68–80) mmHg. After matching, few patients had common comorbidities of hypertension or prescriptions for blood pressure lowering drugs. Most clinical encounters were linked to commercial insurance, 88.3 and 94.0%, for yoga exposed and yoga non-exposed encounters, respectively.The yoga exposed and yoga non-exposed groups both had normal median BMI (24.1 kg/mp < .001) and lower DBP  than no use of yoga (Table p = 0.152), and increased with age from patients aged 40–59 years  to patients aged 60–79 years . The average treatment effect of yoga on DBP was smallest and not statistically significant in patients aged 18–39 years , and increased with age from patients aged 40–59 years  to patients aged 60–79 years , the latter only bordering on statistical significance.To calculate the effect of yoga on blood pressure, we used mixed linear regression modeling. In this data set, use of yoga one or more times per week was associated with lower SBP (− 2.8 mmHg, standard error 0.6, Effect sizes are robust to variable yoga non-exposed-to-yoga exposed encounter ratios and the composition of the yoga non-exposed encounters (Supplementary Fig. 2, Additional File Given that blood pressure is assessed categorically, we also evaluated the relationship between yoga and blood pressure category. Category thresholds for normal blood pressure, elevated blood pressure, stage I hypertension, and stage II hypertension were taken from the 2017 ACC/AHA report . We usedWe observed no association between regular use of yoga and elevated blood pressure or stage I hypertension Fig. . We obseHypertension is the leading surrogate marker for cardiovascular diseases and prevalence of hypertension progressively increases with age in the general population . Here, wThe effect sizes we report in this observational study are consistent with those reported in a meta-analysis across 41 randomized controlled trials and 15 non-randomized controlled trials that estimated yoga reduces SBP by 2.6 mmHg and DBP by 1.6 mmHg in individuals with normal blood pressure at baseline . ReductiLeveraging the EHR as a source of real-world behavioral data to conduct a large-scale observational study is a key strength of this work. Observational studies fill an important knowledge gap between the effects of an intervention under ideal circumstances, in well-controlled trials, and the effects of an intervention in real world, uncontrolled environments . In the Demographically, patients with a documented yoga practice in the EHR are similar to those who reported using yoga in a recent National Center for Health Statistics survey, namely they are young and middle-aged, non-Hispanic, white, women . BarrierFirst, EHR data are not collected for research, and secondary use of the data may introduce unforeseen bias into analyses –33. SecoBlood pressure control at the population level is the most effective way to prevent adverse cardiovascular events. This observational, case-control study demonstrates that yoga is associated with lower systolic and diastolic blood pressures, with increased odds of having normal blood pressure, and with decreased odds of having stage II hypertension in patients aged 40–59 years in a general patient population. Yoga, as used by patients in their daily lives, can be an effective strategy for blood pressure control and the prevention of hypertension at the population level.Additional file 1. List of ICD codes. ICD codes of comorbidities most common to hypertension and identified in this data set.Additional file 2. List of drugs. Antihypertensives, beta blockers, calcium-channel blockers and diuretics identified in this data set.Additional file 3. Supplementary methods, results, and discussion.