According to the hypertension guidelines, calcium antagonists are recommended as antihypertensive drugs for Stage 5 of chronic kidney disease (CKDG5) and late elderly patients, whereas renin-angiotensin-aldosterone system (RAS) inhibitors (RASi) are not recommended. We screened elderly CKDG5D patients at a single outpatient maintenance hemodialysis center for the progression of peripheral arterial disease (PAD) using the ankle-brachial index (ABI) and skin perfusion pressure (SPP) tests, as well as logistic regression analysis, to determine the association between PAD and the treatment with RASi and the association between the treatment with RASi and the need for hospitalization within one year of observation. With the presence of PAD as the explanatory variable and the presence of RASi as the objective variable, the odds ratio was 1.23  in univariate analysis. After adjusting for confounding factors , the odds ratio in multivariate analysis was 0.83 (95% CI 0.46 to 6.08). The presence or absence of PAD was significantly associated with an odds ratio of 3.24  and 4.63  in univariate and multivariate analyses, respectively, when the outcome was hospitalization at one year, regardless of the presence or absence of RASi. However, in univariate analysis, the odds ratio was 1.23 (95% CI 0.37 to 3.82) with RASi status as the explanatory variable and one-year hospitalization as the objective variable. After adjusting for confounders, the odds ratio in multivariate analysis was 0.83 (95% CI 0.46 to 6.08). Although further large-scale, multicenter studies are needed to establish the evidence, our results suggest that RASi treatment may have a suppressive effect on the prevalence of PAD and the need for hospitalization in elderly CKDG5 dialysis (CKDG5D) patients. General hypertension guidelines were published in 2019 -6. HowevThis article was at the 43rd Annual Meeting of the Japanese Society of Hypertension .PatientsThe study was conducted from December 2019 to April 2020 and included 70 patients undergoing chronic maintenance hemodialysis at a single facility.They had agreed to undergo cardio-ankle vascular index (CAVI) testing  and skin perfusion pressure (SPP) testing  as screening tests for PAD in both lower limbs.Methods Study DesignThis study was an observational study of dialysis patients at a single center and had three research objectives:1. This was a cross-sectional study to investigate whether the presence or absence of RASi is associated with the presence or absence of PAD. The presence or absence of RASi was used as the explanatory variable and the presence or absence of PAD as the objective variable.2. This was a retrospective cohort study, in which the presence or absence of RASi was the explanatory variable and the presence or absence of hospitalization from December 2019 to December 2020 was the objective variable. The study was conducted retrospectively using medical records.3. A logistic regression analysis was performed with the presence or absence of RASi and the presence of PAD as explanatory variables and the occurrence of hospitalization during the year as the objective variable. Age, gender, history of dialysis, pulse pressure, and calcium*phosphorus (Ca*Pi) products  were added as explanatory variables, which were considered to be clinically confounding factors. Univariate and multivariate analyses were performed.Data CollectionDuring the same period (December 2019 to May 2020), patients with an ankle-brachial index (ABI) of 0.9 or lower or an SPP of less than 30 on any one CAVI or SPP test were defined as “having PAD,” and the use or nonuse of a RASi was retrospectively determined based on medical records .The CAVI and SPP tests were performed during hemodialysis therapy for all patients. All but two patients underwent regular hemodialysis for three to four hours three times weekly. One patient underwent hemodialysis once a week for three to four hours in combination with peritoneal dialysis, and one patient underwent hemodialysis once a week for three to four hours to keep residual renal function. Each patient’s age, gender, history of dialysis, the presence of diabetes mellitus, and the presence of PAD were noted at the start of the study. The patients were divided into a group treated with a RASi (RASi (+) group) and a group not treated with a RASi (RASi (-) group). The patient’s age and duration of dialysis were investigated in terms of continuous variables and the percentage of patients older than 75 years and the percentage of patients who had undergone dialysis for more than five years. In addition, the following clinical indicators were measured: blood pressure at the start of dialysis, mean blood pressure and pulse pressure , height, weight (dry weight), body mass index (BMI), geriatric nutrition risk index (GNRI) -14, and Primary, Secondary, and Tertiary EndpointsIn line with the research objectives outlined above:1. Logistic regression analysis was performed with the presence or absence of PAD as the objective variable and the presence or absence of RASi as the explanatory variable as the primary endpoint. Age, gender, history of dialysis, and presence of hypertension, which were considered to be clinically confounding factors, were added as objective variables. Univariate and multivariate analyses were performed.2. Logistic regression analysis was performed with the objective variable being the occurrence of hospitalization at one year as the secondary endpoint and the explanatory variable being whether or not the patient was taking RASi. Logistic regression analysis was performed with the objective variable being the occurrence of hospitalization at one year and the explanatory variable being whether or not the patient was taking RASi.3. We performed univariate and multivariate analyses with the objective variable being the occurrence of hospitalization at one year and the explanatory variables being the presence or absence of RASi and the presence or absence of PAD as composite confounders ( RASi (+) and PAD (+), RASi (+) and PAD (-), RASi (-) and PAD (+), RASi (-) and PAD (-)). Logistic regression analysis was performed. We performed univariate and multivariate analyses by adding the clinically confounding factors age, sex, dialysis history, pulse pressure, and Ca*Pi product as objective variables.Statistical analysisSummary statistics were calculated for demographic characteristics and hematological parameters according to treatment group (RASi (+) and RASi (-) groups). We summarized the endpoints on the basis of the treatment group and tested the primary hypothesis using a Kruskal-Wallis test for a numerical variable and a Wilcoxon test for a categorical variable. For the primary and secondary endpoints, we performed a logistic regression analysis to estimate the odds ratio and the 95% confidential interval to calculate p-values. The model included fixed-effect terms for treatment, RASi (+) and RASi (-) group and PAD (+) and PAD (-). P‐values were presented without adjusting for multiple comparisons in an exploratory manner. No statistical sample size calculations were conducted. No imputation for missing data was applied. All statistical analyses were conducted using JMP software version 15.2.1 . A p-value of less than .05 was considered statistically significant.Patient populationIn terms of baseline clinical and laboratory findings, the RASi (+) and RAS (‒) groups had slightly higher serum albumin levels (p = .01), and a higher percentage of patients in the RASi (+) group were receiving ESAs (p = .03) (not described). There were unlikely to be significant differences between the presence or absence of RASi and ESA administration.Twenty-eight patients (41.4%) were judged to have PAD by the CAVI and SPP tests, and 42 patients (58.6%) were judged to have no PAD. There was a significant correlation between the presence of PAD (+) and PAD (‒) and patient age of more than 75 years and less than 74 years, respectively .Of the RASi (+) patients, about 90% were taking ARBs. Of the patients taking ARBs, 5.7% took a low dose, 12.9% took a moderate dose, and 11.4% had a high dose , the largest proportion of patients (28.6%) took two or three medications, followed by 24.3% who took one medication. No medication was taken in 11.4% of patients, and four or five medications were taken in 5.7% and 1.4% of patients, respectively.The most common type of antihypertensive medication, other than ACEi and ARBs, was calcium antagonists (67.1%), followed by beta-blockers (45.7%), diuretics (30%), alpha-blockers (24.3%), and others (1.4%).Primary endpointsWhen the presence or absence of PAD was determined as a target variable and the use or nonuse of RASi as an explanatory variable, logistic regression analysis was performed for univariate analysis, the odds ratio was 1.23 (95% CI 0.37 to 3.82). As a confounding factor, when adjusted according to age, sex, and the presence of hypertension, the odds ratio was 0.83 in multivariate analysis (95% CI 0.46 to 6.08)  in univariate analysis for one-year hospitalization, and 0.73 in a multivariate analysis adjusted by age, sex, presence of hypertension, and duration of dialysis as confounding variables (95% CI 0.21 to 2.44) (Table Tertiary endpointsThe odds ratio for RASi (+) and PAD (+) versus RASi (‒) and PAD (‒) was as high as 4.6 for univariate analysis  with the possible confounding factors of age, sex, dialysis history, pulse pressure, and Ca*Pi products. The odds ratio was 5.92  for multivariate analysis with the possible confounding factors of age, gender, history of dialysis, pulse pressure, and Ca*Pi products. In the PAD (‒) group, the odds ratio for RASi (‒) to RASi (+) was 0.84 , which tended to be slightly lower, though not significant . Similarly, in the PAD (+) group, the odds ratio for RASi (‒) to RASi (+) was 1.86 , which was not significantly different; however, it tended to increase clinically   group and 70% in the RASi (‒) group so there was a clear majority in the RASi (‒) group. According to a statistical survey by Iseki et al.  regardinPrimary endpointsIn this study, we investigated the effect of RASi on PAD in patients with end-stage CKD. As shown in Table Secondary endpointsLogistic regression analysis was performed with hospitalization as the objective variable and the use or nonuse of RASi as the explanatory variable. It showed that the RASi (+) group was not significantly different from the RASi (‒) group, with an odds ratio of 1.23 (95% CI 0.37 to 3.82) for univariate analysis and 1.16 (95% CI 0.34 to 3.73) for multivariate analysis. There was no significant difference between the two groups (Table Tertiary endpointsWhen RASi (+)/RASi (‒) and PAD (+)/PAD (‒) were set as explanatory variables and hospitalization as the objective variable, RASi (+) was significantly higher than RASi (‒) in the PAD (+) group, with an odds ratio of 1.86 (95% CI 0.43 to 10.28) in univariate analysis and 1.53 (95% CI 0.25 to 9.24) in multivariate analysis, indicating that RASi (+) patients tended to have more hospitalizations. On the other hand, in the PAD (‒) group, the odds ratio of RASi (+) to RASi (‒) was 0.84 (95% CI 0.11 to 4.60) in univariate analysis and 0.92 (95% CI 0.15 to 5.76) in multivariate analysis, indicating that the RASi (+) patients tended to have fewer hospitalizations. Hospitalization was defined as a long-term stay of approximately one month. A short-term hospitalization for medical check-ups and percutaneous transluminal angioplasty (PTA) of vascular access was excluded (Table In our study, the lack of sample size was found to be a limitation; however, the results are likely to be clinically significant, although no statistically significant difference was found, leading to this report .As far as we can tell from a review of the past literature, there is no treatment for PAD at this time that has demonstrated the efficacy of pharmacotherapy for prophylaxis. Although there are no guidelines or case reports, we present this report because further evidence suggests that pharmacotherapy may be useful in the prevention of PAD in hemodialysis patients.Although further studies are needed to establish the evidence, it was suggested that RASi may inhibit PAD in CKDG5D patients. In addition, there was a strong possibility that it may prevent hospitalizations.


The intima-media thickness was higher in SSc than in controls . The other parameters measured at carotid  all indicated that arterial stiffness in tension was more pronounced in SSc. Of interest, the direct correlation between PWV and age corresponded closely in SSc. Moreover, a significant difference between SSc and controls as regards the carotid parameters was evident in younger subjects. (4) Conclusions: SSc patients showed an increased arterial stiffness compared to healthy controls. In particular, an SSc-related pathologic effect was suggested by the more pronounced increase in PWV with age and lower values of carotid elasticity in younger SSc patients than in age-matched controls.(1) Background: Systemic sclerosis (SSc) is an autoimmune disease characterized by endothelial dysfunction and fibrosis of skin and visceral organs. In the last decade, attention has been focused on the macrovascular involvement of the disease. In particular, the observation of increased arterial stiffness represented an interesting aspect of the disease, as predictor of cardiovascular risk. (2) Methods: We recruited 60 SSc patients  and 150 age/sex-matched healthy controls in order to evaluate both intima-media thickness of the right common carotid artery and arterial stiffness using the B-mode echography and the SphygmoCor system Systemic sclerosis (SSc) is characterized by endothelial dysfunction and diffuse vasculopathy. Traditionally, the vascular involvement of SSc was considered mainly microvascular, leading to tissue ischemia. Raynaud’s phenomenon, digital ulcers, as well as pulmonary arterial hypertension are typical SSc features that pathogenetically identify functional and structural alterations of microvasculature ,2. HowevArterial stiffness is a typical sign of arterial dysfunction, even in the absence of overt vascular abnormalities. The main pathogenetic feature is damage to elastin fibers of the aorta and its main branches, which are replaced by collagen overproduction . FurtherArterial stiffness is well recognized as an independent cardiovascular risk factor; therefore, its assessment is clinically relevant ,8,9. TheWe recruited consecutive SSc patients classified according to the 2013 ACR/EULAR criteria  and refeSSc patients and controls affected by diseases associated with arterial stiffening, such as arterial hypertension, diabetes mellitus, chronic kidney disease, dyslipidemia, atherosclerotic diseases , chronic heart failure and current or former smoking habits, permanent or paroxysmal atrial fibrillation, were excluded from this study.Chronic vasoactive treatments were not interrupted for the study. However, in the case of prostanoid infusion therapy, the measurements of vascular parameters were performed at least 3 weeks after the last prostanoid administration.All demographic, clinical, laboratory and instrumental characteristics of SSc patients had already been collected in their clinical records. These records included: clinical history, data from the physical examination, C-reactive protein, erythrocyte sedimentation rate, complete blood counts, indices of liver and renal function, autoantibody profiles, plasma NT-pro-BNP, spirometry, DLCO measurement, chest high-resolution computed tomography, ECG and echocardiography.All patients gave their informed consent to the study, which was carried out in accordance with the ethical standards of the 1964 Helsinki Declaration and its later amendments and approved by the Ethics Committee of Catania 1 .All participants were studied in a vascular clinic by the same trained operator (L.Z.) blinded to patients’ clinical histories. Vascular evaluations were performed in a quiet room with a controlled temperature of 22 ± 1 °C between 9:00 and 11:00 a.m. The patients were fasting and refrained from caffeine, alcohol and exercise before the study for at least 12 h.After 15 min of rest in a supine position, brachial blood pressure was measured three times, 2 min apart, using a validated oscillometric device  . The meas and Dd) and the intima-media thickness (IMT) were measured at the right common carotid artery, according to Laurent et al. [The study of right common carotid artery was performed as previously reported . Longitut et al. . It is n®, AtCor Medical, Sydney, Australia) after recalibration with brachial mean blood pressure (MBP) and diastolic blood pressure (DBP) in the contralateral arm and was used to calculate carotid pulse pressure (PP). Brachial MBP was calculated as brachial DBP + 1/3 × brachial PP.The right arm radial pulse wave profile was recorded by applanation tonometry  were measured with the SphygmoCor device, as previously reported , using tThe carotid distensibility, defined as the relative change in luminal area (∆A) during systole for a given pressure change, was calculated as previously described , assuminThe carotid strain, defined as the relative change in the vessel diameter during systole, was calculated using the following equation: Strain = (Ds − Dd)/Dd, where Ds is the systolic internal diameter and Dd is the diastolic internal diameter.The circumferential wall stress (CWS), which represents the tangential force that enlarges the vessel, was calculated as follows: CWS (kPa) = (mean BP × Dm)/2IMTm . The cross-sectional compliance coefficient (CC) represents the absolute change in lumen area during systole for a given pressure change and was calculated as follows: CC = stroke change in lumen area/local pulse pressure.The incremental young elastic modulus (Einc), which represents the elastic properties of the material of the arterial wall , was calculated as previously described , using tAll continuous variables are presented as mean ± standard deviation (SD), after confirming their normal distribution by means of the Kolmogorov–Smirnov test; categorical variables are presented as a percentage value.p values < 0.05 were considered statistically significant.Clinical and hemodynamic variables were compared using analysis of variance (ANOVA) for continuous variables. Spearman linear regression analysis was performed to verify the existence of any significant correlation between two quantitative variables. The statistical analysis was performed using NCSS 2007 and PASS 11 software .This cross-sectional study included 60 SSc patients and 150 age/sex-matched healthy controls. Fifty-six out of 60 (93.3%) SSc patients showed the limited skin subset, 27 patients (45%) presented digital ulcers in their clinical history, 32 (53.3%) interstitial lung disease and 3 (5%) pulmonary arterial hypertension (PAH). Furthermore, anti-centromere or anti-Scl70 autoantibodies were found in 35 (58.3%) and 22 (36.7%) SSc patients, respectively.All patients were treated with calcium channel blockers for Raynaud’s phenomenon. Moreover, 13 patients used endothelin-1 receptor antagonists for digital ulcer prevention or PAH, while 35 were treated with monthly infusion of prostanoids.No significant difference between SSc patients and controls as regards the body mass index (BMI) was noted. The values for blood pressure confirmed that no patients with arterial hypertension were included.The evaluation of the right common carotid artery showed an increase in IMT in SSc patients compared with controls, but a similar internal diameter. Moreover, stiffness of the arterial wall was significantly increased in SSc patients compared with controls . In partp = 0.003). These 13 SSc patients had a mean age of 63.9 (range 52–73) years, whereas the mean age of the entire SSc group was 52 ± 12 years (p = 0.0014). No other SSc characteristics distinguished this patient subgroup from the others.Carotid-femoral PWV > 10 m/s was found in 13 out of 60 SSc patients and 11 out of 150 controls  and muscular  arteries. Moreover, in SSc patients we found the coexistence of stiffening and thickening processes. The increase in the Young’s elastic modulus suggested that alterations of the bioelastic material occur in the arterial wall in SSc. As a consequence of the stiffening process, the radial strain and the distensibility of the common carotid artery were reduced. Of interest, despite the increased common carotid artery IMT in SSc compared with control subjects, the internal diameter was comparable, thus suggesting that, in SSc patients, the thickening of large elastic arteries may proceed in parallel with the enlargement of the arterial wall. Further studies may be needed to confirm this hypothesis.The increase in arterial stiffness in SSc is a crucial point in the assessment of the cardiovascular risk in SSc patients ,10,12, pprimum movens of premature atherosclerosis in RA patients [Rheumatic diseases, such as rheumatoid arthritis (RA), were widely studied as independent risk factors for the increase in cardiovascular risk, due to the chronic inflammatory state ,34,35. Ipatients ,34,35,36per se to the development of accelerated atherosclerosis. Consistently, our findings  did not allow us to find specific correlations found in previous studies ,39. FurtIn conclusion, the evaluation of carotid elasticity, carried out for the first time in our study, could facilitate a better understanding of the specific characteristics of macrovascular abnormalities in patients with SSc.This study, however, has limitations. In fact, some unknown or underestimated factors might have influenced our findings. For instance, many drugs used in SSc are vasoactive substances that could counteract the long-term evolution of arterial stiffness. Furthermore, immunosuppressive agents may inhibit leukocyte activities also in the arterial wall, thus influencing the natural progression of disease. Therefore, considering the high number of confounders influencing endothelial function and arterial alterations, protocols for the evaluation of cardiovascular risk in SSc should be designed within very large, multicenter, prospective studies.


There is suggestive evidence that Obssesive Compulsive Disorder (OCD) is characterized by impaired neuropsychological functions that are also influenced by clinical variables. Several studies show that these neuropsychological deficits could be potential endophenotype markers.The present study aimed to examine neuropsychological patterns in OCD patients and several clinical variables before and after a follow-up of 10 years.This study examined 44 outpatients with OCD. Cognitive performance and clinical data of these patients were documented before and after a follow-up of 10 years. A neuropsychological battery was administered and scored to them including Rey Osterrieth Complex Figure, the Digit-span test, and the State-Trait Anxiety Inventory. As well, several clinical variables were also assessed including sociodemographic variables, general intelligence measured by Progressive Raven’s matrices, Yale Brown Obsessive Compulsive Scale and Hamilton Depression Rating Scale. Finally, data was analyzed using t-Student and Pearson’s correlation.In general, the pattern of neuropsychological dysfunction in patients with OCD remains unchanged during the follow-up period, except for some specific variables. Low scores on some verbal memory tasks were associated with severity of OCD, and nonverbal memory was influenced by depressive symptoms in the first evaluation, while, after the follow-up, as obsessive and affective symptoms improve, there’s no significant change in the neuropsychological pattern.Despite the influence of some clinical and sociodemographic variables on the neuropsychological performance in OCD patients, cognitive dysfunction remains unchanged after a follow-up period of 10 year. These results suggest that cognitive deficits could be considered as a trait marker for the disorder.No significant relationships.


The respiratory/hemodynamic parameters did not differ between the groups at any stage of operation. Blood Pressure and Ppeak-PEEP were significantly higher at the P2 compared to P1 and P3 stages  that correlated with lung compliance changes: C/kg vs. NBPs and Ppeak-PEEP ; C vs. Pulse and Ppeak-PEEP . Although an increase in intraabdominal pressure up to 12(15) mmHg causes significant changes in hemodynamic/respiratory parameters, there appears to be no risk of fatal reactions in 1E, 2E ASA patients. Systemic lidocaine administration doesn’t alleviate circulatory/respiratory alterations during pneumoperitoneum. No lidocaine related episode of anaphylaxis, systemic toxicity, circulatory disturbances or neurological impairment occurred.We assessed the influence of systemic lidocaine administration on ventilatory and circulatory parameters, and the pneumoperitoneum impact on the cardiopulmonary system during a laparoscopic appendectomy in children. A single-center parallel single-masked randomized controlled study was carried out with 58 patients (3–17 years). Intravenous lidocaine bolus of 1.5 mg/kg over 5 min before induction of anesthesia followed by lidocaine infusion at 1.5 mg/kg/h intraoperatively. Respiratory system compliance , PClinicalTrials.gov: 22/03/2019.Trial registration number: NCT03886896. Due to opioid-sparing effect, patients are Protected from specific complications like Prolonged recovery after anesthesia, respiratory complications, Prolonged duration of ileus, postoperative nausea and vomiting, itching, urine retention. Systemic lidocaine administration appeared to be a safe modality, which is consistent with other trials on this topic9.According to the results from our Previous study11. However, due to the creation of pneumoperitoneum, certain physiological alterations must be taken into account during anesthesia for this specific surgical technique.Laparoscopic surgery offers numerous advantages, such as: reduction of intraoperative metabolic stress response, less intraoperative bleeding, reduction of postoperative pain, better cosmetic results, enhanced recovery, reduction in hospital stay, less postoperative wound infectionBoth the respiratory and circulatory system are affected by the increase in intraabdominal Pressure. A decrease in pulmonary compliance is observed, along with various changes in hemodynamic parameters. Episodes of hypertension, hypotension, dysrhythmias, and even cardiac arrest have been reported. This study was undertaken in recognition of the clinical significance of mentioned complications and hypothetically Protective Properties of lidocaine.The study was conducted in the Pediatric Teaching Hospital at the University Clinical Centre of the Medical University of Warsaw, Poland.In this single-blind randomized controlled trial, children were randomly assigned to two groups according to the use of intraoperative intravenous lidocaine infusions to compare the hemodynamic and respiratory reaction at the different stages of anesthesia. The study was conducted between March 2019 and January 2020. Patients were enrolled between 26/03/2019 and 15/01/2020.In accordance with the current Polish law and the Declaration of Helsinki, the study was approved by the Ethics Committee of the Medical University of Warsaw (KB/24/2019).1, as they represented neither the primary nor the secondary outcomes of the above trial.The primary trial was registered at the US National Institutes of Health: NCT03886896. The date of first posted on ClinicalTrials.gov: 22/03/2019. The data presented currently were not reported in the original publicationNalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences (IBIB PAS) was involved in data analysis, results Presentation and discussion.1, only participants with a complete set of the necessary details were included. Therefore the number of participants, and their demographic and clinical characteristics are different from those Presented in the Primary trial1.This paper focuses on the influence of lidocaine infusions on the circulatory and respiratory system. Since the outcomes analyzed in this report required different input data from those originally investigatedChildren Presenting for laparoscopic appendectomy to be anesthetized by physicians involved in the study were assessed for eligibility criteria.Age between 18 months and 18 years;ASA physical status class 1E, 2E, 3E;Patients undergoing laparoscopic appendectomy.The inclusion criteria are listed below:Allergy to local anesthetics or contraindications for the use of lidocaine;ASA physical status class 4 or higher;Severe cardiovascular disease;Preoperative bradycardia;Preoperative atrioventricular block;Renal failure;Chronic treatment with analgesics;Legal guardians’ refusal.The exclusion criteria are listed below:Researchers spoke to the parents or legal guardians and informed them about the study. They described the potential risks and benefits of the Procedure, discussed questions and concerns, and then obtained written informed consent.From the recruited population, patients with complete respiratory module records were included in further analysis. Flow diagram of the study is presented in Fig. Participants were randomly assigned to one of two groups: experimental (Lido) and control (Control).Patients in the experimental arm received intravenous lidocaine bolus of 1.5 mg/kg over 5 min before induction of anesthesia followed by lidocaine infusion at 1.5 mg/kg/h intraoperatively. The infusion was discontinued before the patients’ transfer to the postanaesthesia care unit (PACU).Patients in the control arm received no additional treatment.Other than the studied intervention, both groups of participants were treated according to the same fixed perioperative care Protocol.The peripheral intravenous catheter was inserted in the Emergency Room or in the Surgery Ward when obtaining blood samples. Topical local anesthetics were not used.Due to the Principal diagnosis—acute appendicitis, all the cases were classified as emergencies (E).Upon admission to the operating wing, IV midazolam at 0.05 mg/kg was administered for Premedication. The patient was then transferred to the operating theatre, where their vital signs were captured. In the lidocaine group, the loading dose of lidocaine was administered.Induction of anesthesia was achieved with IV Propofol 4 mg/kg, fentanyl 3 μg/kg and rocuronium 0.6–1.2 mg/kg.Standard monitoring of cardiopulmonary parameters and concentration of anesthetic gases and agents was utilized.The eligible children were assigned to groups according to a computer-generated permuted block randomization list Prepared by a statistician with no clinical involvement in the trial.The size of each block was six. Study allocation ratio was 1:1. Information about the participant’s allocation was concealed in a sealed envelope.During the informed consent Process, the researchers, attending anesthesia teams and the children’s families were blinded to treatment allocation. After the consent had been obtained, the investigator opened the envelope. The study drug was Prepared by a nurse.Throughout the study, all medication was administered to randomized patients according to their allocation.All of the data analyzed in this report were collected during anesthesia.Data on the use of medications and crucial moments such as intubation, skin incision, creation of pneumoperitoneum, end of the surgery, and extubation were collected in the operating theatre (OT) by the anaesthetist—one of the researchers.Hemodynamic parameters were uploaded automatically to a database. Due to the lack of communication between the respiratory module and the server, those data were archived as photos.1 corresponds to baseline readings, at the beginning of mechanical ventilation, P2—at the beginning of laparoscopic surgery after skin incision and pneumoperitoneum creation and readings made at the minimum of respiratory system compliance, and P3 corresponds to the end of surgery (end of pneumoperitoneum), before extubation.2O;C—dynamic compliance of respiratory system, in ml/cmH2O;C/kg—pulmonary compliance per kilogram of body mass, in ml/kg/cmHpeak—peak Pressure measured in the patient–ventilator system, in cmH2O;Ppeak-PEEP—the difference between peak Pressure and positive end-expiratory Pressure, in cmH2O;PPulse—pulse rate obtained by pulse oximetry, bpm;s—systolic blood Pressure, in mmHg;NBPd—diastolic blood Pressure, in mmHg;NBPm—mean blood Pressure assessed as NBPd + (NBPs-NBPd)/3, in mmHg;NBPpeak, C vs. Ppeak-PEEP, C/kg vs. Ppeak, C/kg vs. Ppeak-PEEP, C vs. NBPs, C vs. NBPd, C vs. NBPm, C/kg vs. NBPs, C/kg vs. NBPd, C/kg vs. NBPm, C vs. Pulse, C/kg vs. Pulse.Correlations coefficients for dependencies: C vs. P2 coefficients representing goodness of fit were determined, too.Curve equations for the above dependencies and RParameters were assessed at three stages of anesthesia. Ppeak, Ppeak-PEEP) and hemodynamic parameters  between patient groups and to assess the difference between them at the successive stages of the operation: P1, P2, and P3. The Wilcoxon test was used to compare the P1 vs P2 and P1 vs P3 stages in the same patient group. Then, Friedman’s ANOVA test for repeated measurements was performed to assess the difference in these measures between the P1, P2, and P3 stages of the anaesthesia . STATISTICA , version 10; www.statsoft.com.).Moreover, the Spearman correlation coefficient RThis study was approved by the Ethics Committee of the Medical University of Warsaw (KB/24/2019). The trial was registered at the US National Institutes of Health : NCT03886896. The date of registration: 15/03/2019. Written informed consent was Provided by parents/legal guardians.1, 58 were included in the current analysis, with 29 assigned to the lidocaine infusion group (Lido) and 29 assigned to the control group—without lidocaine infusion (Control).Of the 71 participants who completed the original trialBaseline demographic and clinical characteristics are Presented in Table Lidocaine safety considerations were the major concern of the Primary trial. Frequencies of allergic reactions as well as neurotoxicity or cardiotoxicity episodes were specified secondary outcomes. None of the study participants developed signs of anaphylaxis, systemic toxicity, circulatory disturbances or neurological impairment.peak, Ppeak-PEEP, Pulse, NBPs, NBPd, and NBPm, at any point of examination ; see from Figs. The statistical analyses of this study, concerning respiratory and hemodynamic parameters registered in patients during laparoscopic appendectomy, showed that there were generally no differences between the Lido and Control groups with respect to the following parameters: C, C/kg, P1, P2, P3 in all the variables assessed in the study were statistically significant (P < 0.001); Figs. However, in both patient groups alike, the differences between measurements at P2 level were significantly lower than those measured at P1 and P3  did not return to baseline (P1), and the difference was significant, both when the patient groups were considered together  and C/kg vs Ppeak-PEEP , which are presented in Fig. The strongest significant correlations between the studied parameters were observed for the dependencies: C/kg vs Pd  and C/kg vs NBPm —Supplementary information, Fig. Moreover, moderate but significant correlations were found for C/kg vs NBPs  and C vs Pulse, , whereas weak but significant correlations were observed between: C/kg vs NBP13. At the same time, recommendations for children do not clearly support its use, and some have not even taken lidocaine into consideration15.Lidocaine, a potent local anesthetic and class I B antiarrhythmic agent, is also recommended in perioperative medicine in the adult population as part of a multimodal approach to pain management3, reduction in volatile anesthetic requirement9, and shorter hospital stays3.Despite the increasing popularity of systemic lidocaine administration in the pediatric population, due to the lack of clear evidence derived from randomized controlled trials, in Poland this intervention remains to be regarded as off-label use. Emerging publications report beneficial effects in pediatric patients, especially the opioid-sparing effectThe main objective of the Present analysis is to study systemic lidocaine infusions in terms of safety. The influence of lidocaine on changes in hemodynamic and respiratory parameters during abdominal laparoscopy was also investigated.The paper also explores the physiological consequences accompanying laparoscopic Procedures in children.10. Apart from the advantages associated with the surgical wound, there are also some potential complications that have to be taken into account. In this discussion, we address only the physiological consequences of pneumoperitoneum.The benefits of laparoscopic surgery include faster recovery, reduced postoperative pain, fewer wound-related complications and reduced morbidityWithout a doubt, laparoscopic Procedures affect circulatory and respiratory systems Figs. , 4, 5, 611 intraabdominal Pressure (IAP), patient’s position, volume of carbon dioxide absorbed, patient’s intravascular volume, ventilatory technique, surgical conditions, and anesthetic agents used are the factors responsible for observed changes. In the adult population, IAP below 15 mm Hg increases cardiac output due to venous return reinforcement11. On the other hand, Perugini et al. state that cardiac output decreases while mean arterial Pressure remains unchanged or even increases up to 16%16.Creation of pneumoperitoneum may Provoke a wide range of hemodynamic alterations, such as hypotension, hypertension, arrhythmias and even cardiac arrest. According to Gerges et al.11.Increase in IAP above the level of 15 mm Hg compresses vena cava inferior and collateral vessels resulting in decreased venous return, cardiac output and hypotension11.Veress needle insertion and peritoneal stretch are some of the factors responsible for vagal stimulation leading to bradyarrhythmias. Tachyarrhythmias are attributed to hypercarbia and catecholaminesOur analysis is limited to children in ASA 1E/2E physical status Presenting for laparoscopic appendectomy in neutral or reverse Trendelenburg position with average intraperitoneal Pressure of 12 mmHg, not exceeding 15 mmHg.s, NBPd, NBPm) : P1: 61(55–72) mmHg, P2: 74(68–78) mmHg, P3: 68(61–73) mmHg; P < 0.001). The most plausible physiological explanation of this phenomenon is that positive IAP shifts the blood from minor visceral capillaries to larger vessels, increasing cardiac Preload. According to the Frank–Starling law, an increase in the end diastolic volume Produces an increase in stroke volume.In this study, the creation of pneumoperitoneum affected noninvasive blood Pressure (NBPm) Figs. , 6. The None of the patients experienced the reverse effect, which is a potential complication of laparoscopic Procedures in certain groups of patients , especially when IAP exceeds 15 mm Hg.This study did not reveal any statistically significant differences between NBP in the experimental and the control group Figs. , 6.While NBP is strictly correlated with the presence of pneumoperitoneum, changes in the Pulse rate seemed to be more independent. The Pulse decreased as the surgery progressed Fig. .2 insufflation, the decrease in Pulse might be explained by the baroreceptor reflex. Then, during the stable phase of surgery, a slight increase in Pulse up to a plateau level was observed in some patients, reflecting adaptation to altered hemodynamic conditions  and relative , decreased significantly . Since then, the parameter has been investigated both as a Predictor of mortality and as a guidepost in lung Protective strategies. Driving Pressure (∆P) is calculated as plateau Pressure (Pplat) minus positive end-expiratory Pressure (PEEP), or can be expressed as the ratio of tidal volume (Vt) to respiratory system static compliance (Cstat). Unfortunately, due to the characteristics of the anesthetic device plateau pressure and static compliance were not available, that is why ∆P could not be calculated. Ppeak reflects lung compliance and airway resistance, PEEP was constant throughout the surgery, therefore Ppeak−PEEP seems to be an adequate tool for assessing the overall respiratory reaction to pneumoperitoneum, which was one of the objectives of the study.In 2015, Amato et al.Although an increase of IAP up to 12 (max. 15) mmHg during laparoscopic appendectomy causes significant changes in hemodynamic and respiratory parameters, patients in ASA classes 1E, 2E appeared not to be at risk of experiencing catastrophic reactions. Systemic lidocaine infusions do not alleviate circulatory and respiratory alterations during pneumoperitoneum creation and maintenance.Supplementary Information.


End-stage renal disease (ESRD) patients experience oxidative stress due to excess exogenous or endogenous oxidants and insufficient antioxidants. Hence, oxidative stress and inflammation cause endothelial damage, contributing to vascular dysfunction and atherosclerosis. Therefore, ESRD patients suffer more cardiovascular and hospitalization events than healthy people. This study aims to test the correlations between ROS, SOD3, IL-2, IL-6, and IL-18 and the first kidney disease-related hospitalization or death events in ESRD patients undergoing regular hemodialysis. A total of 212 participants was enrolled, including 45 normal healthy adults and 167 ESRD patients on regular dialysis. Blood samples from all participants were collected for ROS, SOD3, IL-2, IL-6, and IL-18 measurement at the beginning of the study, and every kidney disease-related admission or death was recorded for the next year. Multivariate analysis was conducted by fitting a linear regression model, logistic regression model, and Cox proportional hazards model to estimate the adjusted effects of risk factors, prognostic factors, or predictors on continuous, binary, and survival outcome data. The results showed that plasma SOD3 and serum IL-18 were two strong predictors of the first kidney disease-related hospitalization or death. In the Cox proportional hazards models (run in R), higher IL-18 concentration (>69.054 pg/mL) was associated with a hazard ratio of 3.376 for the first kidney disease-related hospitalization or death (95% CI: 1.2644 to 9.012), while log(SOD3) < 4.723 and dialysis clearance  had a hazard ratio = 0.2730 (95% CI: 0.1133 to 0.6576) for reducing future kidney disease-related hospitalization or death. Other markers, including body mass index (BMI), transferrin saturation, total iron binding capacity, and sodium and alkaline phosphate, were also found to be significant in our study. These results reveal the new predictors SOD3 and IL-18 for the medical care of end-stage renal disease patients. Chronic kidney disease (CKD) puts a heavy health burden on society, and its high economic costs include costs for physician visits, ambulatory care, hospitalization, dialysis, and medication . In partIn general, Toll-like receptor (TLR) overexpression in neutrophils and monocytes may enhance cytokine synthesis, with a subsequent inflammatory response. A clinical study recruited 47 CKD, 13 hemodialysis (HD), and 71 control individuals, finding that the elevation of TLR-4 expression in neutrophils was significantly higher in dialysis patients than in stage 3 and 4 CKD patients. Serum levels of TNF-α, IL-6, and monocyte chemoattractant protein-1 (MCP-1) were also significantly increased in HD and CKD patients compared with healthy controls . One stuThe higher levels of reactive oxygen species (ROS) in uremic patients are due to an imbalance in their production/degradation ratio. This has been validated in patients and models of renal insufficiency, even in early CKD . The plaESRD patients suffer an excess of morbidity and mortality due to cardiovascular disease (CVD), which cannot be fully explained by the classical CVD risk factors . In addiIn this study, we aimed to elucidate the correlation between different potential predictors  and first nephropathy-related hospitalization or death in ESRD patients receiving hemodialysis.We designed a dual-center prospective study and recruited patients receiving routine hemodialysis at Jen-Ai Hospital or Xinren Clinic . We sampled blood from ESRD patients prior to initiation of dialysis treatment at the start of the study and then tracked and recorded each patient’s clinical status  from 1 September 2020 to 30 September 2021. Our primary observed outcome was the first hospitalization or death related to kidney disease. The Ethics Committee of the Clinical Center (ECCC) of Jen-Ai Hospital approved the study (IRB No: 109-76), and all the patients signed the written informed consent.A total of 167 ESRD patients was enrolled in this study. The ESRD diagnosis was made from clinical data and symptoms and was approved by the Office of Health Insurance. All patients underwent an average 4 h hemodialysis program 3 times per week. The exclusion criteria were as follows: age under 30 or over 70 years old, malignancy, acquired immunodeficiency, indigenous people, and those taking antioxidants. We also collected the relevant data from all patients, including age, sex, BMI, primary kidney disease, complete blood count (CBC), monthly routine biochemical test data, Kt/V, Fe supplement dose, serum hs-CRP, IL-2, IL-6, and IL-18. During the 1-year follow-up period, we recorded every causal hospitalization or death related to kidney disease. The enrollment flow chart of this study is shown in TM Human Cytokine/Chemokine Panel A, Cytometric Bead Array, Cat. No. 558267, BD Biosciences, San Jose, CA, USA).Blood samples from normal adults and dialysis patients were collected in CAT blood collection tubes  for ROS/RNS and inflammatory cytokine assays and in LH Lithium Heparin tubes  for SOD determination. Each blood sample was centrifuged at 10,000 rpm for 10 min at 4 °C, and the supernatant serum was transferred to a new tube. One hundred microliters of serum was subjected to the ROS/RNS assay , and the fluorescence content was measured on a multimode microplate reader . SOD3 activity was measured in 50 µL of plasma  ,17. Serup value ≤ 0.05 was considered statistically significant. Continuous variables were expressed as mean ± standard deviation (SD), categorical variables were presented as frequency and percentage (%), and the survival curves of time to the first kidney disease-related hospitalization or death were estimated by the Kaplan−Meier method. In the univariate analysis, the unadjusted effect of each potential risk factor, prognostic factor, or predictor of the first-time kidney disease-related hospitalization or death was examined using the Wilcoxon rank-sum test, Fisher’s exact test, chi-squared test, and log-rank test, as appropriate for the type of data. Next, a multivariate analysis was performed to estimate the adjusted effects of risk factors, prognostic factors, or predictors on the time to the first kidney disease-related hospitalization or death by fitting a Cox proportional hazards model.Statistical analysis was conducted using R 4.1.2 software  as previously described . In statp value > 0.05 until all regression coefficients had effects significantly different from 0 [The regression analysis procedure followed the recommended method as previously described ,19. BrieR2, to assess the GOF fitted to the Cox proportional hazards model. The concordance, which is a value between 0 and 1 in the Cox proportional hazards model, is equivalent to the c statistic in logistic regression, so a value ≥ 0.7 suggests an acceptable level of discrimination power. However, the values of adjusted generalized R2 (0 ≤ R2 ≤ 1), proposed by Van der Net [R2 ≥ 0.15 indicates an acceptable fit for a Cox proportional hazards model.The GOF measures were examined, including concordance and adjusted generalized  der Net , are usup < 0.005) than other primary renal diseases. As shown in p = 0.4761). Serum alkaline phosphate had more significant expression in the hospitalization group (81.92 ± 34.22 IU/L) than the nonhospitalization group . Other variables, including RBC number, albumin, creatinine, Fe, total iron binding capacity (TIBC) and IL-6, were significant according to the primary statistics (p < 0.005). Hospitalization frequency and hospitalization days within 1 year before the start of the study were also meaningful. On the topic of nutrition, serum albumin was significantly different between the nonhospitalization (4.37 ± 0.53 mg/dL) and hospitalization  groups by the Wilcoxon rank-sum test for continuous variables and Fisher’s exact test for categorical variables, but BMI was similar. Of the proinflammatory cytokines, only IL-6 was significant, and IL-2 and IL-18 were not significant, by univariate analysis.A total of 161 adult ESRD patients receiving hemodialysis  was enrolled for analysis. Patient characteristics, including sex, age, body mass index (BMI), etiology of primary renal disease, basic monthly biochemical data, ROS, SOD3, IL-2, IL-6, and IL-18, were analyzed . Patientp = 0.0004), hospitalization days , and kidney disease-related hospitalization frequency  were associated with survival  (p > 0.609) might have been in a more severe chronic inflammatory state, with a high incidence of further kidney disease-related hospitalization or death.survival . When mu–1.6156) . As show2 also were meaningful (p < 0.05), hemoglobin (10.18 ± 1.61 g/dL vs. 9.57 ± 1.11 g/dL), and albumin  were meaningful in the primary statistical results but failed to reach significance in the final Cox proportional hazards model.As shown in aningful . In patip = 0.8629) in the mean serum concentration of IL-18 at baseline by univariate analysis. However, after Cox proportional hazards models were applied to the whole study population, adjusted for first kidney disease-related hospitalization or death according to age, electrolytes, BMI, comorbidity, lipid status, serum iron, nutritional state , dialysis clearance (Kt/V), hs-CRP, IL-2, and IL-6, serum IL-18 concentration was positively correlated with the time to first hospitalization or death  in multivariate analysis. Because the pathophysiological events leading to kidney disease-related hospitalization or death included cardiovascular and infectious diseases, serum IL-18 concentration could act as an independent predictor for all-cause hospital admission or death better than other inflammatory mediators. In the study, after multivariate analysis, hs-CRP, IL-2, and IL-6 failed to show significant results.As shown in p < 0.005, CI: 0.1133–0.6576)  in ESRD patients was a statistically significant predicator of first kidney disease-related hospitalization or death events. Increased levels of plasma SOD3 have been observed in many diseases. In a previous study, a rise in the plasma SOD3 level and a decline in renal function were closely correlated in chronic kidney disease patients . In this–0.6576) .The objective of our study was to evaluate whether serum markers of inflammation , oxidative stress (ROS), and plasma antioxidation SOD3) were associated with the risk of a first kidney disease-related admission or death event in ESRD patients by the 1 year clinical follow-up. Our statistical calculations showed that there were many significant factors in the results, including hospitalization frequency within 1 year before the study, age, BMI, platelets, ALT, phosphate, alkaline phosphate, sodium, serum iron, TIBC, cholesterol, IL-18, and logSOD3 with Kt/V. Most of these predictors have been discussed in many previous studies. In this study, we were more interested in the roles of SOD3 as an antioxidant and IL-18 as an inflammatory mediator in the disease process of ESRD patients. It is well known that CKD patients are consistently in a low-grade inflammatory state, with increased inflammatory markers CRP, IL-6, TNF-α, and fibrinogen  were ass. InflammEven with new treatment and intervention strategies, the poor outcomes of maintenance hemodialysis in ESRD patients continue to attract worldwide attention. Oxidative stress and chronic inflammation play the most important roles in the long-term complications in HD patients, such as infection, cardiovascular disease, atherosclerosis, anemia, and malnutrition ,32,33. AThe expression of SOD3 is extraordinarily complex and ambiguous. SOD3 is a secreted glycoprotein with a unique functional heparin-binding domain (HBD) that is primarily located in extracellular fluids, where it protects cells from damage. Approximately 99% of SOD3 is bound to heparan sulfate proteoglycans in the vascular wall, and the remaining 1% of SOD3 is circulated in equilibrium between the plasma phase and the endothelial glycocalyx ,41. MoleIn a previous study analyzing plasma SOD3 levels in 504 random blood donors, a common phenotypic variant (2.2%) was linked to a 10-fold increase in plasma SOD3 levels . As for It is well known that ROS, induced by endogenous or exogenous stimuli, play a critical role in the activation of the apoptotic process via mitochondria-dependent and mitochondria-independent pathways . In the Increased oxidative stress is a core event of renal function deterioration in CKD patients. Hence, a reduction in oxidative stress can improve renal function and lower inflammation and CVD risks . AuthorsIn this study, plasma SOD3 and IL-18 levels were significantly correlated with the onset of first kidney disease-related hospitalization or death and could be applied as novel predictors in clinical practice. In many studies, the change in plasma SOD3 levels was not consistent between patients at the time of diagnosis. We speculated that the activation of leukocytes and the release of proinflammatory factors in various diseases stimulate the production of ROS, which subsequently promotes the expression of SOD3. In a case−controlled study of 100 patients with coronary artery disease (CAD) and 50 healthy adults, a nonsignificant positive association between MDA and plasma SOD3 was observed . That stESRD patients suffer a higher morbidity and mortality, especially from cardiovascular disease and infections, than the general population. This study discovered that plasma SOD3 and serum IL-18 are better and more efficient predictors of all-cause morbidity and mortality than the common inflammatory mediators IL-6 and hs-CRP in ESRD patients.


The suboptimal function of the allograft often results in misbalances in kidney-controlled processes and requires long-term monitoring of allograft function and viability. As the kidneys are organs with a very high metabolomic rate, a metabolomics approach is suitable to describe systematic changes in post-transplant patients and has great potential for monitoring allograft function, which has not been described yet. In this study, we used blood plasma samples from 55 patients after primary kidney transplantation identically treated with immunosuppressants with follow-up 50 months in the mean after surgery and evaluated relative levels of basal plasma metabolites detectable by NMR spectroscopy. We were looking for the correlations between circulating metabolites levels and allograft performance and allograft rejection features. Our results imply a quantitative relationship between restricted renal function, insufficient hydroxylation of phenylalanine to tyrosine, lowered renal glutamine utilization, shifted nitrogen balance, and other alterations that are not related exclusively to the metabolism of the kidney. No link between allograft function and energy metabolism can be concluded, as no changes were found for glucose, glycolytic intermediates, and 3-hydroxybutyrate as a ketone body representative. The observed changes are to be seen as a superposition of changes in the comprehensive inter-organ metabolic exchange, when the restricted function of one organ may induce compensatory effects or cause secondary alterations. Particular differences in plasma metabolite levels in patients with acute cellular and antibody-mediated allograft rejection were considered rather to be related to the loss of kidney function than to the molecular mechanism of graft rejection since they largely follow the alterations observed by restricted allograft function. In the end, we showed using a simple mathematical model, multilinear regression, that the basal plasmatic metabolites correlated with allograft function expressed by the level of glomerular filtration rate (with creatinine:  Kidneys are the organs with the second-highest metabolic rate, and restricted renal function results in misbalances in kidney-controlled/participating processes, such as the maintenance of acid-base equilibrium, electrolyte and fluid balances, the regulation of hematopoiesis, and the excretion of waste products , but alsIn the field of renal transplantation, metabolomic studies have reported interesting results. Adequate metabolic recovery was recognized as a critical determinant of outcome after kidney transplantation . The metOnly sparse information can be found about the metabolomic changes in blood plasma in relation to allograft function. Circulation serves as the pool of low molecular species ensuring inter-organ metabolic communication and exchange. With an unreliably working kidney, the organism becomes metabolically challenged, and the imbalance may lead to compensatory effects of the other organs as well as secondary damage. The worsening of renal function is clinically determined by two basal approaches—by increasing serum creatinine (Cre) and decreasing eGFR (estimated glomerular filtration rate), which serve also as a quantitative indicator of allograft viability and performance. In this study, we used both mentioned parameters to assess allograft function, and we looked for how the deteriorating condition of the kidneys in post-transplant patients affects levels of plasma metabolites, which have not been explored yet. To achieve as homogeneous a group as possible, we selectively included patients after primary kidney transplantation, identically treated with immunosuppressants and more than 5 years after transplantation in the mean. We also attempted to use the metabolomic profile in the blood to predict allograft function and allograft rejection, which could be of great use as a noninvasive method in clinical practice.The presented analysis consisted of a total number of 55 adult patients (Caucasians) after the primary transplantation of a kidney from a standard criteria brain-dead donor (SCD), who underwent the transplantation in the Transplant Centre Martin, Slovakia. We determined the following parameters of all patients included in the monitoring: age at the time of transplantation, sex, presence of biopsy-proven acute rejection (acute cellular rejection (ACR), acute antibody-mediated rejection (AMR)), proteinuria (standard 24 h urine protein test) and finally eGFR-estimated glomerular filtration rate (according to Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula). Acute rejection was confirmed by graft biopsy and classified according to the Banff classification 2019. Donor-specific antibodies were determined by the LUMINEX methodology (positivity was stipulated at ≥500 MFI). Standard immunosuppression was identical in the whole group, namely tacrolimus , mycophenolate sodium (Myfortic) and Prednisone. The group of patients was homogenous in terms of immunosuppression-average levels of TAC, and daily doses of mycophenolate sodium (Myfortic) and Prednisone were similar (with no significant difference between monitored groups). The average follow-up was 68.4 (SD = 50.7) months after kidney transplantation.Age > 18 years,No active infection,Immunosuppression consisted of TAC, MPA, and Prednisone,Primary kidney transplantation from SCD.Inclusion criteria were as follows:Age < 18 years,Lost to follow up,Active infection,Kidney transplantation from an extended criteria donor (ECD) or living kidney donor,Kidney transplantation in the last 6 months.Exclusion criteria were as follows:A donor with extended criteria means a donor according to the definition of ECD codified in 2002: donors over the age of 60 years without co-morbidities or donors over the age of 50 years with at least two co-morbidities that include blood hypertension, death from cerebrovascular accident, or terminal stage. At the time of blood collection, all patients had clinically determined Cre, eGFR, and proteinuria levels. The stage was assigned by eGFR values according to the generally accepted CKD-EPI formula and KDIGO CKD classification . Patients’ characteristics are summarized in g-force) for 20 min. The samples were stored at −80 °C until use. Plasma denaturation was carried out according to Gowda et al. [g-force) for 30 min, 700 µL of supernatant was taken, dried out and stored at −80 °C. Before NMR measurement, the dried matter was mixed with 100 µL of stock solution  as a chemical shift reference in deuterated water) and 500 µL of deuterated water. Finally, 550 µL of the final mixture was transferred into a 5 mm NMR tube.Blood was collected in EDTA-coated tubes and, within 1 h after collection, centrifuged to plasma at 4 °C, 2000 rpm 380 0 g-forceNMR data were acquired on 600 MHz NMR spectrometer Avance III from Bruker equipped with TCI CryoProbe at T = 310 K. Initial settings  were carried out on an independent sample and adopted for measurements. After preparation, samples were stored in a Sample Jet automatic machine for not more than 2 h and cooled at approximately 5 °C. Before measurement, each sample was preheated on the 310 K for 5 min. An exponential noise filter was used to introduce 0.3 Hz line broadening before Fourier transform. All data were once zero-filled. Samples were randomly ordered for acquisition. 4 signal under 1.0 Hz. All experiments were conducted with a relaxation delay of 4 s.We modified standard profiling protocols from Bruker as follows: noesy with presaturation (noesygppr1d): FID size 64k, dummy scans 4, number of scans: 64, spectral width 20.4750 ppm; profiling cpmg : number of scans: 256, spectral width 20.4750 ppm. For 15 randomly chosen samples, 2D spectra were measured: cosy with presaturation (cosygpprqf): FID size 4 k, dummy scans 8, number of scans 16, spectral width 16.0125 ppm; homonuclear J-resolved (jresgpprqf): FID size 8 k, dummy scans 16, number of scans 32. Samples were randomly ordered for acquisition. For samples, we kept the half-width of the TSP-dwww.hmda.ca) (accessed on 15 March 2022) [4 signal assigned a chemical shift of 0.000 ppm. The peak multiplicities were confirmed in J-resolved spectra, and homonuclear cross-peaks were confirmed in 2D cosy spectra. Peaks assignments are listed in Spectra were solved using a human metabolomic database (ch 2022) , Chenomich 2022) . The proAll spectra were binned to bins of the size of 0.001 ppm. No further normalization method was applied to the data, as we took exactly the same amount of blood plasma for measurements. Then, intensities of selected bins were summed only for spectra subregions with only one metabolite assigned or minimally affected by other co-metabolites. Metabolites showing weak intensive peaks or strong peak overlap were excluded from the evaluation. The obtained values were used as relative concentrations of particular metabolites in a given sample.p-value of 0.05 was used as a threshold to claim significance. The null hypothesis of equality of population medians among stages and groups with/without rejection was tested by the non-parametrical Kruskal–Wallis test for multiple comparisons with Dun’s post hoc test for pairwise comparison using an online tool [Pearson’s correlation was used to determine the linear relations between relative levels of blood plasma metabolites determined by the NMR method and the clinically determined plasma creatinine level (Cre), eGFR value, and level of proteinuria within the patients’ group. Calculations were carried out in OriginPro 2018b  and Matlab . A ine tool . Both teine tool .Note that, in this work, we use the common labeling of BCAAs for branched-chain amino acids—leucine, isoleucine, and valine—and BCKAs for their 2-oxoderivates, branched-chain keto acids—ketoleucine (2-oxoisocaproate), ketosioleucine (3-methyl-2-oxopentanonate), and ketovaline —as well as mentioning the trivial names of BCKAs that better evoke their origin.p-values 0.02, 0.05 and 0.08) correlated with eGFR, and together with alanine also with the stage related to the kidney function. Only BCKAs plasma levels correlated with the level of proteinuria, which is generally recognized as a marker of the severity of chronic kidney disease and as a predictor of a future decline in glomerular filtration rate. The details are summarized in p-value of 3.4 × 10−15   of selected metabolites could improve the correlations with eGFR and Cre. For the regression model, we used all determined plasma metabolites with and without creatinine as independent variables. The predicted vs. measured eGFR values correlated as follows: with creatinine: For metabolites showing strong relations to allograft function, we compared relative plasma levels for clinical stages . The resp-value under 0.05) are listed in p-values in the range 0.08–0.14; ketoleucine as an example is included in The association between allograft rejection and the levels of plasma metabolites was assessed by the comparison of the relative plasma concentrations among patients without rejection (CG) and with acute cellular rejection (ACR) and acute antibody-mediated rejection (AMR). The metabolites levels found to be significantly different  algorithm. As input variables, relative concentrations of plasma metabolites were used. The parameter expressing the discrimination performance was the area under the curve (AUC), derived from the receiver operator characteristic curve (ROC). When discriminating CG against ACR, we obtained the AUC value of 0.49. Classification for the binary system CG–AMR was performed with AUC 0.80 when creatinine was included , where tp-value 0.05 with Cre and 0.16 with eGFR, One of the unique metabolic functions of the kidney is renal phenylalanine hydroxylation to tyrosine, which accounts for approximately 50% of whole-body phenylalanine hydroxylation . Moller Glutamine is one of the most abundant amino acids in plasma. It belongs to the non-essential amino acids; however, under conditions where de novo synthesis does not fulfill the body’s requirements, it is considered as conditionally essential. Besides being a building block for proteins, it serves as essential fuel for all fast-dividing cells, including immunocompetent cells whose proliferation is crucially dependent on glutamine availability ,16,17. RThe post-transplant patients included in our study with acute cellular rejection and acute antibody-mediated rejections showed glutamine plasma levels almost equal to each other and higher in comparison with patients without features of rejection . The eleTaken together, we assume that the plasma glutamine level in patients after kidney transplantation is not straightforwardly associated with only one process, but it reflects the combination of three fundamental processes: decreased glutamine utilization by the kidney, balancing glutamine production by the liver or muscles, and accelerated glutamine consumption by an increasingly activated immune system.p-values 0.02, 0.05, and 0.08) and negatively with proteinuria . In another statistical evaluation, ketoacids visibly decreased in the order CG > ACR > AMR . It seems that, in parallel with worsening graft function, the organism is lacking BCKAs that can neutralize the excessive nitrogen residues through transamination to BCAAs. This property, as well as the fact that ketoacids allow the preservation of nutritional status in the time of low protein intake, makes BCKAs potential adepts for supplementation in patients with worsening function of the allograft. The positive effect of ketoacid supplementation is already well established in experimental models [Relative plasma concentrations of BCKAs, ketoacids produced by deamination from BCAAs, were positively correlated with eGFR  markers of loss of insulin action . LeucineFor the classification of patients divided into subgroups by allograft rejection features, the Random Forest discriminatory algorithm was employed, and the performance was evaluated by the AUC value. To clarify, if the AUC equals 1, the system can be discriminated with 100% sensitivity and specificity; if the AUC equals 0.5, the data are of no practical utility as the probability of correct classification is 50%. The RF algorithm obtained an AUC of 0.8 for the binary system CG–AMR . The perThe search for features that could help to estimate graft function besides the widely used eGFR or Cre level is challenging. The particular relation of some individual metabolites to allograft function expressed by eGFR or Cre observed in this study is discussed above. In this part, we wanted to verify if better relations could be achieved by combinations of metabolites. For this, we employed probably the easiest and most simply understandable multilinear regression model. The great potential of this evaluation method lies in (i) the very good availability of blood plasma, (ii) the fact that the metabolites included in the model are easily detectable by many analytical methods, and (iii) the simple mathematical model used. We compared two models: the first model with relative levels of all plasma metabolites determined by NMR (including creatinine) and the second model without NMR to determine creatinine level. The Cre value should be considered in this section as a quantitative parameter expressing graft function. We examined if the levels of basal plasma metabolites can predict the loss of graft function expressed in eGFR or Cre, respectively. We gained a very promising correlation between predicted and clinically determined eGFR values and an almost ideal correlation between predicted and clinically determined Cre, when using the model with all metabolites, including NMR-determined creatinine . To suppIn this work, we described the relations between kidney allograft function and the levels of basal plasma metabolites in the group of 55 patients after primary kidney transplantation. We discussed restricted phenylalanine to tyrosine hydroxylation by a weakly working allograft, decreased glutamine utilization by the kidney, balancing glutamine production by the liver or muscles, and accelerated glutamine consumption by an increasingly activated immune system as well as shifted nitrogen balance. It seems that allograft function is not linked with energy metabolism, as no changes were found for glucose, glycolytic intermediates, and 3-hydroxybutyrate as a ketone body representative. We concluded that the observed metabolomic changes in plasma are not related exclusively to the sole metabolomic role of the kidney, but the observed relations between metabolomics plasma levels and the allograft function are the results of the complex mutual biochemical pathways in the comprehensive inter-organ metabolic exchange and communication when the restricted function of one organ induces compensatory effects or secondary injury.p-value = 4.0 × 10−26 and r = 0.94, without creatinine: p-value = 3.2 × 10−22 and r = 0.91), and the extent of metabolomics changes in blood plasma has high potential for the estimation of allograft function.The metabolomics alterations in blood plasma in patients with allograft rejection could be largely explained by the various extents of allograft function in these subgroups and only barely affected by the rejection mechanism. The observed changes were not strong enough to satisfactorily classify patients with ACR and AMR rejection. The best result was obtained in the discrimination of patients without rejection to AMR, which was performed with an AUC of 0.80—after the exclusion of creatinine, the AUC was 0.68. However, we showed that the basal plasmatic metabolites in combination manifested a very high correlation with eGFR (with creatinine:


BackgroundHypotension is commonly encountered in patients undergoing lower-segment cesarean section (LSCS) under the subarachnoid block (SAB) owing to decreased vascular resistance caused by the sympathetic blockade and decreased cardiac output because of blood pooling in blocked areas of the body. Perfusion index (PI) is a good indicator of systemic vascular resistance and can foretell hypotension. This study aimed to associate baseline PI with intraoperative hypotension after SAB in LSCS.MethodologyThis was a prospective observational study with a sample size of 50. The baseline PI was recorded every 10 seconds for one minute in a supine position on the right index finger at room temperature of 26°C to 28°C. The blood pressure (BP) and heart rate (HR) were recorded at an interval of one minute for three minutes. The mean of PI, BP, and HR were taken as the preoperative value. Spinal anesthesia was administered as per institutional protocol. Hypotension, defined as mean arterial pressure (MAP) <20% of baseline or MAP <60 mmHg was treated with vasopressors. Regression analysis with the Spearman correlation coefficient was done to correlate PI and hypotension.ResultsThe incidence of hypotension in parturients with PI <2.85 was 28.6% (5/20) and in parturients with PI >2.85 was 82.8% (p < 0.001). The requirement of sympathomimetics was higher in parturients with PI >2.85.The area under the receiver operating characteristic curve was 0.8883. A cut-off PI value of 2.85 can identify parturients at risk for central neuraxial block-induced hypotension with a sensitivity of 80% and a specificity of 75% (p < 0.001).ConclusionsThe PI is a useful tool for predicting hypotension in healthy parturients undergoing elective cesarean section under SAB. Cesarean delivery is the most commonly performed surgical procedure in the obstetric population. It is performed to improve maternal and fetal outcomes or to reduce anticipated complications from spontaneous labor and vaginal delivery. Ease of administration, faster onset of action, and the ability to provide adequate surgical anesthesia make the subarachnoid block (SAB) the anesthetic technique of choice for elective cesarean delivery . In addiGravid uterus with subsequent aortocaval compression causing lower mean arterial pressure (MAP) further aggravates these effects . The heiSevere hypotension increases the risk of fetal complications such as fetal acidosis and bradycardia. Maternal hypotension of a few minutes duration can cause fetal bradycardia even during vaginal delivery. The duration rather than the degree of hypotension is more important in affecting neonatal outcomes -9. ThereThe usual method to measure blood pressure during cesarean section is non-invasive blood pressure (NIBP) monitoring. However, its usefulness is undermined by its failure to detect hypotensive episodes promptly. Perfusion index (PI) is defined as the ratio of pulsatile blood flow to non-pulsatile blood flow in a patient’s peripheral tissue, such as in a fingertip, toe, or ear lobe. It is measured using a pulse oximeter depending on the differential absorption of infrared light . PI can A definitive monitoring method is lacking to speculate on post-spinal hypotension in parturients planned for cesarean delivery. There is a need for an assessment method that is quick, easy to perform, and interpreted easily along with a great degree of sensitivity and specificity. Although a study on the western population  concludeStudy participants and study designThis prospective observational study was conducted after approval from the Institutional Ethics Committee (KIIT/KIMS/IEC/133/2019) in the Department of Anaesthesiology, Kalinga Institute of Medical Sciences, Odisha, India from September 2019 to September 2021 with the Clinical Trial Registry (CTRI) number CTRI/2019/10/021784.2, cardiovascular or cerebrovascular disease, hypothyroidism, hyperthyroidism, hypertension, with baseline MAP <75 mmHg, and those posted for emergency LSCS were excluded from the study.American Society of Anesthesiologists (ASA) II patients who were planned for elective LSCS were included in the study after obtaining written informed consent. Patients with placenta previa, pre-eclampsia, gestational diabetes mellitus, body mass index (BMI) >40 kg/mAnesthetic techniqueThe fluid deficit was calculated according to the 4-2-1 rule . The deficit was corrected over three hours before surgery. In the preoperative room, the baseline PI was monitored with the help of Philips Monitor Efficia CM12 by an anesthesiologist who did not participate further in the monitoring of the patient intraoperatively. The PI was recorded every 10 seconds for one minute in a supine position on the right index finger at room temperature of 26°C to 28°C. PI represents the ratio of pulsatile light absorption to continuous light absorption, i.e., the ratio AC/DC   and HR were recorded at an interval of one minute for three minutes. The mean of PI, BP, and HR were taken as the preoperative value. The patients were transferred to the operation theater and standard monitors were attached, such as electrocardiogram, NIBP, and pulse oximetry. Spinal anesthesia was administered by an anesthetist ignorant of the baseline PI values using Quicke’s 25-gauge needle with 10 mg of 0.5% hyperbaric bupivacaine at L3-L4 interspace in the sitting position. The sensory block level was maintained between T6 and T7 by adjusting the table position. The parturients were excluded from the study if the T6 sensory block level was not obtained and were managed as per institutional protocol. After 20 minutes of spinal anesthesia, maximum cephalad spread was monitored. The PI, HR, BP, and SpOAssessment of hypotension and other side effects2 were monitored continuously and recorded at a three-minute interval. All patients were infused with warm saline at a rate of 10 mL/kg/hour. If the MAP dropped more than 20% of preoperative reading or when the MAP <60 mmHg (whichever was greater), then it was regarded as hypotension [The PI, HR, systolic blood pressure (SBP), diastolic blood pressure (DBP), MAP, and SpOStatistical analysisThe sample size was calculated considering a correlation coefficient of 0.416 which was obtained from the results by Duggappa et al. . With a A total of 56 patients were included in the study. Because of inadequate levels of the spinal blockade, six parturients were excluded from the study. Among them, four achieved sensory block up to T8 dermatome and two up to T10 dermatome and were managed as per the institutional protocol. Finally, 20 patients fell into the group with a PI value of less than 2.85 and 30 patients into the group with a PI value greater than 2.85 Figure .Baseline characteristicsA total of 50 patients were included in the study. There was no statistically significant difference (p > 0.05) in age, gestational age, hemoglobin, height, and weight in parturients with PI <2.85 and in parturients with PI >2.85 Table .Incidence of hypotensionIn our study, the total number of parturients who had hypotension was 30 and those who did not have hypotension were 20 Figure .Receiver operating characteristic curveThe ROC curve yielded 2.85 as a more appropriate cut-off with 80% sensitivity and 75% specificity. The area under the ROC curve (AUC) was 0.8883 with a positive predictive value of 82.8 and a negative predictive value of 71.4 Figure , Table 2Comparison of hypotensionThe incidence of hypotension in parturients with PI <2.85 was 28.6% (5/20) compared to parturients with PI >2.85 was 82.8% 24/30). This was clinically and statistically highly significant (p < 0.001) (Table 0. This wRequirement of vasopressorsThe requirement of vasopressors in parturients with PI <2.85 was 28.6% (6/21) whereas in parturients with PI >2.85 was 82.8 24/29). This was clinically and statistically highly significant (p < 0.001) (Table /29. ThisThe cardiovascular changes in pregnancy, though physiological, can lead to a decrease in systemic vascular resistance, increased total blood volume, and an increase in cardiac output . The extLow BP resulting from reduced systemic vascular resistance leads to a higher PI owing to enhancement in the pulsatile component caused by vasodilatation . TherefoPI provides a non-invasive continuous measure of peripheral perfusion. Its utility in predicting peripheral perfusion in different settings was demonstrated by Mowafi et al.  for the A value of 3.5 was reported in the studies by Duggappa et al.  and ToyaThe sensitivity and specificity of our study were 80% and 75%, respectively, with a baseline cut-off of >2.85, the sensitivity and specificity in the study by Toyama et al.  were 81%Our study has several limitations. First, the PI values are quite sensitive to any stimulus such as stress, anxiety, or movement that can lead to sympathetic overactivity. Hence, to negate anxiety proper counseling was done and baseline PI values were recorded carefully avoiding any movement. Second, hemodynamic parameters such as cardiac output, systemic vascular resistance, and central venous pressure were not measured as arterial and central lines are not mandatory for uncomplicated elective cesarean delivery. Third, we did not analyze arterial blood gas to exclude hypoxia of the mother and the fetus owing to hypoperfusion.The incidence of hypotension was significantly higher in parturients with a baseline PI of more than 2.85 compared to those with a baseline PI of less than 2.85. Hence, the cut-off PI value of 2.85 helps in identifying parturients at enhanced risk of spinal anesthesia-induced hypotension, thereby reducing its deleterious effects by early intervention. Hence, we recommend utilizing PI, a valid tool, as a non-invasive aid to anticipate hypotension during spinal anesthesia for cesarean delivery in day-to-day practice. Future studies are justified to study the minute-to-minute relationship between PI and changes in blood pressure, thereby providing a better correlation between the two variables.


Blood pressure (BP) is a basic determinant for organ blood flow supply. Insufficient blood supply will cause tissue hypoxia, provoke cellular oxidative stress, and to some extent lead to organ injury. Perioperative BP is labile and dynamic, and intraoperative hypotension is common. It is unclear whether there is a causal relationship between intraoperative hypotension and organ injury. However, hypotension surely compromises perfusion and causes harm to some extent. Because the harm threshold remains unknown, various guidelines for intraoperative BP management have been proposed. With the pending definitions from robust randomized trials, it is reasonable to consider observational analyses suggesting that mean arterial pressures below 65 mmHg sustained for more than 15 minutes are associated with myocardial and renal injury. Advances in machine learning and artificial intelligence may facilitate the management of hemodynamics globally, including fluid administration, rather than BP alone. The previous mounting studies concentrated on associations between BP targets and adverse complications, whereas few studies were concerned about how to treat and multiple factors for decision-making. Hence, in this narrative review, we discussed the way of BP measurement and current knowledge about baseline BP extracting for surgical patients, highlighted the decision-making process for BP management with a view to providing pragmatic guidance for BP treatment in the clinical settings, and evaluated the merits of an automated blood control system in predicting hypotension. Approximately 300 million surgical operations are conducted globally every year , 2, withBP is one of the routinely measured variables in the perioperative period; it is the force that propels blood to the tissues and organs. BP is the interplay between cardiac output or stroke volume and systemic vascular resistance at a given filling pressure, which is affected by various hemodynamic elements  such as Pressure autoregulation is a self-regulation mechanism of an organ to maintain stable perfusion amidst fluctuations in BP or perfusion pressure . When BP−12009m−2, which provides the same cardiac output, was used for both groups. Even though the BP was much lower in the low MAP group, the perfusion of the brain was well guaranteed. In contrast, the BP was maintained within the normal range in the perioperative period by surgical stress or vasopressor infusion, which may mask insufficient organ perfusion due to decreased cardiac output. Therefore, the goal of perioperative BP management is to optimize adequate blood flow supply, not just to concentrate on the BP values.Organ perfusion is regulated by perfusion pressure and organ-specific resistance. Perfusion pressure is determined by the gradient between the upstream pressure and downstream pressure . MAP decAppropriate BP monitoring is a prerequisite for obtaining accurate BP values and providing reliable guidance for perioperative BP management. The two most used methods for BP monitoring are intermittent oscillometric manometry with a noninvasive cuff and continuous intra-arterial invasive catheterization; however, cuffless BP measurement is an emergent popular field due to the clinical need and technology advances , 18. IntContinuous intra-arterial invasive manometry is performed using intraperipheral arterial cannula placement, which allows for continuous, real-time, and accurate BP measurement. Conventionally, it is believed that the accuracy of BP measured invasively is more than that measured with cuffs, and invasive BP measurements are often regarded as the reference method due to cuff pressure shows large limits of agreement compared to invasive BP . Howeverr = 0.429), which suggested that BP before anesthesia induction cannot be regarded as the baseline BP. To obtain an accurate baseline BP, Ard et al. [P < 0.01 for all comparisons), specifically systolic BP (138 ± 23 mmHg), diastolic BP (77 ± 14 mmHg), and MAP (97 ± 14 mmHg), whereas no difference was observed between the first two measurements with 128 ± 17 mmHg and 74 ± 11 mmHg and 124 ± 18 mmHg, 73 ± 11 mmHg, and 92 ± 12 mmHg, respectively. Consequently, they concluded that the BP before anesthesia induction could not be used as the baseline BP, while the BP measured in the preoperative holding area could be used as the baseline BP. Hu et al. had consistent findings with theirs [In addition to accurate BP monitoring, obtaining a reliable and true baseline BP might be critical for BP titration and decision-making. As for the definition of baseline BP, it lacks standard definition and also varies with studies. Several studies –31 on thd et al.  conducteh theirs : the BP h theirs  defined h theirs , 36.Currently, it is hypothesized that the preoperative 24 h ambulatory BP is the best reflection of the daily BP, which can be used as the baseline BP . HoweverPreoperative hypertension increases the risk of perioperative adverse events. The ACC/AHA guidelines recommend postponing any elective surgery for a patient with a preoperative BP above 180/110 mmHg , 4. Howeβ-blockers, and calcium channel blockers. Studies have observed that angiotensin-converting enzyme inhibitors and angiotensin receptor inhibitors often complicate protracted IOH [β-blocker intake, especially those with congestive heart failure or recent myocardial infarction, can continue during the perioperative period [β-blockers may be deleterious in the perioperative period, as their intake is characterized by frequent hypotension and end-organ hypoperfusion. The 2008 PeriOperative ISchemic Evaluation (POISE) trial found that although preoperative initiation of β-blockers reduced the risk of nonfatal myocardial infarction, it increased the risk of cardiovascular adverse events  and mortality in the perioperative period [β-blockers increased the 30-day mortality after surgery in elderly patients with hypertension having elevated systolic BP [β-blockers reduced the need of vasopressor and shortened stay in the postanesthesia care unit, it increased risk for mortality within 48 hours after noncardiac surgery. Over the past 30 years, multiple studies have concerned about the best strategy for the perioperative approach to patients receiving β-blockers. Due to the use of β-blockers are not limited perioperatively, whether withholding or continuing and timing is still a debate and needs further study [Commonly used antihypertensive agents include angiotensin-converting enzyme inhibitors, angiotensin receptor inhibitors, cted IOH  and may cted IOH . Therefocted IOH , 41, 42.e period , 44. Howe period . This fitolic BP . While Ktolic BP  found thPreoperative hypotension also increases the risk of postoperative adverse events. Venkatesan et al.  found thHypotension is common during the operative period. However, the definition of IOH remains controversial. Bijker et al.  identifiIOH may lead to inadequate blood supply and various degrees of organ dysfunction. Several studies , 52–76 fPostoperative BP is a basic component of the perioperative period, and its appropriate management is essential for a smooth postoperative recovery. Postoperative hypotension (POH) management is an important component of postoperative BP management .Considering the controversy in POH, the incidence of POH varies considerably (from 8%–48%) when based on different MAP thresholds of 60–75 mmHg . The secWhether there are causal interactions between POH and IOH is unclear. To ascertain the severity of IOH on the occurrence of POH and outcomes, a study involving 2833 patients who were transferred to the surgical intensive care unit postoperatively was conducted to investigate whether there is an association between hypotension and cardiovascular incidents or death within seven postoperative days; there was a strong association between POH and IOH severity, especially the lowest intraoperative MAP . ContrarTimely detection and prompt intervention is essential in POH correction. In the general ward, unlike the conditions in the operating theatre, monitoring of vital signs is usually intermittent with 30 min to 4–6 h intervals. Therefore, POH is often ignored or undetected during the monitoring; approximately 50% of the patients with POH are not identified, and if they are identified, it implies that the POH has been ongoing for a long time . Given tIn the past decades, BP thresholds from popular studies were used as therapeutic targets for perioperative BP management. A BP management strategy using one-size-fits-all principles does not represent an accurate personalized BP threshold for organ perfusion and oxygen supply. The current ACC/AHA guidelines  recommenWith the rapid advances in medical science and improved disease knowledge, perioperative individualized BP management is attracting clinical attention , 95–97. In 2017, a randomized clinical trial involving 678 elderly patients with hypertension who underwent major gastrointestinal operations were enrolled into three MAP groups  receiving intraoperative goal-directed fluid therapy (stroke volume variation: 8%–13%). Also, four vasopressor agents were used to titrate BPs within the target range. This suggested that a MAP level of 80–95 mmHg markedly lowers the possibility of postoperative AKI . IntriguIndividualized BP control considering baseline BP might meet the demands for individuals, and perioperative BP should be tailored in an individual pattern. Futier et al.  pioneereLately, individualized hemodynamic management requiring optimizing the volume simultaneously during individualized BP management was introduced into clinical practice . TypicalFundamentally, there are frequent serial fluctuations in cardiocirculatory parameters prior to hypotension. Hence, the development of a hypotension prediction index will help prevent hypotension. By analyzing BP waveform characteristics using machine deep learning algorithms, Hatib et al.  pioneereGiven the dynamic nature of BP, perioperative individualized BP management is not to set a fixed threshold, but rather an individualized BP target value that considers the baseline BP, pathophysiology, comorbidities, perioperative agent use, and surgery.In clinical practice, individualized BP targets can be achieved, which will ultimately improve patient outcomes through an easy and rapid process. The “5 Ts”  may provide a reference for rapid individualized BP management , 109.Targeting an appropriate BP is a challenge. Clinically, several factors should be considered when setting an appropriate BP target , 111: , normal (systolic BP 90–139 mmHg and diastolic BP 50–89 mmHg), and high baseline BP (systolic BP ≥ 140 mmHg and diastolic BP ≥ 90 mmHg) categories. The BP target for patients with a low baseline BP undergoing noncardiac surgery should be maintained at a MAP ≥ 60 mmHg based on results of multiple studies –57, 64 aFor postoperative BP, maintaining a systolic BP of 90–160 mmHg is a reasonable target for patients with a normal baseline BP. However, for patients with an abnormal baseline BP, these targets should be adjusted according to the preoperative baseline values .BP can be corrected, and hypotension should be avoided. Given the nature of BP, perioperative BP management is a dynamic process and not a fixed point. From existing evidence, maintaining the MAP of normal patients at ≥65 mmHg perioperatively is widely accepted, MAP value at 65 mmHg can be considered a minimum level for BP management and adjustment and at the same time not solely concentrates on the value but tailors individually suffice for organ blood supply.Both IOH and POH have detrimental effects on patient prognosis, and there is paucity of evidence on the direct relationship between hypotension and adverse outcomes, and an absolute BP target is usually selected as the initial target for perioperative BP management. The baseline BP is helpful for setting an appropriate BP target, and personalized BP targets may change over time owing to abrupt pathophysiological alterations perioperatively. Strict BP management relying on baseline BP and maintaining fluctuations within ±20% or ±10% of the baseline BP is an optimal BP control method. Further research is needed to define individual BP harm thresholds and to develop therapeutic strategies to treat and avoid IOH.The newly emerged hypotension prediction index algorithm and automated BP control system are helpful for individualized hemodynamic management, especially for high-risk patients. It is necessary to validate whether the machine learning algorithm or artificial intelligence-based intervention for BP management is valuable for all patients, especially for high-risk patients.