Focal segmental glomerulosclerosis (FSGS) is a serious condition leading to kidney failure. We aimed to investigate the clinical characteristics of FSGS and its differences compared with minimal change disease (MCD) using cross-sectional data from the Japan Renal Biopsy Registry. In Analysis 1, primary FSGS (n = 996) were stratified by age into three groups: pediatric (< 18 years), adult (18–64 years), and elderly (≥ 65 years), and clinical characteristics were compared. Clinical diagnosis of nephrotic syndrome (NS) was given to 73.5% (97/132) of the pediatric, 41.2% (256/622) of the adult, and 65.7% (159/242) of the elderly group. In Analysis 2, primary FSGS (n = 306) and MCD (n = 1303) whose clinical diagnosis was nephrotic syndrome (NS) and laboratory data were consistent with NS, were enrolled. Logistic regression analysis was conducted to elucidate the variables which can distinguish FSGS from MCD. On multivariable analysis, higher systolic blood pressure, higher serum albumin, lower eGFR, and presence of hematuria associated with FSGS. In Japanese nationwide registry, primary FSGS patients aged 18–64 years showed lower rate of NS than those in other ages. Among primary nephrotic cases, FSGS showed distinct clinical features from MCD. FSGS originally referred to steroid-resistant nephrotic syndrome in pediatric patients with segmental obliteration of glomerular capillaries, with or without hyalinosis on light microscopy2. The entity of FSGS has been expanded and FSGS is currently regarded as a group of kidney diseases sharing common glomerular lesions3. There are two pathophysiological types of FSGS: primary and secondary ones. In primary FSGS, it is postulated that circulating permeability factors cause podocyte injury, inducing NS4. Whereas, secondary cases have underlying etiologies such as hypertension, obesity, viruses, drugs, genetic mutations, or adaptive conditions5, and they do not always manifest NS. Therefore, the clinical presentations of FSGS are diverse. Cases with NS  show a different clinical course compared with minimal change disease (MCD) i.e. poor therapeutic response, worse renal prognosis6, and rapid recurrence of proteinuria after kidney transplantation7. However, it is difficult to clearly distinguish nephrotic FSGS from MCD because of their similar clinical presentations and the sampling limitations of pathological specimens9. To date, few studies have described the clinical features of FSGS, as well as the distinction between nephrotic FSGS and MCD using a large sample size.Focal segmental glomerulosclerosis (FSGS) presents with proteinuria, often accompanied by nephrotic syndrome (NS), and may lead to end-stage renal disease10. Cross-sectional studies using this database have described the clinical features of several kidney diseases in Japan19.The Japan Renal Biopsy Registry (J-RBR) is a nationwide, web-based, registry of renal biopsies established by the Japanese Society of Nephrology in 2007The present study aimed to clarify the clinical characteristics of FSGS patients in Japan by age stratification of them and comparison with MCD patients through an analysis of data from the J-RBR compiled between July 2007 and June 2016.Among 30,949 patients who registered to J-RBR between July 2007 and June 2016, 1,410 cases were extracted for the evaluation of FSGS. Additionally, 3656 patients were also extracted for the evaluation of MCD . Fewer patients who were consistent with NS in laboratory data at biopsy were found in the pediatric group and adult group than in the elderly group .For Analysis 1, 996 primary FSGS cases were divided into three age groups: pediatric group (n = 132), adult group (n = 622), and elderly group (n = 242). The detailed age-stratified distribution of the prevalence and proportion of patients with FSGS and MCD are shown in Supplementary Fig. 2). FSGS patients also had higher serum albumin (1.9 vs. 1.7 g/dL), lower daily urinary protein levels (6.28 vs. 7.00 g/day) and higher prevalence of hematuria (52.9 vs. 29.8%) at biopsy.Of 1410 patients with “focal segmental glomerulosclerosis” and 3656 with “minor glomerular abnormalities” on histological diagnosis (histopathology), 306 with nephrotic FSGS and 1303 with MCD were included in Analysis 2 , and presence of hematuria . In Model 2, higher systolic blood pressure , higher serum albumin , and presence of hematuria .As summarized in Table The present study used the data from a Japanese nationwide kidney biopsy registry. This is a unique study focusing on the clinical manifestations of FSGS with a large sample size. Furthermore, this study is the first one to describe the clinical features of primary FSGS from two different viewpoints: age stratification and comparison between nephrotic FSGS and MCD.20. Therefore, approximately 800 patients per year were inferred to be diagnosed with FSGS by biopsy in our country. The prevalence of FSGS varied among races and countries21. An international survey revealed that FSGS accounted for 19.1% of primary glomerular disease in North America, 14.9% in Europe, 6.9% in Asia, and 15.8% in Latin America22. A part of this epidemiological difference could be explained by the presence of genetic variants in apolipoprotein L1 (APOL1) among people with sub-Saharan ancestry23. Additionally, several studies reported that the incidence of FSGS was increasing, especially in the US26. The present study shows that incidence of FSGS in Japan was lower than that in reports from other regions21 and it had not changed for the past decade.In the J-RBR database, FSGS occupied 3.4–4.5% in total number of kidney biopsy. The Research Group on Progressive Renal Disease from the Ministry of Health, Labor and Welfare of Japan reported that the annual number of native kidney biopsy in Japan was estimated 18,000 to 21,00027. However, distinguishing secondary FSGS is challenging and the incidence of secondary FSGS remains unclear. D’Agati reported that 10–20% of FSGS patients are secondary ones3. In J-RBR, secondary cases constituted 16.2% of the total FSGS patients, and our results showed that the etiologies in these patients were different among the age groups; 10.8%, 17.4% and 16.0% among the pediatric, adult and elderly group, respectively. As the etiology, hypertension and obesity were the most common in total or among the adult and elderly group. Unilateral kidney or renal dysplasia, low birth weight and genetic disorders were leading causes of FSGS among the pediatric group . However, the urinary protein level was the lowest in this group. This discrepancy between clinical diagnosis and laboratory data could be explained by the effect of immunosuppressive treatment. Because of the quite high occupancy of MCD in NS of pediatric age, children with NS typically receive empiric treatment centering glucocorticoids and the indication of kidney biopsy are limited to the cases with refractory clinical course i.e., steroid-resistant or frequent relapse. Therefore, it is possible that most pediatric FSGS patients had already received immunosuppressive treatment by the time of biopsy. However, we cannot distinguish whether the data was obtained before or after initiation of immunosuppressive treatment, in the J-RBR data. The adult group showed the lowest prevalence of NS (41.2%) and the highest prevalence of chronic nephritic syndrome (54.3%). Whereas, the elderly group showed a higher prevalence of NS (65.7%) than the adult group. This suggested the differences in indications for renal biopsy among age groups. In Japan, a nationwide health examination program for all community residents, including urinalysis screening, has been conducted for over 40 years28. This regular screening enables early detection of urine abnormalities and early referral to a nephrologist. The suggested indication for renal biopsy in adult patients in Japan is ≥ 0.5 g/day of proteinuria or any amount of proteinuria with hematuria29. Many patients in the adult group may have undergone biopsy based on these suggested indications. Therefore, it is likely that the non-nephrotic cases with a substantial number of secondary FSGS were included to this age group. In contrast, it was also possible that the threshold of indications for renal biopsy in elderly patients might be higher i.e., clinicians attempted to perform biopsy for NS patients but not for the non-nephrotic patients in this age group. The clinical features of overall FSGS patients including secondary FSGS in the J-RBR and their age-group comparison were shown in Supplementary Table Analysis 1 described the clinical characteristics of primary FSGS in three age groups. We showed that the proportion of NS was different in each age group. Previous studies reported that nephrotic-range proteinuria is more frequently seen in children than in adults in FSGS30 and secondary cases with identifiable etiologies had been excluded. Even though classic articles suggested that hypertension, renal insufficiency and hematuria at the onset of disease are helpful to distinguish FSGS from MCD1, none have ever been statistically evaluated for their clinical significance in FSGS with a large sample size. We found that higher blood pressure, higher serum albumin, and incidence of hematuria at biopsy were associated with nephrotic FSGS in two multivariable models. FSGS was associated with older age and lower eGFR in univariate analysis. However, association between higher age and FSGS was not observed in multivariable Model 2, which suggested that there was confounding between age and eGFR. As described above, pediatric patients could represent biased population with the necessity of single or repeat biopsy for steroid-resistant or frequent relapse NS. We conducted sub-analysis only including the patients aged ≥ 18 years  and obtained similar results as original analysis  were consistent with NS31. Another limitation of this study is the lack of information regarding pathological subgroups of FSGS: variants of the Columbia classification27. Previous studies reported that morphologic variants of FSGS demonstrate distinct features in their clinical presentation and prognosis37. A longitudinal investigation is currently underway based on J-RBR database including the additional information regarding Columbia classification.This study has several limitations. First, the J-RBR system did not collect detailed information regarding the etiology of FSGS. All the information was provided by the local coinvestigators. The J-RBR also lacked the information of the findings in electron microscopy and detailed genetic testing that could help discriminating primary and secondary FSGS. It is possible that primary FSGS may include some secondary cases and, therefore, the percentage of secondary FSGS may be underestimated in our study. Second, the J-RBR did not collect the information about total number of glomeruli. Therefore, it was possible that we included the patients without adequate number of glomeruli to distinguish FSGS from MCD in the present study. Third, this study was based on cross-sectional data. Although eGFR was lower in FSGS than in MCD, it was difficult to determine whether the impaired kidney function indicated chronic kidney disease or acute kidney injury. Fourth, as mentioned above, the J-RBR data do not include information on whether the data were obtained before or after the initiation of immunosuppressive treatment. Modification of the J-RBR system has been conducted to achieve a more accurate description of pathological diagnoses, including etiological informationIn conclusion, nation-wide registry system revealed the characteristics and clinical features of FSGS in Japan. The results show that the incidence of FSGS in Japan is lower than that in other countries. When primary FSGS patients were divided into three age groups, the incidence of NS was lowest in the adult group (18–64 years), suggesting that the indications for renal biopsy might have been stricter among pediatric and elderly patients. When the analysis was focused on primary NS at the time of renal biopsy, FSGS showed distinct clinical features, such as younger age, higher blood pressure, higher serum albumin, lower eGFR, lower daily urinary protein level and presence of hematuria compared with MCD.10. As of June 2016, 143 nephrology centers participated in this registry, which included 30,949 patients. The J-RBR enters patient clinical information at biopsy. The J-RBR diagnosis consists of three components: (i) a clinical diagnosis, (ii) a histological diagnosis by pathogenesis, and (iii) a histological diagnosis by histopathology.This cross-sectional study used the data from the J-RBR. The details of the J-RBR system were described in a previous publicationAmong the patients who registered to J-RBR between July 2007 and June 2016, cases whose histological diagnosis (histopathology) was “focal segmental glomerulosclerosis” were extracted for the evaluation of FSGS. Additionally, patients whose histological diagnosis (histopathology) was “minor glomerular abnormalities” were also extracted for the evaluation of MCD  of “focal segmental glomerulosclerosis” without multiple registration (n = 1409), the patients whose histological diagnosis (pathogenesis) was “primary glomerular disease” were defined as primary FSGS unless they had information of etiologies. The patients with identified information of their etiologies  were defined as secondary FSGS. For example, when hypertension was considered to be a cause of FSGS, the case was classified into secondary FSGS. When hypertension was considered as just a concomitant condition, the case was classified into primary FSGS. FSGS lesions in other diseases  and renal graft were excluded. The details of selection for FSGS patients were described in Supplementary Fig. The annual incidence of FSGS and proportion of primary and secondary FSGS and were described. Then, two main analyses were conducted as follows.The cases with primary FSGS were divided into three age groups: pediatric group < 18 years), adult group (18–64 years), and elderly group (≥ 65 years)  and urinary protein ≥ 3.5 g/day or ≥ 3.5 g/gCr and serum albumin ≤ 3.0 g/dL for adult and elderly patients (age ≥ 18). The body surface area (m2) of pediatric patients was calculated by the DuBois formula: height (cm)0.725 × body weight (kg)0.425 × 0.007184.(i) primary cases, (ii) clinical diagnosis of NS, and (iii) laboratory data consistent with NS, which was defined as urinary protein ≥ 40 mg/h/mFrom the patients with histological diagnosis (histopathology) of “minor glomerular abnormalities”, following patients were included: (i) primary MCD, (ii) clinical diagnosis of NS, and (iii) laboratory data consistent with NS. Patients with multiple registrations, secondary MCD, other diseases with no obvious light microscopic glomerular findings , and renal graft were excluded. The details of selection for MCD patients were described in Supplementary Fig. Clinical parameters were compared between nephrotic FSGS and MCD patients.Clinical data at biopsy such as patient characteristics , comorbidities (concomitant hypertension and diabetes), urinary findings , and blood test findings  were extracted from the J-RBR database.38: eGFR [mL/min/1.73 m2] = 110.2 × reference-sCr/sCr (mg/dL) + 2.93, reference-sCr =  − 1.259 × Height (m)5 + 7.815 × Height (m)4 − 18.57 × Height (m)3 + 21.9 × Height (m)2 − 11.71 × Height (m) + 2.628 , reference sCr =  − 4.536 × Height (m)5 + 27.16 × Height (m)4 − 63.47 × Height (m)3 + 72.43 × Height (m)2 − 40.06 × Height (m) + 8.778  and adults (age ≥ 18)39: eGFR [mL/min/1.73 m2] = 194 × sCr (mg/dL)−1.094 × Age−0.287 , eGFR [mL/min/1.73 m2] = 194 × sCr (mg/dL)−1.094 × Age−0.287 × 0.739 . Additional diagnostic information, including details of etiology were also extracted.eGFR was calculated using equations based on serum creatinine (sCr) level for Japanese children (age < 18)Clinical characteristics were expressed as median/interquartile range and frequency number/percentage. We used the Kruskal–Wallis test to compare continuous variables and the chi-squared test to compare the proportions of categorical variables among the age groups.We used the Mann–Whitney U test to compare continuous variables and the chi-squared test to compare the proportions of categorical variables between nephrotic FSGS and MCD. Logistic regression analysis was used to evaluate the association between each variable and diagnosis of FSGS compared to MCD. Variables with P < 0.05 in univariate analysis and variables with clinical importance  were included in the multivariable model, while we excluded variables with strong correlations (Pearson’s correlation coefficients > 0.40) or clinical relevance.Statistical analyses were conducted using STATA IC version 14.0 . The statistical significance level was set at P < 0.05.Written informed consent was obtained from all participants and/or their legal guardians. All procedures performed in the present study were in accordance with the standards of the ethics committee of the Japanese Society of Nephrology  and the ethics committee of Nagoya University , and with the Helsinki Declaration of 1975 and its later amendments. J-RBR is registered in the UMIN Clinical Trial Registry (UMIN000000618).Supplementary Information.


The uremic toxins indoxyl sulfate (IS) and p-cresyl sulfate (pCS) accumulate in patients with chronic kidney disease (CKD) as a consequence of altered gut microbiota metabolism and a decline in renal excretion. Despite of solid experimental evidence for nephrotoxic effects, the impact of uremic toxins on the progression of CKD has not been investigated in representative patient cohorts. In this analysis, IS and pCS serum concentrations were measured in 604 pediatric participants (mean eGFR of 27 ± 11 ml/min/1.73m2) at enrolment into the prospective Cardiovascular Comorbidity in Children with CKD study. Associations with progression of CKD were analyzed by Kaplan-Meier analyses and Cox proportional hazard models. During a median follow up time of 2.2 years (IQR 4.3–0.8 years), the composite renal survival endpoint, defined as 50% loss of eGFR, or eGFR <10ml/min/1.73m2 or start of renal replacement therapy, was reached by 360 patients (60%). Median survival time was shorter in patients with IS and pCS levels in the highest versus lowest quartile for both IS  and pCS . Multivariable Cox regression disclosed a significant association of IS, but not pCS, with renal survival, which was independent of other risk factors including baseline eGFR, proteinuria and blood pressure. In this exploratory analysis we provide the first data showing a significant association of IS, but not pCS serum concentrations with the progression of CKD in children, independent of other known risk factors. In the absence of comorbidities, which interfere with serum levels of uremic toxins, such as diabetes, obesity and metabolic syndrome, these results highlight the important role of uremic toxins and accentuate the unmet need of effective elimination strategies to lower the uremic toxin burden and abate progression of CKD. Identifying modifiable risk factors for the continuous loss of renal function that characterizes chronic kidney disease (CKD) is a major challenge towards improving treatment for patients with CKD. While hypertension and proteinuria are established risk factors for progression of CKD both in adults and children, even optimal current treatment still cannot prevent many patients progressing to end-stage kidney disease –3.CKD leads to alterations in the gut microbiome (dysbiosis) and accumulation of gut derived uremic toxins in plasma . We havein vitro [in vitro and in vivo for nephrotoxic effects of uremic toxins, associations of IS and pCS serum levels with progression of CKD have only been investigated in a single study of adult CKD patients to date [The accumulation of these toxins in the circulation has deleterious consequences, as their plasma concentrations are associated with cardiovascular events in adult CKD patients and with surrogate markers of cardiovascular disease (CVD) in pediatric patients , 6. In ain vitro . In animin vitro , 9. Whil to date . Here we2 were included in the study. Written informed consent was obtained from all patients and/or parents. The study was approved by the Ethics Board of the University of Heidelberg (S-032/2009) and subsequently by the local review boards of each participating institution . All prIn the 4C study all participating centers were visited annually by trained regional coordinators. Every 6 months an update of the medical history and medication, clinical status and anthropometric data were obtained and blood and urine samples were collected and stored for central laboratory analysis. Office systolic blood pressure (SBP) was documented as an average of three oscillometric measurements using local devices. SBP and body mass index (BMI) were normalized for height and age (SBP SDS and BMI SDS respectively) as previously described. . GlomeruSerum samples were available in 604 patients at the baseline visit. Total serum levels of IS and pCS were measured centrally using reverse-phase separation and fluorescence detection, as described previously .Baseline characteristics are given as mean ± standard deviation (SD), median with interquartile range (IQR) or frequencies , as appropriate. Serum concentrations of IS and pCS measured at the baseline visit were used to analyze an association with renal survival time during follow up. Summary statistics stratified by CKD stage are provided for IS and pCS. As the distribution of IS and pCS was skewed, these variables were log transformed for further analysis. The assumption of normal distributed data was proven  after log transformation. Correlation of IS and pCS (log transformed) with eGFR was quantified by means of Pearson correlation coefficient. In a multivariable linear regression analysis the association of log transformed IS (pCS) with clinically relevant variables at baseline was assessed .p value of the log-rank test and median survival time. By means of a Cox proportional hazards model the association of IS or pCS with renal survival was analyzed providing adjusted hazard ratio (HR) with 95% confidence interval (CI) and p value. Different models were considered to evaluate if adding IS or pCS to the standard model (model 0) improved model fit. Covariates of model 0 were sex, renal diagnoses, residency, and baseline levels of eGFR, age, proteinuria (log transformed), SBP SDS, BMI SDS, serum albumin, hemoglobin and phosphorus. In model 1, IS or pCS was added to the set of basic covariates. By means of a forest plot the effect (HR with 95% CI) of IS (pCS) on renal survival was visualized for different patient characteristics  based on separate Cox models with IS (pCS), the respective patient characteristic and the other remaining covariates included. Model 1 was repeated with categorized IS or pCS . Quality of the models was compared based on the Akaike information criterion (AIC), with lower values indicating a better fit. The AIC value is the expected, relative distance between the fitted model and the unknown true mechanism that generated the observed data.The primary endpoint was renal survival defined as time from baseline to the composite event of either eGFR of <10ml/min or 50% loss in eGFR or start of RRT, whatever occurred first, as described previously , 15; if 5. All analyses with respect to IS were carried out separately for the whole sample  and, as sensitivity analyses, for the sample excluding patients with IS levels above the 95% UPL (consolidated cohort). As this was an exploratory study, p-values were interpreted descriptively and p<0.05 was considered statistically significant. Missing values were not imputed. Data were analyzed using SAS® Software version 9.4 .A subset of patients with very high IS levels was identified by determining the upper 95% prediction limit (UPL) in a regression of eGFR on log-transformed IS  5. All a2 at baseline denoted as total cohort in the following. Patient characteristics are given in 2. CAKUT was the most common (70%) underlying primary renal disease.Between October 2009 and August 2011 a total of 704 children were enrolled in the 4C study. IS and pCS serum levels were measured in 604 patients with available blood samples and an eGFR between 10–60ml/min per 1.73 mSerum IS and pCS concentrations were negatively correlated with eGFR (r = -0.46 for IS and r = -0.43 for pCS respectively). In 45 patients IS levels exceeded the 95% UPL calculated for the total cohort. These patients had a younger age (11.2 ± 3.3 versus 12.2 ± 3.3 years) and a lower hemoglobin (11.1 ± 1.70 versus 11.7 ± 1.64 g/l) compared to the rest of the cohort, but no other significant differences in baseline characteristics including medication with phosphate binders or antibiotics and iron supplementation . AdditioIn a multivariable regression analysis  IS levelDuring a median follow up time of 2.2 years , the composite renal survival endpoint was reached by 360 patients (59.6%). The median renal survival time was 3.5 years . Frequency and allocation of different endpoints as well as drop-out reasons are shown in We found a significant association of serum IS and pCS concentrations with renal survival , led to “unmasking” of the effect of higher IS levels. Furthermore, a higher BMI-SDS was associated with better renal survival in the multivariable model, and the relative contribution of high IS levels to renal survival showed the highest hazard ratio in underweight, possibly malnourished patients. While obesity is regarded as an independent risk factor for progression of CKD in adults and children , 26, ourin vivo [Therapeutic efforts to decelerate progression of CKD by lowering serum IS levels have so far been unsuccessful. A reduction of IS levels by administration of the oral adsorbent AST-120 had no significant effect on renal survival in clinical trials –29. Thisin vivo , 32. Aniin vivo . TherefoThere are several limitations of our analysis. First, the 4C study was not designed specifically to evaluate the effect of microbial derived uremic toxins, but more general effects on progression of CKD. It is known that serum levels of gut-derived uremic toxins, such as IS and pCS, are potentially confounded by various factors such as age, diabetes, obesity and metabolic syndrome, which have a direct impact on the composition and function of the gut microbiome and hence, on microbial metabolism , 35. FurFinally, we acknowledge the risk of attrition bias as a consequence of the high drop-out rate during our study follow up, limiting the power of our statistical analysis. On the other hand, the large number of patients enrolled in this study and the choice of a composite endpoint enables us to show a significant association of IS with progression of CKD for the first time in children.In conclusion, our study shows a significant association of serum IS, but not pCS, with the progression of CKD in children, independent of other known risk factors such as baseline GFR, blood pressure and proteinuria. These results highlight the unmet need of effective elimination strategies to lower the uremic toxin burden, especially in patients with advanced CKD stages, in order to abate the progression of CKD.S1 FigLog-transformed serum levels of indoxyl sulfate (A) and p-cresyl sulfate (B) are correlated with eGFR in 604 children with chronic kidney disease at study entry. Linear regression of log-transformed serum levels of indoxyl sulfate (IS) and p-cresyl sulfate (pCS) showed a significant correlation with eGFR (Pearson correlation coefficient r = -0.46 for IS and r = -0.43 for pCS). 45 patients had IS levels above the 95% upper prediction limit (UPL). While no patients had pCS levels above the 95% UPL, some patients had pCS levels below the 95% lower prediction limit.(PDF)Click here for additional data file.S1 TableData shown as mean ± standard deviation, median (interquartile range) or n (%) as appropriate. p-value indicates group difference between consolidated cohort and those patients with IS levels exceeding the 95% UPL. IS = indoxyl sulfate; UPL = upper prediction limit; CAKUT = congenital anomalies of the kidney and urinary tract; Post-AKI = chronic kidney disease after acute kidney injury; BMI = body mass index; eGFR = estimated glomerular filtration rate; uPCr = Urinary protein creatinine ratio; SDS = standard deviation score; Non-Ca phosphate binders = non calcium containing phosphate binders; Ca phosphate binders = calcium containing phosphate binders. Countries: GER = Germany; CH = Switzerland; AT = Austria; FR = France; IT = Italy; PT = Portugal; PL = Poland; LT = Lithuania; CZ = Czech Republic; SRB = Serbia; UK = United Kingdom.(PDF)Click here for additional data file.S2 TableDiagnostic groups were compared to patients with the diagnosis of CAKUT. Residency was defined as living in Mediterranean or Non-Mediterranean countries. Physical activity was compared to being physically inactive (0 hours). SE = standard error; CAKUT = congenital anomalies of the kidney and urinary tract; Post-AKI = chronic kidney disease after acute kidney injury; BMI = body mass index; eGFR = estimated glomerular filtration rate; Ca-based P binders = calcium-based phosphate binders; uPCr = Urinary protein creatinine ratio; SDS = standard deviation score.(PDF)Click here for additional data file.S3 TableSurvival analysis using the PHREG SAS procedure. If the event occurred between two visits the later of the two visits was taken as occurrence of the event instead of using linear interpolation. Model 0 represents a Cox model with sex, age, diagnosis, region of residence, body mass index SDS, blood pressure SDS, estimated glomerular filtration rate, urinary protein creatinine ratio, hemoglobin, serum phosphorus and albumin as covariates, calculated either for the total cohort (n = 569) or for the consolidated cohort . Model 1a includes serum IS, 1b IS quartiles, 1c serum pCS and 1d serum pCS quartiles as a covariate to model 0. Models 1e and 1 f include serum IS and serum IS quartiles respectively as covariates to model 0 in the consolidated cohort. IS and pCS are used as logarithmic values in all models. For all variables associated with renal survival  please refer to (PDF)Click here for additional data file.S4 TableSurvival analysis for interval-censored data using the ICPHREG SAS procedure. Model 0 represents a Cox model with sex, age, diagnosis, region of residence, body mass index SDS, blood pressure SDS, estimated glomerular filtration rate, urinary protein creatinine ratio, hemoglobin, serum phosphorus and albumin as covariates, calculated either for the total cohort (n = 569) or for the consolidated cohort . Model 1a includes serum IS, 1b IS quartiles, 1c serum pCS and 1d serum pCS quartiles as a covariate to model 0. Models 1e and 1 f include serum IS and serum IS quartiles respectively as covariates to model 0 in the consolidated cohort. IS and pCS are used as logarithmic values in all models. For all variables associated with renal survival  please refer to (PDF)Click here for additional data file.S5 TableCAKUT = congenital anomalies of the kidney and urinary tract.(PDF)Click here for additional data file.


Takayasu's arteritis (TA), also known as “pulseless disease”, is a nonspecific inflammatory arteritis of large and medium caliber arteries of unknown aetiology with a predilection for young women of childbearing age. Although the evolution of the disease is not affected during pregnancy, it can result in uncontrolled hypertension, multiple organ dysfunction, and stenosis that hinder regional blood flow. Associated pregnancy, therefore, poses an increased risk to the mother and foetus due to the many cardiovascular complications that can occur in the course of the disease, making anaesthesia for caesarean delivery especially challenging to the anaesthesiologist. We report the successful anaesthetic management of a case of TA undergoing caesarean section in view of a previous caesarean delivery. We also engage in a brief review of the related literature. Takayasu's arteritis (TA) is a granulomatous pan-endarteritis of unknown aetiology, with a predilection for Asian women in the reproductive age group, culminating in impaired perfusion of the major organ systems ,2. AlthoA 33-year-old pregnant lady, having TA with grade 2 hypertensive retinopathy and hypothyroidism on medications under regular antenatal care and an uneventful pregnancy, was admitted to our hospital for elective caesarean section. Significant physical findings included her left carotid pulse being impalpable, left radial and brachial pulse being feebly palpable, and blood pressure variance in the limbs.A 24-hour ambulatory blood pressure monitoring revealed values slotting our patient into the high normal category according to the European Society of Cardiology criteria . The right arm was selected for non-invasive blood pressure monitoring and the pulse oximetry was used on the left hand. Adequate intravenous access (18 G cannula) was secured, crystalloid co-loading was commenced, and appropriate antibiotic prophylaxis was administered. CSEA was instituted using the loss of resistance (LOR) technique in the sitting position at the L4-5 vertebral interspace. An epidural catheter was placed 4 cms into the epidural space, following which subarachnoid block (SAB) was administered with 25 G Quinkie needle and 2 ml of 0.5% hyperbaric bupivacaine deposited in the subarachnoid space. Additionally, 3 ml of 0.25% bupivacaine was given via the epidural catheter immediately after placing the patient in the supine position, to achieve requisite surgical anaesthesia. Caesarean section was commenced and the surgery was completed in 47 minutes. The intraoperative course, both surgical and anaesthetic, was mostly uneventful except for a single episode of mild hypotension, which was managed with fluid supplementation and a single bolus of vasopressor (mephentermine 6 mg). Her postoperative course was also uneventful and included postoperative pain management by epidural top-ups with 0.0625% bupivacaine.ASA standard monitoring was established on the day of surgery and the baseline parameters were noted [heart rate of 90 bpm, blood pressure of 155/98 mmHg right arm, 132/93 mmHg left arm, 116/81 mmHg right thigh, 111/63 mmHg left thigh, and oxygen saturation  and has a peak incidence during the second and third decades of life . While tPreoperative workup should include an assessment of end-organ damage due to arteritis as well as a comprehensive overview of biochemical and radiological changes. Our patient had evidence of stenotic occlusion of the left brachial artery; otherwise, she had normal renal function tests, no demonstrable aneurysmal lesion, and did not manifest other major systemic symptoms. We resorted to routine non-invasive blood pressure monitoring since complications of arterial cannulation are common in patients with peripheral vasculopathies. The classic indications of instituting perioperative invasive blood pressure monitoring include subjects with unmeasurable non-invasive blood pressure, prolonged surgeries, and persistently uncontrolled blood pressure .General anaesthesia, as well as different combinations of regional anaesthesia, have been variously described for caesarean section in patients with TA with reasonable success. However, both general anaesthesia, as well as the more common forms of central neuraxial blockade , can reduce organ perfusion significantly. Both modalities hence tend to worsen the existing TA-induced ischemia and have also been associated with a higher rate of perioperative morbidity and mortality. On the other end of the haemodynamic spectrum, general anaesthesia in caesarean sections can also trigger a severe hypertensive response due to inadequate anaesthetic depth during rapid sequence intubation (RSI), till baby delivery or awake extubation . AnterioIn contrast, better haemodynamic control and continuous neurological assessment in an awake patient is a desirable feature of regional anaesthesia, which favoured its choice in our case. Epidural anaesthesia, SAB, and CSEA using low doses of local anaesthetic with or without additives have all been successfully reported in cases of TA. The slow onset of a sympathetic block with a lesser probability of sudden haemodynamic perturbations and hence a better regulation of fluid administration is a desirable feature of epidural anaesthesia besides being a reliable means of adequate postoperative analgesia ,15. SAB In TA with severe blood pressure discrepancy between the upper and lower limbs (difference of more than 10 mmHg between upper limbs and 20 mmHg between lower limbs), neuraxial anaesthesia is best avoided as it compromises regional blood flow . Our patMeticulous attention to perioperative fluid and vasopressor administration is paramount in patients with TA because of propensity to cardiac dysfunction and ensuing pulmonary edema ,19. AlonPain can also cause unwanted haemodynamic fluctuations or worsen PAH in the postoperative period, and postoperative epidural top-ups with low-dose bupivacaine kept our patient pain-free. These along with the sequential introduction of her regular antihypertensive medications as per her haemodynamic measurements kept her blood pressure controlled in the immediate postoperative period, which was again very critical for the overall outcome.In TA with pregnancy, the anaesthetic considerations need to be decided on a case-to-case basis after an in-depth analysis to decide on a safer technique. In this index case, CSEA resulted in a safe patient outcome, and we believe it can be explored as a viable option for caesarean sections in TA.


Treating hypertensive patients by integrating the patient-centered approach would influence the practice and outcome of treatment. Our purpose was to determine whether the implementation of a patient-centered approach in health care delivery can improve adhering to guidelines and the quality-of-care.A retrospective study was conducted using secondary data from the electronic medical records of the patients treated in the two primary care outpatient settings at the Family Medicine (FM) and Social Security (SS) clinics. A key feature of the FM clinic is the incorporation of a patient-centered approach in its service delivery. Individual information regarding initial assessment and treatment at the follow-up visits was reviewed for 1 year. Comparison of adherence to treatment guidelines between the two primary care clinics was performed by using chi-square, Fisher’s exact test or a t-test. To explore the difference in blood pressure and BP control between the two clinics, linear and logistic regression analysis respectively were performed with an adjustment for CV risk score in 2016 as a key confounder.p <  0.001) lower than those recorded in the SS clinic. There was a 2.96 times higher chance for BP goals to be achieved in patients in receipt of hypertensive care at the FM clinic (p = 0.004).The evidence included 100 records from each clinic, showed variation between the two primary care sites. The FM clinic had more complete records regarding family history of hypertension, assessment for secondary causes, prescription for lifestyle modification and appropriate adjustment of medication. Higher levels of blood pressure control were recorded in the FM clinic, specifically systolic pressure 2.92 mmHg (p = 0.073) and diastolic pressure 5.38 mmHg (Adopting a patient-centered approach in service delivery could improve the quality of care for hypertension patients in primary care in Thailand. Hypertension is one of the leading causes of mortality worldwide and the number of patients is increasing , 2. UncoTreating hypertensive patients by complying with standard treatment guidelines would create more BP controlled –8, and cMany hypertension treatment guidelines advocate a patient-centered approach to be integrated in all aspects of service care , 14. TheThailand has incorporated the concept of PCM into the Thai hypertension treatment guidelines since 2015. It was recommended briefly in one paragraph that physicians should concern themselves with forming individual treatment plans for the patients . The for, they have access to the same physical resources from the hospital, such as readiness of facilities and tools, capability of further assessment or medical record system. The differences between the two clinics are described in the In order to assess the potential benefits of integrating PCM in delivering healthcare to hypertensive patients, a clinical audit of medical records was carried out in two primary care clinics. The clinics were: 1) the family practice clinic run by the Department of Family Medicine (FM clinic) and 2) the general practice clinic for patients under the social security scheme (SS clinic). Both clinics are part of Maharaj Nakorn Chiang Mai HospitalThe aim of this review was to explore whether adherence to hypertension treatment guidelines differs between these two different service settings, effect on ability to do PCM, and to explore whether the differences are associated with better control of hypertension.This is a retrospective review of electronic medical records of patients who received hypertension treatment in FM clinic and SS clinic in Maharaj Nakorn Chiang Mai Hospital.FM clinic is a teaching and service clinic for medical students and family medicine residents. The service in this clinic is generally provided by Family Medicine residents and staff who are trained in the PCM approach. The number of patients per day is restricted. An appointment can be made to see the same physician for continuity of care.The SS clinic is a clinic to serve patients who use the social security scheme. The service being provided by a rotation of the residents and staff who are trained in a variety of specialisms. Consequently, there are variations in practice between the physicians and continuity of care by the same physician is nearly impossible. Supplementary Table 1, Additional file The sample size calculation was conducted based on the prior statistical evidence in these two clinics. The hypertension control rate of FM clinic and SS clinic were 65 and 45%, respectively. We used the two independent proportion formula. To reach a power of 80% and alpha value of 0.05, the estimated size sample was 96 people per unit of service. We then decided to take 100 samples from each clinic.The first 100 hypertensive patients from each clinic that met the inclusion criteria were included in the review. The inclusion criteria were those who had a record of any visit in October 2016 and had records of further visits in a 1 year follow up period in September 2017. To avoid cross contamination, any records of the patients who had a consultation with a family medicine physician in the SS clinic were excluded. As about 5% of the services in SS clinic provided by family physicians which would impact the interpretation. The first 20 records of the same patients from each clinic were reviewed independently by two researchers (NB and PS). The reviewers compared their assessment and any disagreement was resolved through discussion and consensus. The next 160 records (80 for each reviewer) were randomly assigned and reviewed by either one of the two researchers.Initial assessmentContinuous monitoring and assessment for target organ damage (TOD)Prescription for lifestyle modificationPrescription of medication and dose adjustmentThe Thai guidelines for treatment of Hypertension 2015 follows the 2013 Practice guidelines for the management of arterial hypertension by the European Society of Hypertension and the European Society of Cardiology and The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure . The resFor section 1, detailed accurate initial assessment at diagnosis, evaluation of secondary hypertension, and family history assessment. For section 2, continuous monitoring and assessment for TOD records were assessed to see whether they had such investigations. For lifestyle modifications in section 3, the medical records were assessed for whether there was any documentation of lifestyle modifications. For prescription of medication in section 4, records were assessed whether the physician had adhered to the recommended dosage and class of hypertensive medication as well as whether the physician adjusted the dose of the medication when the target blood pressure was not achieved. The definition and assessment period for each topic can be found in Supplementary Table 2, Additional file The mean BP over the year, excluding the first BP in October 2016 (as the first BP was included in cardiovascular (CV) risk assessment and treated as a confounder), was used as an outcome and also used to classify whether the control of BP was achieved. BP goals were 140/90 mmHg for general patients and 130/80 mmHg for chronic kidney disease patients with proteinuria, diabetes patients aged 50 years or less or with albuminuria.Comparison of adherence to treatment guidelines between the two primary care clinics was performed by using chi-square, Fisher’s exact test or a t-test. To explore the difference in blood pressure and BP control between the two clinics, linear and logistic regression analysis respectively were performed with an adjustment for CV risk score in 2016 as a key confounder. A CV risk calculation was done using a Thai CV Risk Score application which estimates the 10-year risk of developing a major cardiovascular event based on the patients age, gender, smoking behavior, presence of diabetes and their last measurement of blood pressure, total cholesterol, low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) in 2016. The software used for analysis was STATA (version 15.1).p <  0.001) with a higher average percentage of 10-year CV risk .Age, comorbidities, type of antihypertensive drug, and the CV risk between the patients attending the two clinics were statistically significant differences (described in Table p <  0.001) and secondary causes of hypertension than those in the SS clinic . Only about 4% of patients had documentation pertaining to the physical examination for evidence of secondary hypertension in both clinics . Most patients (> 90%) had their glucose, lipid profiles and kidney function monitored in both clinics  and dietary approach  was of statistically significantly higher incidence at the FM clinic.Prescription for lifestyle modification was not commonly recorded. Details are described in Table In case of the appropriateness of choice of type and dosage of anti-hypertensive drug treatment, the majority (over 90% of patients) received appropriate initial treatment Table . There wp <  0.001) than those attending the SS clinic. After adjustment for CV risk score, patients attending the family medicine clinic were almost 3 times more likely to have a controlled average BP .Comparison of BP control between the clinics by adjusting for the calculated CV risk score, indicates there is some weak evidence to suggest that the average BP was lower among patients receiving care at the FM clinic. The average systolic blood pressure was 2.92 mmHg lower among those attending the FM clinic  and the average diastolic blood pressure was 5.38 mmHg lower  and the assessment of 10-year CV risk were similarly low in both clinics. Both of these aspects are useful for raising of awareness in patients –24 and tAppropriate adjustment of the dose and discussing on changing risky behaviors are practiced more frequently in the FM clinic, may be due to the longer consultation time available which allows for PCM and the finding of workable ways forward and common ground . The goaThe evidence concerning the measurement of the integration of PCM in practice using the routine data records is scarce . HoweverThese findings suggest that adopting a more PCM approach in the delivery of primary care services may help improve hypertensive care in Thailand through increased adherence to standard guidelines which would subsequently improve control of BP. Any method to enhance the PCM practice should be useful. This should include concerning more about family context, collaborating with the patient in making a treatment plan and supportive service system.The strength of this study was the use of the same electronic medical record system which standardized many aspects of the data. This reflects real world practice as well as being able to control importation systems and contextual factors associated with hypertensive control. However, there were some limitations. Firstly, data was derived from routine records, which might underestimate the adherence to guidelines if these practices are not documented. The necessitated faster clinical pace in the SS clinic could lead to poorer documentation. There is a need for recognition by all stakeholders that every record is important, especially in the case of continuity of treatment. All information related to disease assessment and treatment should recorded even if it only consists of a short phrase. Due to time pressures in the SS clinic the use of administrators to complete records would ease the workload. Secondly, further adjustments for SES were not possible as it’s not routinely recorded in electronic records database and the interpretation of results could be limited by the decreased sample size. Due to the small sample size and from using one clinic in each arm in a single setting, the results may not be generalizable. Further research using multiple settings would be useful. Moreover, PCM should have already been tailored to each individual socioeconomic conditions. Finally, the study was conducted under the hypothesis that PCM is integrated in the practice and services. The performance pertaining to PCM was not directly measured as our aim was not to assess the perceptions or experiences about PCM practice as conducted in most studies . LimitedThere is room for improvement in adherence to clinical practice guidelines for treatment of hypertension. Task shifting, use of standing orders or technology to support many aspects at the clinic would improve compliance to guidelines. Adopting a patient-centered approach, through concepts of PCM, in delivering healthcare services could also improve the quality of care for hypertensive patients in Thailand.Additional file 1: Table S1. The demographic data of two primary outpatient department clinics, FM clinic and SS clinic, in 1 year. The duration was 260 days.Additional file 2: Table S2. The details of the checklist according to the 2015 Thai Hypertension Guidelines.


Supplemental Digital Content is available in the text. P>0.2). In all participants random allocation to canakinumab did not reduce blood pressure (P>0.2) or incident hypertension during the follow-up period . IL-1β inhibition with canakinumab reduces major adverse cardiovascular event rates. These analyses suggest that the mechanisms underlying this benefit are not related to changes in blood pressure or incident hypertension.While hypertension and inflammation are physiologically inter-related, the effect of therapies that specifically target inflammation on blood pressure is uncertain. The recent CANTOS (Canakinumab Anti-inflammatory Thrombosis Outcomes Study) afforded the opportunity to test whether IL (interleukin)-1β inhibition would reduce blood pressure, prevent incident hypertension, and modify relationships between hypertension and cardiovascular events. CANTOS randomized 10 061 patients with prior myocardial infarction and hsCRP (high sensitivity C-reactive protein) ≥2 mg/L to canakinumab 50 mg, 150 mg, 300 mg, or placebo. A total of 9549 trial participants had blood pressure recordings during follow-up; of these, 80% had a preexisting diagnosis of hypertension. In patients without baseline hypertension, rates of incident hypertension were 23.4, 26.6, and 28.1 per 100-person years for the lowest to highest baseline tertiles of hsCRP (https://clinicaltrials.gov. Unique identifier: NCT01327846.URL:  Preclinical evidence suggests that elevated blood pressure is associated with a proinflammatory state mediated, in part, by cytokines, such as IL-1β, that alter endothelial, immune, and central nervous system responses potentiating the development of hypertension.1 For example, IL-1β is increased in the kidneys of mice with angiotensin II–induced hypertension,7 and activation of IL-1 receptor 1 enhances renal sodium transporter activity resulting in salt retention.8 In mouse models genetic deletion of IL-1 receptor 1,9 pharmacological blockade of IL-1 signaling,10 and administration of an IL-1β neutralizing antibody therapy11 have been demonstrated to reduce blood pressure. Downstream of IL-1, IL-6, and CRP are implicated in the development of hypertension through angiotensin II14 and central nervous system-mediated T-cell activation15 and vascular inflammation.1 Immune cell infiltration and their release of inflammatory cytokines like IL-1β have not only been associated with blood pressure elevation but also with end-organ damage associated with hypertension.16 Despite this evidence, the effect of therapies that specifically target inflammation on blood pressure is largely unknown.Hypertension and inflammation are physiologically inter-related.17 and hospitalization for heart failure18 in patients with a history of myocardial infarction and a persistent proinflammatory response. Furthermore, while lipid levels did not change in CANTOS, the magnitude of cardiovascular benefit associated with canakinumab was related directly to the magnitude of inflammation inhibition achieved as detected by on-treatment reductions in hsCRP and IL-6.20 Per protocol, all CANTOS participants had blood pressure systematically measured before randomization and throughout trial follow-up. CANTOS thus afforded the unique opportunity to test formally whether IL-1β inhibition reduces blood pressure, prevents the development of incident hypertension, or modifies relationships between hypertension and cardiovascular events.In the recent CANTOS (Canakinumab Anti-inflammatory Thrombosis Outcome Study), canakinumab—a fully human monoclonal antibody targeting IL-1β—significantly reduced rates of recurrent cardiovascular eventsThe data from the study is not available to other researchers.21 Between April 28, 2011, and March 3, 2014, CANTOS enrolled 10 061 patients with a history of myocardial infarction and concentrations of hsCRP of 2 mg/L or greater from over 1000 clinical sites in 39 countries. The study excluded patients with a history of chronic or recurrent infections, previous malignancy other than basal cell skin carcinoma, a suspected or known immunocompromised state, or a history of (or high risk for) tuberculosis or HIV-related disease, and those using systemic anti-inflammatory treatments. All participants provided written informed consent to participate in the trial, which was monitored by an independent data and safety monitoring board.CANTOS was a randomized, double-blind placebo-controlled trial that evaluated 3 doses of canakinumab  administered subcutaneously once every 3 months as compared with matching subcutaneous placebo for the prevention of major adverse atherosclerotic events.Clinical history including cardiovascular risk factors and a preexisting diagnosis of hypertension was documented by enrolling physician before randomization. A diagnosis of incident hypertension was made in patients with no prior history of hypertension and a blood pressure of >140/90 during follow-up.Investigators were instructed to record resting, seated blood pressure in triplicate after the subject had been sitting for at least 5 minutes with back supported and both feet placed on the floor before drug administration at baseline and 3, 6, and 12 months using an appropriately sized blood pressure cuff with a validated automated device or a manual sphygmomanometer. Blood pressure for each visit represents the mean of triplicate readings rounded to the nearest integer for systolic and diastolic measurements.19 Samples were assayed for hsCRP and samples from selected sites assayed for IL-6 concentrations in a central laboratory as previously described.20Blood samples were obtained from all trial participants in placebo and canakinumab groups at randomization and at 3 months before repeat canakinumab (or placebo) injection.22 heart failure hospitalization,18 and all-cause mortality. Median follow-up was 3.7 years.The primary end point of CANTOS was a composite of adjudicated recurrent myocardial infarction, stroke, or cardiovascular mortality. The key prespecified secondary cardiovascular end points included these events as well as adjudicated episodes of hospitalization for unstable angina requiring urgent coronary revascularization. Additional major end points adjudicated by the trial end point committee included cardiovascular mortality, cancer mortality,2 tests were used to assess for significant differences between these quartiles for categorical variables, and Wilcoxon rank-sum tests for continuous variables. Cox proportional-hazard models stratified according to time since the index myocardial infarction and trial part were used to evaluate whether increasing levels of hsCRP associated with incident hypertension during trial follow-up in patients with no preexisting diagnosis of hypertension and to estimate relative hazards for major adverse cardiovascular events, myocardial infarction, coronary revascularization, stroke, heart failure hospitalization, and all-cause mortality in treatment groups as compared with those allocated placebo in all study participants. Analyses compared the time to clinical event and adjusted for characteristics known to influence hsCRP, including age, sex, body mass index, LDL (low-density lipoprotein)-cholesterol, and diabetes mellitus.For the current analyses, study participants were divided into 4 quartiles according to systolic blood pressure at study enrolment (baseline). χThe trial is registered.The trial was sponsored by Novartis Pharmaceuticals. The sponsor was responsible for data collection. The corresponding author had full access to all study data and was responsible for the decision to submit for publication.A total of 9549 of the 10 061 patients randomized in CANTOS had blood pressure data available at baseline and at 3 months. At enrolment, a preexisting diagnosis of hypertension was documented in 79.6% of patients with a population median blood pressure of 130/79. Stratified by quartile of baseline systolic blood pressure  the upper quartile was older with higher lipid levels  and higher rates of diabetes mellitus, hypertension, stroke, and antihypertensive therapy . In analyses limited to those with normal blood pressure at trial entry, canakinumab as compared to placebo did not reduce the rate of new hypertension diagnoses . Furthermore, no reduction in blood pressure was identified in patients randomly allocated to canakinumab who achieved a greater than median reduction in inflammation as assessed by on-treatment concentrations of hsCRP and IL-6  following acute coronary syndrome in post hoc analysis of the 182 in the Medical Research Council Interleukin-1 Receptor Antagonist Heart study.25 Yet, as reported here in 9549 CANTOS subjects, none of the 3 doses of canakinumab evaluated compared with placebo altered blood pressure at 3, 6, or 12 months. Potential explanations of these apparent differences include sample size, duration of follow-up, different approaches to IL-1 inhibition and distinct inclusion criteria. CANTOS enrolled patients with stable atherosclerosis and a prior myocardial infarction whereas MRC ILA Heart enrolled patients following an acute coronary syndrome. Perhaps most significantly a prior diagnosis of hypertension and prior myocardial infarction was present in only 30% and 24% of patients in MRC ILA Heart compared to 80% and 100% of patients in CANTOS, respectively. As such, the proportion of patients prescribed antihypertensive medication at baseline was higher in CANTOS.In atherosclerotic mice, genetic deletion of IL-1 receptor 116 and interferon-γ targeting reduces cardiac arrhythmias and fibrosis without significant effects on blood pressure.26 As such, in patients with hypertension, anti-inflammatory therapy may provide benefit without blood pressure reduction. Consistent with previous literature and with clinical practice, absolute rates of adverse events in CANTOS increased with baseline systolic blood pressure in patients randomly allocated to both canakinumab or placebo. As previously reported, the 150 mg dose of canakinumab reduced the risk of the composite primary end point in CANTOS by 15% compared to placebo (3.86 versus 4.50 events per 100 person-years).17 Although not statistically significant, random allocation to canakinumab reduced the composite primary end point by 16% in patients with a baseline systolic blood pressure of 130 to 140 mm Hg (3.80 versus 4.54 events per 100 person-years) and 21% in patients with a baseline systolic blood pressure >140 mm Hg (4.43 versus 5.61 events per 100 person-years).In rats with angiotensin II–induced vascular injury and hypertension, it has been shown that mycophenolate mofetil prevents renal damageAs a post hoc analysis of a randomized controlled trial, these data may be prone to type I error. Yet, despite our very large sample size, our analysis detected no interaction between canakinumab efficacy and blood pressure level nor any effect on measured blood pressure itself. This analysis was also limited by the total number of cardiovascular events after stratification by baseline systolic blood pressure, especially for less frequent outcomes such as stroke. By contrast, strengths of our study include its large sample size and consistency of results across follow-up timepoints and each dose of canakinumab.While inhibition of IL-1β with canakinumab reduces cardiovascular event rates, these analyses suggest that the mechanisms underlying this benefit are not related to changes in blood pressure or incident hypertension.Hypertension and inflammation are physiologically inter-related. Yet, the mechanisms through which inflammation and elevated blood pressure interact, and their causal relationships, remain uncertain. CANTOS afforded the unique opportunity to test whether IL-1β inhibition reduced blood pressure, prevented the development of incident hypertension, or modified relationships between hypertension and cardiovascular events. While inhibition of IL-1β with canakinumab reduced cardiovascular event rates, these analyses suggest that the mechanisms underlying this benefit are not related to changes in blood pressure or incident hypertension.The investigator-driven CANTOS (Canakinumab Anti-inflammatory Thrombosis Outcomes Study) trial was funded by Novartis. A.M.K. Rothman and A. Webb are supported by Clinical Research Career Development Fellowships from the Wellcome Trust .None.


Extended criteria donors (ECD) are widely utilized due to organ shortage, but they may increase the risk of graft dysfunction and poorer outcomes. Hypothermic oxygenated perfusion (HOPE) is a recent organ preservation strategy for marginal kidney and liver grafts, allowing a redirect from anaerobic metabolism to aerobic metabolism under hypothermic conditions and protecting grafts from oxidative species–related damage. These mechanisms may improve graft function and survival.With this study, we will evaluate the benefit of end-ischemic HOPE on ECD grafts for livers and kidneys as compared to static cold storage (SCS). The aim of the study is to demonstrate the ability of HOPE to improve graft function and postoperative outcomes of ECD kidney and liver recipients.This is an open-label, single-center randomized clinical trial with the aim of comparing HOPE with SCS in ECD kidney and liver transplantation. In the study protocol, which has been approved by the ethics committee, 220 patients (110 liver recipients and 110 kidney recipients) will be enrolled. Livers and kidneys assigned to the HOPE group undergo machine perfusion with cold Belzer solution (4-10°C) and continuous oxygenation . In the control group, livers and kidneys undergoing SCS are steeped in Celsior solution and stored on ice. Using the same perfusion machine for both liver and kidney grafts, organs are perfused from the start of the back-table procedure until implantation, without increasing the cold ischemia time. For each group, we will evaluate clinical outcomes, graft function tests, histologic findings, perfusate, and the number of allocated organs. Publication of the results is expected to begin in 2021.Dynamic preservation methods for organs from high-risk donors should improve graft dysfunction after transplantation. To date, we have recruited 108 participants. The study is ongoing, and recruitment of participants will continue until January 2020.The proposed preservation method should improve ECD graft function and consequently the postoperative patient outcomes.ClinicalTrials.gov NCT03837197; https://clinicaltrials.gov/ct2/show/NCT03837197 ; Archived by WebCite® at http://www.webcitation.org/76fSutT3RDERR1-10.2196/13922 Transplantation is the ideal therapeutic treatment for end-stage liver and kidney disease. However, this treatment seems to be the victim of its own success. Although the number of liver transplantation (LT) and kidney transplantation (KT) procedures is increasing, as recently reported by the Italian registry, we face a dramatic decrease in the number of available organs .Compared with standard donors, extended criteria donor (ECD) grafts are more vulnerable to the intracellular harmful effects of ischemia, such as a decrease in the availability of adenosine triphosphate (ATP), increase in reactive oxygen species, and release of lysosome enzymes with consequent alteration of cell structure and function ,3. In adOrgan preservation is crucial when ECD transplant grafts are utilized. To date, static cold storage (SCS) is the most widely used method for organ preservation due to its simplicity and effectiveness in reducing metabolism and the associated oxygen need . HoweverOver the last decade, researchers have focused their attention on investigating alternative strategies for organ preservation. Preclinical and clinical studies have explored normothermic 35-37°C), sub-normothermic (20-25°C), and hypothermic (4-10°C) machine perfusion with (hypothermic oxygenated perfusion [HOPE]) or without (hypothermic machine perfusion) oxygen 5-37°C, s.In this study, we will evaluate the benefit of end-ischemic HOPE on ECD grafts (liver and kidney) as compared with SCS. Organs will be perfused through a recently developed machine perfusion device from the beginning of back-table procedures until implantation, without increasing cold ischemia time (CIT). The aim of the study is to demonstrate the ability of HOPE to improve graft function and post-operative outcomes of ECD kidney and liver recipients.In an open-label, single-center, randomized clinical trial, we will compare HOPE (study group) to SCS (control group) in ECD KT and LT. In the HOPE group, 55 livers and 55 kidneys will be preserved by SCS at 4-10°C from the end of organ retrieval until arrival at the transplant hospital. Afterwards, grafts are preserved with HOPE at 4-10°C for a minimum of 1 hour for livers and 2 hours for kidneys until implantation in the recipient. HOPE starts during back-table graft preparation. During the back-table procedure, organs are flushed with a preservation fluid (Belzer solution). Then, the organ is perfused with HOPE through a closed recirculating system.In the SCS group, 55 livers and 55 kidneys will be preserved by SCS at 4-10°C from the end of the organ retrieval until implantation in the recipient.In this study, 220 patients will be enrolled, with 55 in each of the following groups: LT-HOPE, LT-SCS, KT-HOPE, and KT-SCS.The trial design is outlined in Based on the number of transplants usually performed at the participating center, this clinical study is estimated to be accomplished in 2 years, including 12 months of patient enrollment and 12 months of follow-up. Enrollment at the Bologna Transplant Center started in January 2019 and will end in January 2020 .2, serum bilirubin >3 mg/dL, aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >3 times the upper reference threshold, sodium >165 mmol/L, intensive care unit stay >7 days, steatosis >40%, or CIT >12 hours [Donors are considered eligible for the trial if they meet the United Network for Organ Sharing criteria for ECD. For kidneys, these include donor age ≥60 years or 50-59 years plus 2 or more of the subsequent risk factors: death due to cerebrovascular accident, history of hypertension, donor serum creatinine >1.5 mg/dL, or CIT >20 hours. For livers, these include hemodynamic deterioration, donor age >65 years, donor BMI >30 kg/m12 hours .Exclusion criteria include donor age ≤18 years, split-liver recipients, LT for acute liver failure, pre-emptive renal transplant, and intraoperative surgical complications before the organ implantation. Donors after circulatory death will also be excluded, because Italian law requires 20 minutes of a “no touch period” before the death declaration, causing prolonged warm ischemia and subsequent mandatory perfusion of the organ .All adult (age ≥18 years) patients waitlisted for LT or KT will be enrolled in the study after providing written informed consent.Patients are randomized 1:1 to the HOPE and SCS groups according to the treatment list produced by the randomizer tool. For KT, patients are stratified according to the duration of CIT before HOPE starts (longer or shorter than 12 hours); grafts with CIT >20 hours are excluded from the study. For LT, patients are stratified according to the contemporary presence of ECD liver criteria (more or less than 5 criteria). The study information and informed consent form are distributed to potential recipients. Randomization is performed for patients who sign the consent form after the organ is deemed suitable for transplantation.To favor comparison between paired kidneys, when both kidneys from the same donor are allocated to the same center, grafts are automatically assigned to a study group and the corresponding control group. Furthermore, in cases where there are multiple transplants occurring at the same time, we prioritize LT over KT, to reduce the CIT.Organs are procured using the technique developed by Starzl. Following aortic clamping, abdominal organs are flushed in situ through the aorta and portal vein with cold Celsior solution, retrieved, dipped in a bag filled with preservation fluid, and stored on ice . Pretransplant biopsies are performed according to our retrieval protocol.Retrieved organs are stored on ice during the transfer from donor to the transplant hospital, during the biopsy analysis, until cross-matched results are returned, and until the final decision regarding donor and recipient eligibility.Organ perfusion is conducted with the Vitasmart  machine, expressly designed for ex vivo perfusion of abdominal organs . This maKidney perfusion is performed through the renal artery at a pressure of 25-30 mm Hg. Liver perfusion is performed through the portal vein at a pressure of 5 mm Hg.2), pH, and lactate levels. Two perfusate samples are collected at the beginning and at the end of perfusion to rule out bacterial or fungal contamination.Flow, pressure, and temperature are monitored and stored on a USB memory device during organ perfusion. Gas analysis of the effluent perfusate is accomplished at the start of perfusion (T0) and then every 30 minutes to determine carbon dioxide partial pressure, oxygen partial pressure  with new oxygenated perfusion fluid during the back-table preparation, with the aim of removing waste products and residual microthrombi. After the back-table preparation is completed, the organ is treated with continuous HOPE until transplant. Organ perfusion is continuously monitored. As previously reported ,8, minim2 of 500-600 mm Hg) is used for perfusion.Belzer machine perfusion solution  at 4-10°C, in sterile conditions, and with continuous oxygenation .KT and LT are performed according to the center’s standard techniques. Kidneys are implanted into either the iliac fossa with arterial anastomoses to the external, common, or internal iliac arteries or vein anastomoses to the external or common iliac veins and ureter-bladder anastomoses over a single stent. Livers are transplanted orthotopically preserving the inferior vena cava with a piggyback technique.Postoperative management, including immunosuppression and antimicrobial, antifungal, and antithrombotic prophylaxis, follows the standard local protocol .The rate of EAD and the Liver Graft Assessment Following Transplantation (L-GrAFT) risk score ,17 will EAD is defined by the presence of at least one of the following lab results: bilirubin >10 mg/dL, international normalized ratio >1.6 on postoperative day 7, ALT >2,000 IU/mL within the first 7 postoperative days, or AST >2,000 IU/mL within the first 7 postoperative days . The L-GThe incidence and timing of DGF will be evaluated and correlated with the outcomes of the kidney recipients . DGF is Secondary outcome measures in the LT groups are the incidence of PNF, defined as patient death or the need for early retransplantation within the first 7 postoperative days, excluding acute vascular complications ; postrepSecondary outcomes for kidney recipients are the incidence of PNF, defined as irreversible graft dysfunction with graft loss, which can also be due to rejection or vascular thrombosis; postreperfusion syndrome rate; number of dialyses required in the posttransplant follow-up; LHS; renal function, as measured using creatinine level and estimated glomerular filtration rate, at discharge, 1, 3, and 6 months posttransplant; occurrence of acute rejection events, anastomotic or nonanastomotic ureteral stenosis, or vascular thrombosis within 6 months from the transplant; graft survival, defined as the time from transplant to graft loss or return to dialysis; and patient survival.Tissue and perfusate samples are assessed for oxidative stress and metabolic state using reverse transcription polymerase chain reaction (RT-PCR), enzyme-linked immunosorbent assay (ELISA), Luminex technology multiplex assays, and mass spectroscopy analysis. Tissue and perfusate samples are also assessed for the inflammatory markers CD39, CD73, E-selectin, vascular cell adhesion molecule 1, intercellular adhesion molecule 1, hypoxia-inducible factors to tumor necrosis factor-α, interleukin 6, and interleukin 8 using Luminex technology multiplex assays and/or ELISA and RT-PCR.Specific markers related to renal function and tubular injury, including alpha-1-microglobulin, beta-2-microglobulin, albumin, clusterin, cystatin C, epidermal growth factor, neutrophil gelatinase-associated lipocalin, osteopontin, urinary total protein, trefoil factor 3, hepatocyte growth factor, and macrophage stimulating protein, are measured using Luminex technology multiplex assays and/or ELISA in perfusate and/or ultrafiltrate samples collected before and after ex vivo organ reperfusion.Adenosine, ATP, adenosine diphosphate, adenosine monophosphate, riboflavin, and succinate levels are measured in tissue, perfusate, ultrafiltrate, and reperfusion fluid using high-performance liquid chromatography.Finally, miR-21, a small target molecule involved in renal and liver ischemia-reperfusion injury processes, is measured.Tissue injury is evaluated using histopathological analysis before and after ex vivo organ perfusion. Biopsy samples are taken during organ retrieval to assess graft suitability, after graft reperfusion into the recipient, and at the end of the transplant. Pretransplant biopsies are obtained according to our center practice. All tissue samples are sent to Bologna Transplant Center to reduce interlaboratory bias in preparing the slides.For the livers, parenchymal and vascular damage are evaluated. For the kidneys, glomerular, vascular, tubular, and parenchymal damage are evaluated. Tissue samples are examined by two double-blind pathologists, who grade any damage from moderate to severe.In addition, we perform immunohistochemical assays to investigate endothelial and epithelial cell injury, ischemia- reperfusion damage, the pro-inflammatory and anti- inflammatory environment, growth factors, dedifferentiation, repair, and apoptosis using specific stainings. Electron microscopy is performed to assess the features of oxidative injury, focusing on preservation of epithelial mitochondria, endothelial cells of the glomerular and peritubular capillaries, and liver sinusoids.Tissue and perfusate samples are collected and coded to guarantee privacy and data protection in accordance with EU regulations. Perfusate and tissues samples collected for RT-PCR are snap-frozen and stored at –80°C. Tissue collected for immunohistochemical assays are preserved in glutaraldehyde solution.Postoperative follow-up is carried out according to the local protocol. Hepatic and renal function tests and abdominal ultrasound are performed at each follow-up visit. Follow-up will end at 12 months.Technical assistance by a team of expert technicians is provided during all phases of the machine perfusion procedures.Vascular endothelial damage is avoided by perfusing the liver solely through the portal vein, leaving the hepatic artery untouched, and keeping the perfusion pressure of the renal artery and portal vein at low levels, which we previously demonstrated as being safe in preclinical and clinical studies ,8.Demographic, clinical, and biological data of donors and recipients are collected and prospectively entered in the database. The data registration is anonymous, and a study identification code is assigned to each transplant, in accordance with the Helsinki Declaration.Missing values are handled properly by the researchers to achieve accurate inferences about the data during the analyses of the results.The sample size was calculated using the primary outcomes of EAD and DGF for LT and KT, respectively, and the secondary outcomes of PNF and LHS, as reported in similar studies ,19,20.In particular, the rates of PNF and EAD are expected to decrease for the LT-HOPE group, thereby improving the postoperative course and LHS. We are expecting the following reductions in these parameters: PNF, 5% (HOPE) vs 10% (SCS); EAD, 10% (HOPE) vs 20% (SCS); and postoperative LHS <21 days, 80% (HOPE) vs 50% (SCS).In KT, HOPE should reduce the rate of DGF from 50% to 30%, with a general improvement in the postintervention outcomes.Based on these parameters, the total sample size was estimated at 220 patients, with distribution throughout the 4 groups as already explained .The sample size was calculated to account for a dropout risk of 5-10% for the year.A preliminary analysis will be performed when half of the enrollment is completed.To monitor and optimize the planned surgical and clinical procedures, real-time data analyses are performed before the final data collection. In detail, we are performing two interim analyses on the data from the first 7 posttransplant days. The primary analyses will be performed after the enrollment of 60 patients. The second analyses will be performed after the enrollment of 160 patients.P values <.05 will be considered statistically significant.The continuous variables will be compared using parametric (ANOVA) or non-parametric  tests according to the data distribution, and the categorical variables will be compared using chi-squared tests. Multivariate analysis will be performed using forward stepwise logistic regression analysis. Survival analysis will be conducted using the Kaplan-Meier method. The research protocol, including the forms for data treatment, study information, and participant content forms, were approved by the Emilia-Romagna Region Ethics Committee, which is the ethics committee for the transplant center, and the National Health System Research.Written, informed consent is obtained prior to final enrollment. Randomization is performed as recommended by the ethics committee, and all members of the research team learns the treatment type of each recipient only after their inclusion. Possible protocol changes will be applied after the approval of their amendments by the National Health System Research and then the local ethics committee.Recipients are insured against study-related adverse events with a protocol-specific insurance policy.The principal investigator and all members of our research scientific group have declared no conflict of interest.We will describe the data and transcribe the results with the aim to develop an original article for submission at a scientific review, national conferences, and international conferences.With ECD LT and KT, the use of adequate organ preservation techniques may improve posttransplant outcomes without compromising graft function and survival, thereby increasing the donor organ pool.Dynamic preservation methods for organs from high-risk donors should improve the functional recovery of the graft with a lower expected DGF for KT and EAD for LT.To date, we have recruited 108 participants. The study is ongoing, and recruitment of participants will continue until January 2020.This study suggests that the use of adequate organ preservation techniques may improve the posttransplant outcomes without compromising graft function and survival, thereby increasing the donor organ pool. The concept of dynamic organ preservation was developed by Carrel and Lindbergh in the 1930s ,22. An iAn important aspect of this study is the use of the same perfusion device for liver and kidney grafts, which differs from previous studies ,20,26,27Increasing evidence suggests that HOPE of the graft should start immediately after retrieval. This might reduce the accumulation of waste products, such as succinates, and the perfusion should result in better restoration of mitochondrial function -25.2, pH, and lactate levels. Two perfusate samples are collected at the beginning and at the end of perfusion to rule out bacterial or fungal contamination.Our protocol starts with washing the graft for 30-40 minutes during organ preparation to completely remove the waste elements that were released and accumulated from the start of ischemia. And, the organ perfusion system is equipped with an adsorbing hemofilter to remove cytokines and avoid fat embolism. Following this step, oxygenation and recirculation of the preservation fluid begin. Flow, pressure, and temperature are monitored and stored on a USB memory device during organ perfusion. Gas analysis of the effluent perfusate is conducted at the start of perfusion (T0) and then every 30 minutes to determine carbon dioxide partial pressure, pOAnother important aspect is the simplicity of this organ preservation procedure in terms of organization and management. We do not need a perfusion specialist, and we have had no procedure-related adverse events. In addition, starting from the back-table procedures, CIT is not prolonged.Advantages of this HOPE system include its simplicity and improved LT and KT outcomes.In conclusion, we aim to demonstrate the ability of HOPE to improve graft function and postoperative outcomes of ECD kidney and liver recipients.


Blood pressure in humans presents a circadian variation profile with a morning increase, a small postprandial valley, and a deeper descent during night-time rest. Under certain conditions, the nocturnal decline in blood pressure can be reduced or even reversed (non-dipper), which is related to a significantly worse prognosis than a normal fall pattern (dipper). Despite several advances in recent years, our understanding of blood pressure's temporal structure, its sources and mechanisms is far from complete. In this work, we developed an ordinary differential equation-based mathematical model capable of capturing the circadian rhythm of blood pressure in dipper and non-dipper patients with arterial hypertension. The model was calibrated by means of global optimization, using 24-h data of systolic and diastolic blood pressure, physical activity, heart rate, blood glucose and norepinephrine, obtained from the literature. After fitting the model, the mean of the normalized error for each data point was <0.2%, and confidence intervals indicate that all parameters were identifiable. Sensitivity analysis allowed identifying the most relevant parameters and therefore inferring the most important blood pressure regulatory mechanisms involved in the non-dipper status, namely, increase in sympathetic over parasympathetic nervous tone, lower influence of physical activity on heart rate and greater influence of physical activity and glucose on the systemic vascular resistance. In summary, this model allows explaining the circadian rhythm of blood pressure and deepening the understanding of the underlying mechanisms and interactions integrating the results of previous works. Homeostatic regulatory mechanisms allow keeping physiological variables in the human body within acceptable ranges. These mechanisms operate all the time, generating dynamic variation profiles such as the blood pressure profile. Blood pressure is regulated mainly by the neurohumoral system that includes the renin-angiotensin-aldosterone system, natriuretic peptides of the endothelium, the sympathetic nervous system and the immune system. These regulatory mechanisms allow the human body to respond to changes in factors such as physical activity and diet  based on the mechanisms of physiological control of blood pressure to explain the circadian variation profile of dipper and non-dipper patients with essential hypertension. The development of this model allowed explaining dipper and non-dipper patterns integrating the results of previous works that attempted to explain differences between these subjects, evaluating different physiological variables.The mathematical model was based on the expected physiological response resulting from the interaction between the different variables involved in the medium-term blood pressure regulation. Several mechanisms are known to be involved in the control of blood pressure. However, to simplify the model and ensure identifiability, fundamental inputs that have more significant influence or represent the behavior of a set of variables that affect the circadian variation in blood pressure were used in this work. The chosen input variables included in the model are norepinephrine (NE), physical activity (A), and glycemia (glc), and the dependent variables are systemic vascular resistance (SVR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR).Physical activity was chosen since previous works have established that it is one of the determinants of the variation in blood pressure and the variability of heart rate  of the SVR due to the activity. Analogously, the larger the value of ki4, the smaller the regulation (activation) of the HR due to the activity.The equations were formulated based on the dynamics of the interactions described in the scheme of n is a constant that represents the impact of glucose on vasodilatation and k1 represents the basal rate of vasoconstriction (without the influence of the activity and the glucose). Finally, the expression ki2 value is related to the self-regulatory capacity of SVR.Several mechanisms regulate vascular resistance. Some regulatory molecules are capable of generating a short-term response; for example, the action of catecholamines, like norepinephrine, on alpha-adrenergic receptors causes vasoconstriction  and (4) describe the change of blood pressure over time, which depends directly on SVR because, for a given blood flow, an increase of vascular resistance generates an increase in the pressure on the blood vessels' walls (SBP and DBP). In addition, the influence of BP over HR is captured by the expression Guyenet, . This reThus, the following system of four differential equations and seven parameters was obtained:Some variables, as changes in fluid volume, were not considered due to unavailability of data; however, these variables were enough to capture the general pattern of the circadian rhythm of blood pressure.Experimental data on physical activity, heart rate, and blood pressure (systolic and diastolic) for dipper and non-dipper subjects measured every 30 min over 24-h were extracted using the Engauge Digitizer software from the work of Hermida et al. . The datThe norepinephrine data for dipper patients was extracted from the work of Linsell et al.  and van The glycemia data for dipper patients was extracted from the work of van Dijk and for non-dipper patients, these values were increased by 4.7, 13.3, and 8.1% 2 h after each of the three meals: breakfast, lunch, and dinner, respectively, according to what was reported by Pistrosch et al. .The systemic vascular resistance (SVR) data to fit the model was obtained using the following equation  for subjects with essential hypertension of 79.5 ml  , are calculated using the experimental values , yiexpNC(tn), and the values predicted by the model, yimodel(tn), at each time, tn.The analysis of residuals was carried out using Equation (7), where the residuals, qqplot and hist functions. Furthermore, to corroborate these results, the Shapiro Wilks test of normality was used using MATLAB's swtest function with an alpha value of 0.05.To evaluate the residuals, a QQ plot and a histogram were plotted using MATLAB's yi with respect to each parameter pj evaluated for the best parameter set was computed using the SENS_SYS third-party MATLAB function . In this work, the local sensitivity of each variable Then, normalization was performed using the following equation:Srelij(tn) was calculated for each parameter (j), variable (i), and time point (tn) obtaining relative sensitivity trajectories for each parameter and each variable . The analysis of these results is complex, due to the large number of sensitivity values (for each time and variable). Therefore, a sensitivity index for each parameter was calculated using the following equation  and the covariance matrix Q(tn)  was obtained from the local sensitivity matrix ) Ljung, :Q(tn) is a 4-by-4 diagonal matrix calculated using the standard deviation of the data for SBP, DBP, HR, and the estimated standard deviation for SVR at each time point and S(tn) is a 7-by-4 matrix obtained from the local sensitivity values of each of the four variables with respect to each of the seven parameters at each time point (Equation 8).where According to the Cramér–Rao theorem, the inverse of the FIM represents an approximation of the covariance matrix of the error of the objective estimator of minimum variance Ljung, . In thisp ± 1.96 σjj  can be calculated using the following equation  compensated by an appropriate change in the other parameter value. This prevents the parameters from being uniquely identifiable even if the model output is very sensitive to changes in the individual parameters. A singular FIM indicates the presence of unidentifiable parameters, and correlations between parameters that are >0.95 may lead to singular FIM.3 and k4 were fixed to one due to its high correlation with ki3 and k2, respectively; they were kept in the model to ensure dimensional homogeneity. The table shows the common parameters between dipper and non-dipper subjects  and the parameters with different values for each type of subject .After several iterations in the search for equations representing the data, it was possible to adjust the same model to both dipper and non-dipper subjects. The experimental data and the model predictions for the dipper and non-dipper subjects can be seen in 1, n, ki1 and ki2 are part of Equation (1), of which only ki1 presents a different value between both types of subjects, suggesting a difference in the SVR response to physical activity in non-dipper subjects. On the other hand, in Equation (2), a greater value for parameter ki3 was obtained for dipper subjects. This can be due to the range of HR values that is slightly smaller in non-dipper subjects . In Equation (3), parameters ki4, k2 have higher values for dipper subjects, which can be explained by a higher activation baseline that requires a smaller increase in each time interval and a greater influence of physical activity on HR. The 95% confidence interval values indicate that all parameters are statistically significant. The value of the objective function was 0.0015; namely, the mean of the normalized error for each data point is 0.15%.The parameters kp-value = 0.762).The QQ plot and histogram of the residuals  show a di1 have higher sensitivity for non-dipper subjects than for dipper subjects, parameters k1, ki2, ki3, and k2 have similar sensitivity for dipper and non-dipper subjects, and parameter ki4 has higher sensitivity for dipper subjects than for non-dipper subjects. Parameters ki1 and ki4 have different sensitivity and they are related to physical activity, which indicates a different response to physical activity for non-dipper subjects. Additionally, the higher sensitivity of parameter n can be due to higher glycemia (glc) values for non-dipper subjects.The results obtained for the sensitivity analysis are summarized in 1 and ki2, but only dippers subjects had a correlation value >0.95. The correlation between the rest of the parameters was <0.95. Therefore, the confidence intervals of the estimated parameters indicate that the model is capable of representing the data of dipper and non-dipper subjects with essential hypertension.The results obtained for the identifiability analysis are summarized in i1, ki3, ki4, and k2, and different sensitivities for the parameters n, ki1, and ki4. In the case of parameters k1 and ki2, they present equal sensitivity and the same values for both dipper and non-dipper subjects. But, parameter n has equal value and greater sensitivity in non-dipper patients. This is related to the higher glycemic values and the narrower range of norepinephrine values of non-dipper subjects  indicates a greater influence of physical activity and glucose on SVR; namely, as the glucose and physical activity increase, the SVR decreases more in non-dipper than in dipper subjects.In this work, a model capable of capturing the blood pressure profile of dipper and non-dipper subjects is proposed. The results obtained show different values between the two groups for the parameters ki1 of non-dipper patients  is not entirely surprising and indicates that, in non-dipper patients, there is an imbalance in the autonomic nervous system, i.e., an increase in the sympathetic over the parasympathetic tone in non-dipper subjects. This coincides with what was reported by Hojo et al. and Nakano et al., which suggested a decrease in the sympathovagal balance, with an acceleration of sympathetic function and a deceleration of parasympathetic function in non-dipper subjects with essential arterial hypertension  with high levels of sympathetic activity has been related to post-execution hypotension in patients with hypertension  and (4), has equal sensitivity in both types of subjects but a greater value in the case of dipper subjects. This could indicate a greater influence of SVR than HR on the regulation of BP in non-dipper subjects. In addition, the value of k2 is lower in non-dipper subjects, which coincides with a greater sympathetic basal stimulation of heart, leading to higher HR values in non-dippers. Besides, the lower sensitivity of the ki4 parameter in non-dipper subjects indicates a lower influence of physical activity on heart rate in non-dippers. This coincides with the findings of Robinson et al.  average data of different subjects were used, (ii) data from different works with sample sizes and different populations were used, (iii) many variables were not considered to avoid identifiability issues, and (iv) the parameters obtained do not necessarily imply causal associations and may reflect the interaction of the variables used with other unmeasured physiological variables. Despite these limitations, the adjusted model allowed predicting blood pressure with a mean of the normalized error of 0.15% for each data point. Finally, the development of this model allowed integrating the findings of several investigations that attempted to explain the different profiles of blood pressure from changes in individual physiological variables and the residual analysis using the non-calculated variables showed a normal distribution, which further supports the model assumptions.Data generated during this study are available from the corresponding author upon reasonable request.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.