Although aortic calcification has a significant negative impact on prognosis in patients on hemodialysis (HD), risk factors for aortic calcification progression remain unclear. The aim of this study was to investigate the relationship between malnutrition and aortic calcification progression in patients on HD.Between April 2015 and October 2016, we treated 232 patients on HD. Of those, we retrospectively evaluated data from 184 patients who had had regular blood tests and computed tomography (CT) scans. The abdominal aortic calcification index (ACI) was quantitatively measured by abdominal CT. Nutritional status was evaluated using the Geriatric Nutritional Risk Index (GNRI). A normalized treatment ratio of functional urea clearance was evaluated by Kt/V. The difference in ACI values between 2015 and 2016 was evaluated as a ΔACI, and patients were stratified into two groups according to ΔACI value: high  and low . Variables such as age, sex, comorbidities, dialysis vintage, serum data, and GNRI were compared between ΔACI-high and ΔACI-low patients. Factors independently associated with a higher ΔACI progression (ΔACI ≥75th percentile) were determined using multivariate logistic analysis.Median values of ACIs in 2015 and 2016 were 40.8 and 44.6%, respectively. Of 184 patients, 125 (68%) patients experienced ACI progression for 1 year. The median ΔACI and 75th percentile of ΔACI were 2.5% and 5.8%, respectively. The number of patients in the ΔACI-low and ΔACI-high groups were 128 (70%) and 56 (30%), respectively. There were significant differences in sex, presence of diabetic nephropathy, HD vintage, serum albumin, serum phosphate, C-reactive protein, intact parathyroid hormone, Kt/V, and GNRI. Multivariate logistic regression analysis revealed that independent factors associated with a higher ΔACI progression were male sex, serum phosphate levels, HD vintage, and GNRI of < 90.Our results suggest that poor nutritional status is an independent risk factor for the progression of aortic calcification. Nutrition management may have the potential to improve progression of aortic calcification in patients on HD.UMIN000028050.UMIN Clinical Trials Registry  Arterial calcification is a typical phenomenon of patients with chronic kidney disease (CKD) and those undergoing hemodialysis (HD) , 2. ArteMalnutrition is highly prevalent among patients on maintenance HD. Malnutrition is significantly associated with arterial sclerosis, cardiovascular disease (CVD), and total mortality of HD patients . There ehttp://www.med.hirosaki-u.ac.jp/~uro/html/IRB/IRBdoc.html.This was a retrospective, single center, observational study. The study was conducted in accordance with the ethical standards of the Declaration of Helsinki and was approved by the Ethics Committee of Hirosaki University Graduate School of Medicine (authorization number 2016–225). The participants in this study provided their verbal informed consent, and it was recorded in medical chart. Pursuant to the provisions of the ethics committee and ethics guidelines in Japan, written consent was not required in exchange for public disclosure of study information in the case of retrospective and/or observational study using materials such as existing documentation. The ethics committees in Hirosaki University School of Medicine approved this consent procedure. The study information was open for public referral at Between April 2015 and October 2016, we treated 232 patients who had undergone 3–4 h of maintenance HD or online hemodiafiltration using a dialysate containing 3.0 mEq/L calcium three times a week at the Oyokyo Kidney Research Institute in Aomori, Japan. Almost all patients had undergone annual abdominal computed tomography (CT) scans to detect incidental renal tumor and other malignancies. Of these, we excluded patients with severe aortic calcification, including calcification extending along the entire length and almost all of the circumference of the abdominal aorta, or who had an inadequate interval (≤10 months) of abdominal CT scans. Finally, we selected 184 patients who had undergone adequate abdominal CT scans  was defined as a cause of CKD. Current smoking was defined as smoking at least one cigarette during the study period. Previous history of CVD was defined as having any previous description of ischemic heart disease, cerebrovascular accident, or peripheral arterial disease recorded in the patients’ medical records. Every two months, patients underwent a routine laboratory exam before each HD session. We obtained laboratory data for serum phosphate, serum albumin, serum calcium, C-reactive protein (CRP), and i-PTH between April 2015 and October 2016. We used the mean blood pressure of six dialysis sessions on the day of blood and serum test as a representative value of blood pressure. Hypertension (HTN) was defined as having a systolic blood pressure of ≥140 and/or a diastolic blood pressure of ≥90 mmHg. Serum calcium level was corrected using the following formula: corrected calcium = total calcium + 0.8 × , if serum albumin level was < 4.0 g/dL. The normalized dialysis dose (Kt/V) was calculated using the following equation: Kt/V = −Ln (Ct/Co − 0.008 × t) + (4–3.5 × Ct/Co) × ΔBW/BW. Ct divided by Co represents the ratio of post-dialysis to pre-dialysis serum urea nitrogen, t represents dialysis time, and W (kg) represents post-dialysis body weight.We used CT scans  to evaluate abdominal aortic calcification in all subjects. Images were obtained with a 5-mm slice thickness. Abdominal aortic calcification was semi-quantitatively measured from CT images of the area above the common iliac artery bifurcation by conducting 10 scans at 5-mm intervals, as described elsewhere . Measure2) of 22. We used mean GNRI between April 2015 and October 2016 as a representative value.The GNRI is calculated by the following formula: GNRI = 14.89 × serum albumin (g/dL) + 41.7 × . Ideal body weight was calculated from height and using a body mass index  were determined using multivariate logistic regression analysis.t-test , and Mann–Whitney U-test . Multivariate logistic regression analysis was conducted to evaluate an independent predictor for higher ΔACI progression (ΔACI ≥75th percentile). Based on previous studies, well-known aortic calcification progression factors such as HD vintage, HTN, i-PTH, serum phosphate, corrected calcium level, DMN, sex, age, and current smoking were included in multivariable models. Odds ratios (ORs) with 95% confidence intervals (CIs) associated with each factor were calculated after adjusting for potentially confounding factors. Probability (P) values < 0.05 were considered statistically significant.Statistical analyses were conducted using SPSS version 22.0 . Categorical variables (such as sex) are presented as percentages. Continuous variables with a normal distribution and are expressed as the mean ; those with a non-normal distribution are expressed as the median . Wilcoxon signed-rank test was performed to compare ACI-2015 and ACI-2016 values. Sex , HTN , DMN , current smoking , and GNRI < 90  were included as binary variables in the model. Comparisons between ΔACI-high and ΔACI-low groups were performed using Fisher’s exact test or Chi-square test, Student’s P < 0.001)  undergoing HD  Fig. . Median P = 0.005, Fig. P = 0.031, Fig. P = 0.015, Fig. P < 0.001, Fig. P = 0.004, Fig. P < 0.001, Fig. P = 0.002, Fig. P < 0.001)  syndrome and/or fetuin-A. CKD-related inflammation causes malnutrition and progressive atherosclerosis, which is known as MIA syndrome . Fetuin-Several studies have reported that patients on maintenance HD experience more rapid progression of vascular calcification than do healthy individuals . Our resSeveral limitations of this study should be described. First, this study was conducted retrospectively at a single center. In addition, its small sample size and selection biases prevent us from obtaining definitive conclusions. Second, our semi-quantitative measurement of aortic calcification did not enable us to evaluate its change in thickness. Third, we could not address the impact of medications such as phosphate binders, cinacalcet, and antihypertensive drugs, nor of dietary habits and normalized protein catabolic rates, which represent protein intake. Finally, because the GNRI requires only serum albumin, body weight, and height, it does not reflect total body composition, which consists of muscle mass, fat, and total body water. Despite these limitations, using a simple and accurate nutritional assessment tool, we were able to demonstrate an independent association between malnutrition and progression of aortic calcification in patients on maintenance HD. In our next study, we plan to address the relationship between malnutrition, fetuin-A, and aortic calcification.A potential role between malnutrition and aortic calcification may exist in patients on maintenance HD. Our findings may encourage clinicians to pay greater attention to nutrition management to prevent the progression of arterial calcification.


P < 0.001), with an AUC of 0.721 (95% CI: 0.628–0.817). In patients with tumors larger than 2 cm (n = 40) and those with clear-cell histology (n = 44), the AUCs for ESM-1 were 0.771 and 0.721, respectively. In control subjects, serum ESM-1 levels were higher in older (>50 years) individuals (P < 0.001). Among the study cohort, the AUCs for ESM-1 were 0.813 in individuals 50 years of age or younger (n = 55) and 0.637 in individuals older than 50 years (n = 57). In RCC patients, serum ESM-1 levels were reduced 1 month (P = 0.047) and 3 months (P = 0.009) after surgery. These results suggest serum ESM-1 can serve as a serologic biomarker for diagnosing and monitoring RCC, particularly in patients younger than 50 years.To determine the suitability of serum endocan (ESM-1) levels for diagnosing and monitoring renal cell carcinoma (RCC), we measure serum ESM-1 levels in 56 RCC patients who had undergone radical or partial nephrectomies and 56 age- and sex-matched healthy kidney donors. Measurements were made before and 1 month and 3 months after surgery. The areas under the curve (AUCs) were determined from receiver operating characteristic (ROC) analyses. RCC patients had higher mean serum ESM-1 levels than control subjects (0.59 ± 0.07 vs. 0.52 ± 0.08 ng/mL,  Renal cell carcinoma (RCC) is the most common malignant tumor in the kidney . Althouget al. [Endocan, or endothelial cell-specific molecule-1 (ESM-1), is a soluble 50-kDa dermatan sulfate proteoglycan expressed by the vascular endothelium . ESM-1 iet al.  suggesteP = 0.027). In the control group, the mean serum ESM-1 level did not vary according to sex  but was higher in older (>50 years) participants than in participants who were younger (≤50 years) . In the RCC group, the mean serum ESM-1 levels were not different between patients with clear-cell RCC and non–clear-cell RCC. In patients with clear-cell RCC, the serum ESM-1 levels were significantly higher in patients with large tumors and higher stages. However, no statistically significant differences were seen among patients in the entire RCC group (Table Patient characteristics are summarized in Table P < 0.001)  and with clear-cell histology (n = 44), AUCs for ESM-1 levels were 0.771 and 0.721, respectively. Because of the older age of patients in the RCC group and the higher levels of serum ESM-1 in older participants, we performed a multivariate linear regression analysis. After controlling for effects of age and gender, we found that RCC significantly affects the serum level of ESM-1 (P < 0.001) .Patients with RCC had higher serum ESM-1 levels than control group participants  Figure . The are) Figure . With a 1) Table .When we In this study, we found that serum ESM-1 levels were higher in patients with RCC than in healthy individuals. Although serum ESM-1 levels were influenced by age, they were also promoted by the presence of RCC. Thus, serum ESM-1 can potentially be used as a diagnostic marker for RCC.et al. [Increased levels of ESM-1 have been found in the sera of patients with colorectal cancer, hepatocellular carcinoma, and acute leukemia –15. Moreet al.  demonstret al. . Howeveret al. . MoreoveIn the results of the subgroup analysis, we found that the diagnostic performance of serum ESM-1 for RCC improved in patients with tumor size larger than 2 cm. It is attributable to the reflection of the tumor burden by serum ESM-1, which is in line with the previous study . With tht-tests. The decreased levels were maintained for up to 3 months postoperatively. We believe these findings suggests that serum ESM-1 can be a surveillance marker for RCC.The measurement of serum ESM-1 levels after the surgical removal of RCC was not performed in previous studies. We found that the levels decreased postoperatively, although they remained higher than in the control group. We could not exclude an effect from the surgery itself, because postoperative serum ESM-1 levels were not obtained from the healthy control subjects. Nevertheless, the differences were statistically significant in paired Although elevated serum levels of ESM-1 in RCC have been reported, this study included the largest number of patients with RCC and healthy control subjects. Our results indicated that ESM-1 can be used as both a diagnostic and a surveillance biomarker. In addition, we found that ESM-1 showed improved diagnostic performance in a young cohort. These novel findings represent strengths of our study.Some limitations of this study must be considered: First, this study did not include patients with benign renal masses. Currently, we only have a small number of patients with benign renal masses in our database, and a larger cohort is needed to investigate the efficacy of serum ESM-1 levels in differentiating RCC from benign renal masses. Second, serum ESM-1 levels are also elevated in other types of cancers and thus are not specific for RCC. However, unlike hepatocellular carcinoma and colorectal cancer, RCC has no serologic biomarker for diagnosis. Third, the prognostic ability of ESM-1 in RCC was not assessed in this study, because only two cases of recurrence were seen during the median 27 months of follow-up. Therefore, a longer follow-up involving patients with more advanced stages of RCC is required to evaluate the use of serum ESM-1 levels for prognosis.The results of our study show that serum ESM-1 levels can serve as a diagnostic biomarker for RCC, particularly in patients younger than 50 years. Moreover, the assessment of serum ESM-1 levels can be utilized for monitoring patients with RCC after surgery. Although a validation in a larger cohort is necessary, we conclude that serum ESM-1 can potentially be clinically applied for diagnosing and monitoring RCC.From October 2013 to March 2015, we prospectively enrolled patients undergoing nephrectomies in the urology department at Severance Hospital. In total, 56 patients with pathologically confirmed RCC underwent partial or radical nephrectomies. For the control group, we included 56 age-matched and sex-matched individuals from a cohort of healthy kidney donors who had undergone donor nephrectomies during the same period. This study was approved by the Institutional Review Board of Severance Hospital (IRB no. 4-2013-0166), and informed consent was obtained from all participants before study enrollment.g within 30 minutes of collection, and the sera were divided into aliquots and stored at −80°C for subsequent measurements of ESM-1 levels.Blood sampling was performed the day before surgery for all participants and at 1 month and 3 months after surgery for patients in the RCC group. Blood samples were centrifuged for 15 minutes at 1,000 × 2SO4. The absorbance was determined at 450 nm on a spectrophotometer. All assays were performed in duplicate.In all serum samples, the level of ESM-1 was quantified by use of a commercially available ELISA kit . Serum was diluted twofold before analysis. Experiments were performed according to manufacturer’s instructions. Microwell plates were coated with 100 μL of capture antibody (2 μg/mL) and incubated overnight at 4°C. The coated plates were blocked with 5% skim milk in tris buffered saline (TBS) for 1 hour at 37°C. After a washing step with phosphate buffered saline (PBS), the plates were incubated with 100 μL of serum specimen for 1 hour, and then washed and incubated with 100 μL of secondary antibody  for 1 hour at room temperature. After the washing, 100 μL of streptavidin-horseradish peroxidase  was added and incubated for 30 minutes. After a final washing, 50 μL of tetramethylbenzidine substrate was added and the reaction was stopped with 1 N HESM-1 levels in the control group were compared according to the sex and age (≤50 years vs. >50 years) of the participants. Serum ESM-1 levels were then compared between control subjects and RCC patients, as well as according to tumor size, pathologic stage, Fuhrman grade, and histology in RCC patients. ROC curves were generated and the AUCs were calculated. The optimal cutoff value, which maximizes sensitivity and specificity, was obtained by use of the Youden index. In addition, we performed subgroup analyses of RCC patients with tumor sizes larger than 2 cm or with clear-cell histology.Although RCC and control groups were matched by age and sex, patients in the RCC group were older than those in the control group. Because of the higher levels of serum ESM-1 in older participants than in their counterparts in the control group, we performed multivariate linear regression analyses to evaluate whether the presence of RCC significantly increases the level of serum ESM-1.t-tests or one-way analyses of variance, whereas qualitative variables were compared by use of chi-square or Fisher’s exact tests. Statistical analyses were performed by the Statistical Package for Social Science for Windows, Version 18.0 . A P-value < 0.05 was considered significant, and all P-values were two-sided. The ROC analyses and plotting graphics were performed by R Version 3.2.5 software (http://www.r-project.org).Preoperative and postoperative (at 1 month and 3 months) ESM-1 levels were compared. The quantitative values were compared by use of Student’s


In 20 cases (35.7%), the bacteremia was hospital-acquired, since it occurred more than 48 h after the hospital admission. The most frequent microorganisms isolated in blood culture were Staphylococcus aureus, Proteus spp., and Bacteroides spp. The bacteremia was polymicrobial in 14 cases (25.0%). Overall mortality was observed in 23 episodes (41.1%). The risk factors independently associated with mortality were hospital-acquired bacteremia , polymicrobial bacteremia , and serum albumin <23 g/L . BAPU is an uncommon complication of pressure ulcers and is mainly caused by S. aureus, Proteus spp., and Bacteroides spp. In our hospital, the incidence of BAPU has declined in recent years, coinciding with the implementation of a multidisciplinary team aimed at preventing and treating chronic ulcers. Mortality rate is high, and hospital-acquired bacteremia, polymicrobial bacteremia, and serum albumin < 23 g/L are associated with increased mortality.The objective of this study is to evaluate the clinical and microbiological characteristics of bacteremia associated with pressure ulcers (BAPU) and factors associated with mortality. This study was a prospective observational cohort study of patients with BAPU at a teaching hospital between January 1984 and December 2015. Fifty-six episodes were included. The incidence of BAPU decreased from 2.78 cases per 10,000 hospital discharges in the period from 1984 to 1999 to 1.05 cases per 10,000 hospital discharges in the period from 2000 to 2015 ( Pressure ulcers are a frequent complication in patients with limited mobility. They mainly develop in elderly patients with debilitating diseases and in patients with spinal cord injuries. A prevalence of 11–25% in nursing homes and 3–11% in hospitals is estimated . The greThe main infectious complications that can develop from pressure ulcers are cellulitis, abscess, osteomyelitis, and bacteremia , 6. BactAs part of our prospective study of all bloodstream infections, we have specifically studied the episodes of BAPU during a period of 32 years.All consecutive patients with BAPU admitted between January 1984 and December 2015 in a 350-bed teaching hospital serving a population of approximately 200,000 were prospectively included in the study. If a patient presented for more than one episode of bloodstream infection caused by the same microorganism separated by less than 4 weeks, only the first episode was analyzed. Criteria for inclusion in the study included all of the following: one or more true positive blood cultures; presence of one or more pressure ulcers; positive culture of the ulcer, including at least the microorganism(s) isolated in the blood culture, with identical resistance phenotype; and exclusion of other sources of bloodstream infection. In order to rule out other sources of bacteremia, a chest x-ray and a urinary cell count were obtained in all cases, as well as a urine culture when leukocyturia existed. If there was any symptom or sign suggesting an intra-abdominal infection, ultrasound and/or abdominal CT were performed. Cases were excluded if these or other examinations suggested that another source of bacteremia was possible.Blood cultures were requested by the patients’ physicians. In each case two sets of blood cultures were obtained. From 1984 to 1987, a 5-ml volume of venous blood was inoculated aseptically into the broth phase of Castaneda’s biphasic medium consisting of brain heart infusion agar and broth . The media were incubated at 37 °C. From 1988 to 2015 blood cultures were collected in bottles with aerobic and anaerobic media without resins and processed with the BacT/Alert automated system (bioMérieux). Samples for ulcer culture were obtained by swabbing, perilesional puncture, or surgical debridement, depending on the characteristics of the ulcers. All samples were seeded in aerobiosis and anaerobiosis on blood agar, chocolate agar, MacConkey agar, anaerobic selective medium and thioglycolate liquid medium (bioMérieux). Identification of microorganisms was performed using biochemical tests included in the commercial systems Api (bioMérieux) and Microscan (Beckman Coulter). The minimum inhibitory concentration (MIC) was determined by microdilution  for aerobic microorganisms, and using the disc-diffusion or the E-test method for anaerobic bacteria. The results were interpreted according to the criteria of the Clinical Laboratory Standards Institute  until 2013 and according to the criteria of the European Committee on Antimicrobial Susceptibility Testing (EUCAST) from 2014 on.All cases were directly evaluated at admission by one of the authors . The data for each episode were recorded on a predefined form with 97 items and stored in a database.Pressure ulcers were defined as localized lesions of the skin and underlying tissue caused by compression between bony prominences and external surfaces. Ulcers attributable to vasculopathy, peripheral neuropathy, surgery, or trauma were excluded. Ulcers were classified according to the National Pressure Ulcer Advisory Panel criteria . When moBacteremia was considered to be hospital-acquired, healthcare-related or community-acquired according to Friedman criteria . InformaInitial empirical antibiotic treatment was considered appropriate when at least one in vitro active antibiotic was included in the treatment within the first 24 h of the onset of bacteremia.Overall mortality rate was defined as death by any cause within the first 30 days since the onset of bacteremia. Death was considered directly related to bacteremia when it occurred within 7 days after the last positive blood culture or, if later, when there were signs of uncontrolled infection or complications of bacteremia.Incidence of BAPU was calculated as episodes of bloodstream infection associated with pressure ulcers per 10,000 hospital discharges.U test. Categorical and stratified continuous variables were compared using the chi-square test or the Fisher’s exact test as appropriate. Odds ratios (ORs) and 95% confidence intervals (CI) were calculated. Statistical significance was defined as p < 0.05. Multivariate logistic regression analysis of factors potentially associated with mortality was performed including all the variables that achieved p < 0.20 in the univariate analysis. The SPSS (version 15.0) software package was used for the statistical analysis.Descriptive analysis was performed using means with standard deviation (SD) for continuous variables and percentages for categorical variables. Continuous variables were compared using the Mann-Whitney p < 0.001).During the study period, 56 consecutive episodes of BAPU were identified in 53 patients. The incidence of BAPU was 1.70 episodes per 10,000 adult patient discharges, over the whole study period. This incidence was significantly higher in the 1984–1999 period  compared to the 2000–2015 period , healthcare-related in 15 cases (26.8%), and community-acquired in 21 cases (37.5%). The baseline and clinical characteristics are summarized in Table Staphylococcus aureus followed by Proteus spp., Bacteroides spp., and Escherichia coli. Only 4 episodes of BAPU were caused by methicillin-resistant S. aureus (MRSA), all from 2002, and only one episode was caused by ESBL-producing Enterobacteriaceae. No bacterial isolates were carbapenem-resistant. Of the four episodes caused by Pseudomonas spp., two were hospital-acquired and two were community-acquired. The most frequently isolated microorganisms from the ulcer cultures were E. coli and Proteus spp., followed by S. aureus, Bacteroides spp., Pseudomonas spp., and Enterococcus spp.Microorganisms isolated from blood culture and ulcer culture are detailed in Table p = 0.22). In 42 cases (75.0%) there was more than one ulcer. The characteristics of the ulcers are shown in Table In 49 cases (87.5%), the ulcers responsible for bacteremia were already present at admission, whereas in 7 cases (12.5%) they were acquired during the hospital stay. The percentage of hospital-acquired ulcers during the period from 1984 to 1999 (17.6%) was higher than in the period from 2000 to 2015 (4.5%), although the difference was not statistically significant (p = 0.46). Patients who died had significantly lower serum albumin (21.8 ± 4.9 g/L) than patients who survived . Table Empirical antibiotic treatment was appropriate in 44 cases (78.6%). All patients were treated locally with ulcer cleaning. Surgical debridement was performed in 36 cases (64.3%). Overall mortality was observed in 23 cases (41.1%). Death was considered directly related to bacteremia in 12 cases (21.4%). The age of the patients who died (77.5 ± 14.5 years) was not significantly different from the age of the patients who survived , lower than the percentages observed in most hospitals in our country [Pressure ulcers may constitute an important reservoir of multiresistant microorganisms, especially MRSA, with the consequent risk of bacteremia by this pathogen –26. It h country .Osteomyelitis is a well-known complication of pressure ulcers. It should be suspected in ulcers with a torpid course that do not improve despite intensive local treatment , 30. A pOverall mortality was high, although slightly lower than previously reported , 9. In oSurgical debridement of the ulcer is an important element in the management of BAPU. It is a safe procedure in patients with advanced ulcers, despite the comorbidities that these patients usually present . Galpin Finally, although broad-spectrum antibiotic treatment and surgical debridement are important elements for the management of BAPU, the most effective measure is the prevention of pressure ulcers through early detection of patients at risk and the adoption of appropriate preventive measures –40.S. aureus, Proteus spp., and Bacteroides spp. Its incidence in our institution has declined in recent years. Mortality rate is high and hospital-acquired bacteremia, polymicrobial bacteremia, and serum albumin < 23 g/L are associated with increased mortality.In conclusion, BAPU is an uncommon complication of pressure ulcers and is mainly caused by


Mesenchymal stem cells form a population of self-renewing, multipotent cells that can be isolated from several tissues. Multiple preclinical studies have demonstrated that the administration of exogenous MSC could prevent renal injury and could promote renal recovery through a series of complex mechanisms, in particular via immunomodulation of the immune system and release of paracrine factors and microvesicles. Due to their therapeutic potentials, MSC are being evaluated as a possible player in treatment of human kidney disease, and an increasing number of clinical trials to assess the safety, feasibility, and efficacy of MSC-based therapy in various kidney diseases have been proposed. In the present review, we will summarize the current knowledge on MSC infusion to treat acute kidney injury, chronic kidney disease, diabetic nephropathy, focal segmental glomerulosclerosis, systemic lupus erythematosus, and kidney transplantation. The data obtained from these clinical trials will provide further insight into safety, feasibility, and efficacy of MSC-based therapy in renal pathologies and allow the design of consensus protocol for clinical purpose. Conventionally, they are characterized by (1) the expression of several surface markers such as CD44, CD73, CD90, CD105, CD166, CD271, and Stro-1 together with the absence of CD14, CD34, CD45, and HLA-DR; (2) the capacity to adhere to plastic [ in vitro into mesodermal cell types like osteoblasts, adipocytes, and chondrocytes [The mesenchymal stem cells (MSC), also called mesenchymal stromal cells, are adherent, fibroblast-like cells capable of self-renewal and multilineage differentiation. They were identified nearly half a century ago from cell cultures of murine bone marrow by Friedstein, who defined them as colony-forming unit fibroblasts . In the drocytes –10. An idrocytes –13.  In vitro expansion is a necessary procedure to obtain a sufficient number of MSC, but the maximum number of in vitro passages is mostly nonstandardized. A major risk is that through multiple cycles of replications (25 to 30 population doublings) MSC would give rise to a population of senescent cells [ in situ senescence associated beta galactosidase tests, would allow a better control of the MSC population composition and therefore reduce adverse effects [Interestingly, the MSC currently used for patient therapy are nonclonal MSC, a more heterogeneous population of cells. In effect, clonal cultures would be more homogeneous and therefore preferable but cannot be expanded into a sufficient number of daughter cells. Therefore, the percentage of stem cells contained in every nonclonal population can vary and must be evaluated independently before clinical use through, for example, colony-forming unit (CFU) assays and the evaluation of the multipotential capacity of CFU . In vitrnt cells . These cnt cells . Monitor effects , 17. in vivo mouse model of hindlimb ischemia, clinical and histological analysis revealed that bmMSC and adMSC presented different properties. Therefore, while MSC isolated from various tissue have similar characteristics, further characterization would be beneficial for clinical use. Finally, preclinical studies by Melissa Little's group describe the existence of MSC-like cells in the kidney that could support local tissue turnover and/or repair [MSC form a heterogeneous cell population likely to have a pericytic origin . They car repair . Their dMSC possess the ability to migrate into damaged tissues in response to combinational signals . This prWhile initial findings on the therapeutic properties of MSC indicated an important role for homing, engrafting, and differentiation of the cells at the site of injury, numerous additional studies demonstrate a very limited replacement of damaged tissues by transdifferentiation ability and replacement potential , 68. In From the first published article in 2000 by Liechty et al., numerous studies have demonstrated the ability of MSC to modulate the immune system , 73–75. Recent evidence emphasizes the importance of the interactions between the MSC and their environment, as other immunomodulatory properties come into effect in a paracrine/endocrine manner. MSC are able to release dozens of active biological factors that act on local cell dynamics, by decreasing apoptosis, reducing inflammation and fibrosis formation, promoting angiogenesis and recruiting resident progenitor cells, and stimulating mitosis and/or differentiation process , 97. MSC Soluble factors are involved in different processes: (1) immune system signaling like IL-6, IL-8, monocyte chemoattractant protein-1 (MCP-1/CCL2), and TGF-β; (2) extracellular matrix remodelers like tissue inhibitor of metalloproteinases 2 (TIMP-2), fibronectin, periostin, collagen, and metalloproteinase inhibitors; (3) growth factor and regulators such as insulin-like factor 1 (IGF-1), hepatocyte growth factor (HGF), and vascular endothelial growth factor (VEGF) [(i)r (VEGF) , 98–104. Microvesicles are divisible in shedding vesicles released by membrane budding (particles of 50–200 nm) and exosomes released from intracytoplasmic multivesicular bodies (bilipid membrane vesicles of 50 nm or less). Regardless of their origin, microvesicles are perfect vehicles to deliver mRNA, miRNA, surface receptors, and biologically active molecules like lipids or proteins. These molecules can modulate or reprogram functions of other cells, like enhancing survival and blocking the programmed death system [(ii)h system –109. Rech system .Additionally, recent studies showed positive effect on the kidney structure through fibrosis reduction mediated by MSC. This effect occurs independently of the source of MSC  and injury model  –113. in vitro and in vivo experiments [An additional important property of the MSC is to decrease the severity of organ injury through the reduction of the oxidative stress . Exosomeeriments , 115. in vitro and in vivo experiments using MSC created great enthusiasm in the scientific community, offering new possibilities of cell-based therapies for a wide range of diseases. To date, more than 600 clinical trials conducted worldwide, either completed or ongoing, involve the use of MSC as reported in the US National Institute of Health database . As many as 30 of them use MSC to treat kidney-related diseases, out of which 9 started within the last year , chronic kidney injury , focal segmental glomerulosclerosis , diabetic kidney disease , autoimmune disease , and kidney transplantation .AKI—previously called acute renal failure—is characterized by the rapid loss of kidney excretory function. Its causes are numerous and can be divided into three categories: prerenal disease such as renal ischemia , intrinsic renal disease such as exposure to nephrotoxic substances , and systemic disease, or postrenal-like obstruction of the urinary tract. It is typically diagnosed on the basis of characteristic laboratory findings, that is, elevated blood urea nitrogen and creatinine, or decreased urine output, or both .NCT00733876) an exploratory study (phase I), was completed in October 2013 and involved 16 patients. Its aim was to determine the safety and efficacy of bmMSC administration in patients at high risk of developing AKI following on-pump cardiac surgery. The administration route of allogeneic MSC was through the distal thoracic aorta, to avoid cell entrapment in the lungs, which might induce respiratory distress. Study results indicate the absence of specific or serious adverse events during a 6-month follow-up period. Preliminary analysis showed that MSC administration is safe at all tested doses, confers early and late protection of kidney function, and lowers both length of hospital stay and need for readmission [NCT01275612) proposes to test the feasibility and safety of systemic infusion of donor ex vivo expanded MSC to repair the kidney and improve renal function. A third, larger phase II study (NCT01602328) evaluates kidney recovery following allogenic bmMSC infusion in patients with AKI after undergoing cardiac surgery. No results have been reported so far for these two trials [Interesting preclinical results obtained in various mouse models paved the way for the development of novel therapies involving the use of MSC in AKI patients. In fact, no drug is presently available to treat this condition, and the treatment is essentially supportive, including renal replacement therapy whenever necessary. Around 50% of critically ill patients die from AKI, and while most surviving patients completely recover their renal function within weeks, some develop chronic kidney disease (CKD) requiring kidney transplant . Howeverdmission , 118. A o trials .The number of individuals affected with chronic kidney disease (CKD) is rising worldwide, mainly due to a remarkable increase in atherosclerosis and type 2 diabetes. An estimated 8–16% of the general population has CKD, and its prevalence increases with age to about 30% in people aged over 70 years . CKD is  in vivo studies suggest beneficial regenerative effects of cell-based therapies in animal models of CKD [NCT02166489 and NCT02195323) and two adMSC (NCT02266394 and NCT01840540). These explorative studies are either ongoing or only just completed, and no preliminary result has been provided so far.CKD is characterized by reduced renal regenerative capacity. Severals of CKD . AdminisNCT02585622), based on the successful preclinical experiments in diabetic mice treated with bmMSC [Diabetic kidney disease (DKD)—also called diabetic nephropathy—is a clinical syndrome associated with kidney damage, which can progress to chronic kidney disease. It is the leading cause of ESRD in the industrialized world, accounting for about 40% of new cases in the US and EU. The five-year mortality rate is 39%—a rate comparable to many cancers. The economic cost of DKD and its progression to ESRD represents an astounding 13% of the US healthcare budget. In spite of this enormous social and economic cost, there have been no specific therapies successfully developed for DKD in the past 25 years. The current treatment paradigm relies on early detection, glycemic control, and tight blood pressure management with preferential use of renin-angiotensin system blockade . To addrth bmMSC . This stFocal segmental glomerulosclerosis (FSGS) is a rare but major cause of ESRD. The rate of recurrence is higher in children compared with adults and in patients submitted to a subsequent kidney transplant. Furthermore, after kidney transplantation, approximately 30–40% of patients with FSGS develop recurrent FSGS. Its incidence is increasing worldwide . in vivo models of FSGS can be found in literature, but all presented promising results, leading to a translation to the clinic [6 cells/kg/dose) according to the dose most commonly used for graft-versus-host disease (GVHD) treatment. No adverse event was observed, and the patient presented a stable renal function and stabilized proteinuria without the need of further plasmapheresis. In addition, some circulating inflammatory factors decreased and their levels were still low after one year. Recently, a clinical trial (NCT02382874) was opened to evaluate safety and efficacy of intravenous infusion of allogeneic adMSC in 5 refractory FSGS patients. They will be followed up for a year following injection.In FSGS, glomerular lesions caused by various insults directed to or inherent within the podocyte lead to foot process effacement. The resulting loss of integrity of the glomerular filtration barrier, which regulates permselectivity, causes in turn proteinuria. Traditional pharmacological approaches, consisting of corticosteroids and calcineurin inhibitors, fail to achieve a sustained remission in most patients. Therefore, there is a pressing need to develop alternative therapies for this glomerulopathy . Very fee clinic . An artie clinic . Seven, https://clinicaltrials.gov/, examining the safety and therapeutic benefit of MSC therapy in patients with primary or treatment-refractory SLE. Three studies favor the use of ucBMC and two bmMSC. A small pilot study (NCT00698191) involving only four patients with treatment-refractory SLE showed that systemic administration of allogeneic ex vivo expanded bmMSC improved renal function and reduced SLE disease activity, such that patients were in disease remission for up to 12 months after treatment [NCT01741857) involved 40 patients with active and refractory SLE that were injected intravenously with allogenic ucMSC on days 0 and 7 [γ, produced predominantly by CD8+ T-cells in SLE patients, are a key factor involved in the stimulation of allogeneic ucMSC to produce indolamine 2,3-dioxygenase, which can then inhibit the proliferation of T-cells from SLE patients [NCT02633163) has been uploaded in December 2015 and proposes the injection of either low or high dose of ucMSC or a placebo. This prospective, double-blind, multicenter, controlled study will enroll an estimated 81 treatment-refractory LSE patients and will follow the disease outcome for 1 year. Of note, another two concluded studies have an unknown status (NCT01539902 and NCT00659217).SLE is a chronic autoimmune disease characterized by a wide range of clinical manifestations that can affect many organs in the body, with significant morbidity and mortality. Nephritis remains the most significant manifestation of SLE and standard treatments include high doses of corticosteroids, cyclophosphamides, and other immunosuppressive and biological agents. Most patient outcome improves greatly following therapy, but strong side effects including infection, ovarian failure, and secondary malignancy can worsen the prognosis and lead to patient death , 45. SLEreatment . A folloreatment , 127. A reatment . None of 0 and 7 . Safety patients . Interes in vivo studies showed that MSC can successfully regulate immune response and support kidney repair [NCT00752479) [NCT00658073), Tan et al. assessed the benefits of autologous bmMSC injection versus anti-CD25 antibody in ESRD patients that underwent kidney transplant [NCT00734396). The treatment included full immunosuppressive regiment and intravenous bmMSC injection 6 months after transplant. No adverse effects were noted and two patients showed resolution of tubulitis, while five patients had less donor-specific mononuclear cells, indicating a possible immunomodulatory effect of the MSC. In an ongoing phase II clinical trial by the same group (NCT02057965), 70 renal allograft recipients will receive autologous bmMSC injections or control [NCT02387151) [ de novo HLA antibody development and extensive immune monitoring, renal function, and opportunistic infections. An unregistered small clinical trial already assessed the safety and efficacy of autologous bmMSC transplantation in four patients that underwent living-donor renal transplantation and the effect on the immunophenotype and functionality of peripheral T lymphocytes following transplantation [https://clinicaltrials.gov/ reported interesting result. In the first one, Vanikar et al. [NCT00659620) has an unknown status and did not present any publication. It is clear that MSC-based therapy in kidney transplantation is in its infancy, and no real evidence of its benefits for the patient has been shown so far.Kidney transplant in ESRD patients offers the best chance of survival and improves health-related quality of life compared to remaining on dialysis. Better and more potent immunosuppressive drugs have improved significantly the short-term outcome of the surgery in the last two decades. However, the long-term graft survival rate beyond the first year showed only a small increase . Clinicay repair . There ay repair . An expl0752479) , 129. In0752479) , 75. Theansplant , 52. In ansplant , 130, th control . Patient2387151) . Indeed,antation . All patr et al. , 134 evar et al.  involvinr et al. . Howeverr et al. , 136. Ner et al. . Peng etr et al. , 137. PaNCT02409940). Presently, both autologous and allogenic MSC are used in cell therapy, and some questions remain regarding which cell type leads to the best disease outcome. The use of autologous MSC is not always preferred nor possible because patients can present cells with reduced qualities or quantities [It is noteworthy that one registered clinical trial aims to compare the use of autologous and allogenic bmMSC treatment in kidney transplantation patients and will help to elucidate the effect of the bmMSC on the T-cell repertoire of the recipients  . HoweverMSC form a population of well-characterized, easily obtainable cells with therapeutic properties effective in numerous experimental models of kidney diseases. The underlying mechanisms of action of the MSC have been extensively described and consist essentially in immunomodulatory and paracrine effects. However, the translation of preclinical studies into robust, effective, and safe patient therapies remains limited. The many clinical trials that have been conducted and completed will undoubtedly provide further insight into safety, feasibility, and efficacy of MSC-based therapy in renal pathologies. The preliminary results available still lack long-term follow-up data and the absence of consensus between therapeutic protocols, in particular in terms of MSC preparation, donor characteristics, and concomitant immunosuppressive treatment in kidney transplant recipients, is noteworthy. As a broad range of approaches have been developed, a careful selection of the best one will have to be made in the future in an effort to reach a certain harmonization in clinical practices , 48, 145


Diabetic nephropathy is the leading cause of end stage renal disease. The number of kidney transplantation (KT) due to diabetic nephropathy is increasing and there is debate on glycemic control after KT. In this study, we used a multi-center database to determine the relationship between post-transplant glycemic control and the outcomes of KT in patients with diabetic nephropathy.We conducted a retrospective chart review of kidney transplant recipients (KTRs) with diabetic nephropathy from three tertiary hospitals to analyze the association between post-transplant glycemic control and the clinical outcomes of graft failure, including patient death and biopsy-proven acute rejection (BPAR). We assessed time-averaged glucose level and hemoglobin A1c (HbA1c) for 36 months after KT.rd quartile of time-averaged HbA1c was associated with significantly better graft outcomes than the 1st, 2nd or 4th quartiles. There were no significant differences in the risk of BPAR across the 4 quartiles of glucose and HbA1c.Among 3,538 KTRs, a total of 476 patients received kidney transplantation because of diabetic nephropathy. Mean time-averaged glucose and HbA1c levels were 147 ± 46 mg/dl and 7.7 ± 1.5%, respectively. Patients with diabetic nephropathy had poor graft and patient survival rate compared with non-diabetic nephropathy. Among KTRs with diabetic nephropathy, the highest quartile of time-averaged glucose was related to poor graft outcomes and the 3Strict glycemic control before KT might not be related to successful outcomes but poor glycemic control after KT is associated with poor graft outcomes. There was no significant relationship between pre- or post-transplant glycemic control and BPAR. Diabetic nephropathy is the leading cause of end stage renal disease (ESRD). In the United States Renal Data System (USRDS) 2013 annual report, diabetes was the most common cause of ESRD at nearly 50% of total incident dialysis .Poor glycemic control in diabetic patients without nephropathy is a well-known risk factor for cardiovascular  and all-Pancreas and islet transplantation is important in restoring the glycemic control through conferring insulin independence for KTRs with type I diabetes. It is well known that successful pancreas and islet transplantation is associated with improvements not only in kidney function and kidney graft survival rates ,11, but The American Society of Transplantation (ATC) published guidelines for the care of KTR in 2009. They recommended targeting HbA1c around 7.0–7.5% and avoiding HbA1c ≤ 6.0%, especially if hypoglycemic reactions are common in the patient . In the The objective of this study was to examine the association between post-transplant glycemic control and long-term clinical outcomes of transplantation . We hypothesize that poor glycemic control after kidney transplantation is associated with poor graft outcome.We performed a multicenter cohort study including patients admitted to three tertiary hospitals: Seoul National University Hospital (SNUH), Asan Medical Center University of Ulsan College of Medicine (AMC), and Kyungpook National University Hospital (KNUH). A total of 3,538 adult KTRs aged ≥18 years who underwent transplantation between 1997 and 2011 were included in this study. Patients who had multiple organ transplantation  were excluded. The patients with diabetes were selected regardless of the type . Diabetes was diagnosed as follows . A clinical diagnosis of DN included consistent urinary albumin-to-creatinine ratios ≥300 mg/g with no other causes of proteinuria. The present study was performed in accordance with the ethical standards of the Helsinki Declaration and was approved by the Institutional Review Boards and Research Ethics Committee of the three centers .Patient characteristics were collected from a review of medical records. Transplant-related variables included age; gender; body mass index; primary cause of kidney failure; dialysis modality and duration; type of immunosuppressant; and history of pre-transplant hypertension, ischemic heart disease, and cerebrovascular disease. Pre-transplantation laboratory values for glucose, and HbA1c were obtained, and every 3months follow-up for glucose and HbA1c values were obtained. In addition, donor-related variables, including age and donor type were reviewed. Estimated glomerular filtration rate (eGFR) was calculated by the Modification of Diet in Renal Disease (MDRD) GFR equation .Induction therapy was mostly done with basiliximab or anti-thymocyte globulin (ATG) in high risk patients. Maintenance therapy was started with cyclosporine or tacrolimus, mycophenolate mofetil (MMF), and prednisolone.The primary endpoint was graft failure in transplant recipients. Graft failure was defined as composite of graft dysfunction that necessitated new renal replacement therapy after transplantation or patient death, which included death with functioning graft. The secondary outcome was a biopsy-proven acute rejection (BPAR) defined as a clinically meaningful acute rejection proven by kidney biopsy. Acute rejection episodes which were revealed in a protocol biopsy but not treated were not included.To investigate the effect of glycemic control on the outcomes, a comparison of outcomes among 4 quartiles of glucose and HbA1c was performed. Continuous variables were reported as means and standard deviations, and categorical variables were presented as frequencies with percentages. Continuous variables such as recipient and donor age and dialysis duration were compared using one-way ANOVA; categorical variables, such as proportion of comorbidities, cause of ESRD, and previous RRT modality, were compared using the Chi-square or Fisher exact test. The significance threshold for all analysis was set at p < 0.05. The independent risk factors for graft and patient survival were analyzed using multivariate Cox proportional hazard regression models. Appropriate covariates that were statistically significant in the univariate Cox proportional hazard regression analysis were included. All the variables were analyzed using the IBM SPSS software package .During the study period, 3,538 patients underwent kidney transplantation. The number of kidney transplants has increased each year and the proportion of kidney transplantation due to DN has also increased . Among 3Data was collected for patients with DN from time of transplant to 36 months follow up. Of the 476 patients included in the data analysis, the majority were male (66.9%) and mean age at time of transplantation was 50 ± 10.2 years. In addition, 43.3% of patients received living-related transplants, 32.3% living-unrelated transplants, and 24.4% deceased-donor transplants. The mean HbA1c before transplantation was 7.5 ± 1.7% and the mean random glucose level was 194 ± 113 mg/dl.Compared with non-DN, patients with DN were older and had higher BMI. Donors of DN group was older and there were more living unrelated donors. There was no significant difference in duration of dialysis, dialysis modality before transplantation, immunosuppressant use, and 1-year eGFR between the two groups. Baseline characteristics of the two groups did not fully match .p <0.001; p <0.001; p = 0.035). There was no difference in 1-year serum creatinine , and 1-year estimated GFR in patients with diabetic nephropathy .During the follow-up period, 9.3% (284/3052) of non-diabetic patients developed post-transplant DM. Sixty graft failures (12.6%) and 30 deaths (6.3%) occurred in patients with DN, compared to 354 graft failures (11.6%) and 117 deaths (3.8%) in patients with non-DN. Post-transplant patient survival of KTRs with DN was poorer than that of KTRs with non-DN (p < 0.001). Post-transplant glucose levels were lower than baseline levels, in the range of 120–160. The mean time-averaged glucose levels and HbA1c at 36 months were 147 ± 46 mg/dl and 7.7 ± 1.5%, respectively.The median follow up duration for patients with diabetic nephropathy was 49.9 months. During the follow up period, events of graft failure were confirmed in 62 (13%) patients in diabetic nephropathy. The changes in fasting glucose levels and HbA1c every 6 months were shown in p = 0.01; rd quartile of time-averaged HbA1c showed good graft survival compared to the other quartiles , 2nd  and 4th quartiles  were related to poor graft outcomes compared with the 3rd quartile (7.6–8.6%), after adjusting age, gender, comorbidities, donor age, donor type, and BPAR  with diabetic nephropathy. There was no significant relationship between BPAR and baseline/time-averaged glucose or between BPAR and HbA1c levels .This multicenter retrospective cohort study reports the clinical outcomes of kidney transplantation in diabetic nephropathy and its relationship with post-transplant glycemic control. Graft and medical outcomes after kidney transplantation for diabetic nephropathy were poor compared to outcomes for patients with non-diabetic nephropathy. In addition, post-transplant glycemic control, assessed by time-averaged glucose levels and HbA1c, affected graft survival. The HbA1c group with 7.6–8.6% showed the best graft outcome. However, pre-transplant glycemic control was not associated with graft survival. Our results suggest that post-transplant glycemic control is more important than pre-transplant glycemic control for long-term graft outcomes. Acute rejection was not associated with pre- or post-transplant glycemic control.The relationship between post-transplant glycemic control and clinical outcomes after kidney transplantation in clinical studies is controversial. Hyperglycemia is associated with ischemic reperfusion injury in animal models . Also, iGlycemic control in kidney transplantation is challenging. The main pathophysiological mechanism of hyperglycemia after transplantation is pancreatic beta cell dysfunction in the context of insulin resistance. There are immunosuppressive agents which causes dysglycemia: corticosteroids, calcineurin inhibitors including tacrolimus and cyclosporine, as well as the mammalian target of rapamycin inhibitors (sirolimus and everolimus). In particular diabetic nephropathy patients who underwent kidney transplantation had difficulty controlling their diabetes because of complications, such as autonomic neuropathy. Therefore, the American Society of Transplantation (ATC) recommends targeting HbA1c 7.0–7.5% and avoiding targeting HbA1c ≤ 6.0% .In our study, strict glycemic control as well as poor glycemic control were related to poor graft outcomes, which supports the ATC recommendations for glycemic control, although the exact range of HbA1c does not fit to that. We suggest that HbA1c might be more important parameter than glucose to survey for post-transplant glycemic control because, unlike glucose, it seems to be associated with graft outcome.Our study has some limitations. First, as with all retrospective studies, our data cannot be interpreted causally. Second, the data for glucose levels could contain both fasting and random glucose levels because we cannot recognize whether the blood samples were collected before or after a meal. Third, we classified the laboratory findings into quartiles using cutoffs suggested by the data, rather than by the clinical literature. Furthermore, we had no information regarding diabetes medications, and whether patients were taking oral agents or insulin. This may be a confound as Wiesbauer et al. suggested that diet and oral medications seem to be superior to subcutaneous insulin obtaining optimal glycemic control . Also thHowever, to our knowledge, this study represents the largest cohort study of Asian kidney transplantation to date, using multicenter cohort data. Furthermore, we used both glucose levels and HbA1c as indices of glycemic control. By measuring time-averaged glucose and HbA1c, we were able to reduce observed variability over time and examine overall trends in the association between glycemic control and survival. However, these methods may mask significant changes in laboratory parameters that are important to survival.In conclusion, our study suggests that strict glycemic control might not be necessary for managing hyperglycemia after kidney transplantation, and that a good glycometabolic control may improve particularly long-term graft outcomes. As a parameter of glycemic control after kidney transplantation, HbA1c may be superior to glycemia because it may predict graft outcomes.S1 File(XLSX)Click here for additional data file.


Previous research shows that existing asthma quality of life questionnaires fail to measure the burden of oral corticosteroids that can be used to treat severe asthma, and are therefore not fit for purpose for severe asthma according to the USA’s Federal Drug Authority’s (FDA) criteria for content validity. Patient input and documentation of that input is key to achieving content validity according to FDA guidelines. This paper describes the process of constructing a new questionnaire to measure the burden of asthma symptoms and burden of treatment in severe asthma, using criteria specified by the FDA.A draft severe asthma questionnaire (SAQ) was constructed using qualitative input from severe asthma patients who took part in an earlier study. The aim of this study was to improve that draft questionnaire using a further group of patients. In four iterative focus groups, 16 people with severe asthma completed the draft questionnaire, discussed the wording and structure and suggested changes that were incorporated into the final version.The original intention to ask patients to identify whether problems were caused by asthma symptoms or side effects of medication was abandoned as the attribution of cause was found to be difficult and inconsistent. The recall period of 2 weeks was acceptable but fails to reflect the patients’ desire to express the variability of severe asthma. Patients suggested improvements to the wording of the draft questionnaire, including splitting some items in two, combining two items in one, and changes to some of the words in individual items and the response scale.The final version of the questionnaire was substantially different from one constructed using only qualitative reports from patients about the quality of life deficits of severe asthma. Patients make a valuable contribution to the questionnaire if they are asked to comment and improve an initial draft and where patients are treated as partners in the process of questionnaire construction, rather than only as a source of information to experts who construct the questionnaire. Several asthma specific quality of life scales have been developed –3, and aThe documentation provided by the FDA  proposedSevere asthma is defined as asthma that requires treatment with high dose inhaled corticosteroids plus a second controller and/or systemic corticosteroids to prevent it from becoming “uncontrolled” or that remains “uncontrolled” despite this therapy .the quality of life burden of asthma symptoms and the side effects of asthma medication as perceived by people who meet the criteria for severe asthma. The scale is intended to be appropriate for use in clinical trials where different types of asthma treatment are compared, as well as providing a monitoring tool in clinical practice. In order to be useful in these contexts, the SAQ should enable patients to describe their health-related quality of life in a way that is meaningful to the patient, to be sufficiently short and easy to complete so as to reduce patient burden, and to have response scales that are sensitive to change.In contrast to mild or moderate asthma, two distinguishing features of severe asthma are (a) poor asthma control causing symptom variability over time including exacerbations that may require inpatient care and (b) an increased burden of side effects from medication. The concept of health-related quality of life in this instance must therefore include both types of deficit. The Severe Asthma Questionnaire (SAQ) is intended to measure is The high burden of treatment in severe asthma, especially oral corticosteroids, is important because of the development of new biologic agents that, in addition to improving asthma control, can lead to a reduction in the use and hence side effects of oral corticosteroids. In an evaluation of the quality adjusted life years (QALY) one of these biologic agents, the National Institute for Care Excellence (NICE) noted that “some benefits of avoiding the adverse effects of oral corticosteroid use had not been fully captured in the QALY measure. P. 45” . FrustraAlthough the primary intention is to have a single questionnaire that captures both the benefits and side effects of treatment in a single metric, there would be merit if these two aspects could be disambiguated so as to provide information for clinical practice. Thus, there is an extension to the concept defined above, namely to provide independent assessments of the burden of asthma symptoms and the burden of side effects of asthma treatment. This extension was based on the assumption that that patients could identify two components of health-related quality of life: that caused by the symptoms of the disease, and that caused by the symptom side effects of treatment.The FDA documentation specifies that qualitative studies should ensure that the “domains of an instrument are appropriate and comprehensive relative to its intended measurement concept, population, and use” . We haveThe FDA documentation of patient reported outcomes (PRO) specifies that studies should provide a “test of whether patients understand the items” and establish that “the concepts represented in the PRO instrument’s conceptual framework are confirmed, that the response options and recall period are appropriately comprehended, and that the instrument’s readability is adequate for the intended population.” . The FDAA 15 item draft questionnaire was constructed on the basis of domains identified in our earlier research , reflectThe aim of this study was to improve this draft questionnaire by presenting it to patients and asking for comments and ways of improving it.Patients who were attending a severe asthma clinic in the UK were invited to attend a focus group. Patients were selected so as to recruit both genders, a range of ages and severity assessed by British Thoracic Society (BTS) steps of asthma management (which is defined by treatment) and representative of the population of patients seen in this clinic. There were four focus groups, 16 participants of whom 12 were female, with ages ranging from 24 to 69 years and a mean age of 47 (SD = 13.53). Participants were at BTS steps 3, 4, and 5. More females than males were able to take part in these day-time focus groups.Patients gave written informed consent to take part in a study on the development of a questionnaire, and completed the questionnaire on arrival. The purpose of the focus group was explained – for patients to help construct a severe asthma questionnaire. Patients were asked specific questions about every element of the questionnaire, including the introductory words, the response scale, and the individual items. For each element the patients were asked to describe what they understood by the meaning of the element and individual words in the element. Patients were encouraged to discuss if and how the element under consideration could be improved, including the balance between different types of item in the questionnaire. The sessions were moderated by one of the authors, observed by another, and changes recommended by patients noted. The recommended changes were then implemented into the next version of the questionnaire which was presented to the subsequent group. All authors contributed to and approved the final version of the questionnaire. The sessions lasted up to 2 h and were audio recorded.The study was approved by the Plymouth Hospitals NHS Trust, ethical approval number 16/NE/0188, IRAS ID: 207,601.Information gained from patients during the iterative process of questionnaire modification can be divided into four categories.One of the aims of questionnaire development was to provide independent assessments of the impact of asthma symptoms versus the impact of the side effects of asthma medicines on quality of life. Despite iterative changes in wording, we found that although some patients in each focus group could answer the question of relative impact, significant problems arose for some patients and these are noted below.P5. I have a lot of medication, that counteracts medication that I’m on, but I still consider it my asthma medication, because it’s all for that. So would you include things like that? 16.20. 20/07/16P1. Zopiclone sleeping tablets, because you get, stop sleeping when you’re on 10mg. 16.25. 20/07/16P2. And I know that Zopiclone that I’m now on, does have side effects, and it’s addictive, and I’m now addicted to it. 19.25. 20/07/16First, some patients noted the difficulty in identifying asthma medicines from other medicines, and in particular those medicines that were taken to counteract the side effects of asthma medicines. Patients differed as to whether these side effect medicines should be considered asthma medicines or not.P15. It’s actually like making my brain think. Cos I’ve never been asked any of these questions before, in the whole time I’ve been under Consultants and everything, I’ve never been asked any of this stuff. 14.11. 22/07/16Second, the issue of deciding between disease versus treatment was perceived as difficult and unfamiliar task.P13. It’s very difficult, as you tend to ignore those as life, rather than these are side effects caused by your medication. 08.05. 21/07/16 PMP16. I think what’s interesting here is, I’m not sure what the side effects are. 25.03. 22/07/16.Third, for patients who had been on long term oral corticosteroids since childhood, many were unaware that this type of medication had side effects.Finally, some symptoms may be caused either by the disease or treatment. For example, patients can experience fatigue after an exacerbation requiring admission to hospital (which of particular problem in relation to child care), but it is unclear whether fatigue is a response to the exacerbation, the reduction in oral corticosteroids or simply the stay in hospital.The conclusion drawn from patient feedback was that it is possible for some patients to make a meaningful assignment of problems to asthma symptoms versus side effects of medicine. However, because in each focus group one or more patients who reported problems in relation to this concept, the conclusion was any assessment of the concept of symptom attribution would not be content valid.Yea, last couple of weeks. Four weeks is really hard. How many people can remember how you were four weeks ago? 40.50 20/07/17P6. I think if you’re going into, if you want detail then two week is about my limit really [laughs]. 09.06. 21/07/16 AMThe moderator explained to patients that the aim of the questionnaire was to use it in clinical trials, and that a 2 week recall period is used elsewhere . PatientP4. It’s bad enough when you go to the chest clinic and fill them out isn’t it. Because they say, in the last four weeks how have you been feeling, and I’m thinking, that’s four weeks ago. 06.30. 20/07/16The use of a 2 week period was supported by a second participant who was critical of other asthma QoL questionnaires used as part of clinical practice that require a 4 week assessment period.P7. It sounds extremely like you are going on textbook asthma, but asthma is never textbook. 31.17 21/07/17 AMHowever, although patients could report on the last 2 weeks, they felt that this recall period provided a poor description of their experience of asthma.P7. The thing is, if you want a genuine direct answer, and you want the best results possible, you probably would have to break it down into months. 07.28. 21/07/16 AM.P3. Just do 3 sections and say, what’s it been like in the last 12 months, and then particularly the last 6 months, and then particularly in the last month. 40.00. 20/07/16Patients would like to be able to express how their asthma affected them over a longer time period.P13. I know exactly when I will be ill, I know that I really struggle with the mould season in the autumn, and that in the spring, between February and May is my good time of year. 11.05. 21/07/16 PMP7. Think seasons’ll be good because people are going to be affected, as you say depending on, what their aller [sic], you know the allergic asthmatics. So if you’re allergic to the funguses in the autumn, you might be worse in the autumn, you’ve got the spring flowers, you’ve got the summer grass. 06.40. 21/07/16 AMPatients indicated that their symptoms and quality of life varied with the season.P3. You have a chance at remembering how you felt on average, because you can have bad days and you can have good days. 41.00. 20/07/16Patients also indicated they would like to assess their quality of life on average.In order to satisfy the competing demands of a clinical trial and the patients’ desire to provide a more holistic description of their asthma, one solution explored was to ask patients to rate all items on a 2 week period but also, on a separate page, to assess global health-related quality of life during the four seasons of the year. The additional questions about the four seasons  was found acceptable by patients in the focus groups. After the focus groups were completed, an international group of clinicians advised that seasons do not apply in some countries. In order to satisfy patient preference without referring to seasons, four global season questions were replaced by one global question to assess quality of life during the last 2 weeks and two global questions to assess quality of life during the best and worst months of the year. This solution was found acceptable by a small group of patients in clinic.The initial response scale for the 15 items consisted of a 7-point scale of how a patient’s life was affected, with patients asked to write a number in a box to show whether the aspect of life was attributed to asthma symptoms, asthma medicines except oral steroids, and oral steroids.As reported above, patients found it difficult to attribute cause to symptoms, and several felt that tick boxes were preferable to writing numbers. Because of patient feedback, subsequent versions of the response scale were simplified to a tick box scale.P7. difficult I would find better because restricted, you know, means there’s a limit, you know, difficult could be to any degree. 43.20. 21/07/16 AMFollowing discussion, the final questionnaire has a response scale with a 7 point difficulty scale: very, very difficult (worst possible); very difficult; difficult; moderately difficult; slightly difficult; very slightly difficult (just noticeable); no problem, with quantifiers taken from earlier research on the use of quantifiers in category rating scales [The meaning of the words used in the response scale was discussed. Patients interpreted the word ‘restricted’ – the word used in the original format of the scale – in a sense equivalent to ‘I am unable to’ rather than in terms of a limitation that varied in degree, and patients suggested the term ‘difficult’ instead.g scales . This fiP4. And stop calling it, ex…P1. Oh exacerbation (Mispronounced).P4. Nobody calls it that! We all call it asthma attack. 57.30. 20/07/16Although the term exacerbation was not used in the questionnaire, when the moderator suggested that sometimes health professionals used words that patients did not like, patients gave the following response.P6. Yea it should be recognised that peoples’ families are taking on a burden. 42.53. 21/07/16 AMPatients suggested several changes to the items and wording of the questionnaire and this was done iteratively. In an early version of the questionnaire there was a question about family life. Patients were asked to rate the difficulty of their asthma and its treatment associated with “My family life. For example: child care, family responsibilities”. Discussion indicated that there were two very different aspects of family life: that of the patient and that of the patient’s family. The impact of family is much pronounced in severe asthma because of the frequency of exacerbations and hospitalisation.As a result, the final version of the questionnaire has two items relating to family life (see Table P2. Omeprazole, if you’re on it long term, can be quite damaging. 19.00. 20/07.17P1. Steroids used to improve my life, I thought they were wonderful because I was able to do things, and now I am at the stage where I am taking a lot of steroids every day and I can’t. I struggle with the stairs, I struggle to have a shower, you know it’s, it’s crap. 24.11. 20/07/17P1. I used to think of the benefits, now I think of the side effects because I’m reaping them. 14.40. 20/07/17In the draft questionnaire, there was one item concerning worries about medicines. Discussion with patients showed that there were two distinct concerns: that asthma medicines would become less effective over time, and that the medication would produce side effects.P6. Should there be somewhere about the more longer term problems, like the cataracts and the diabetes, so that you’ve got a record all these. 53.41. 21/07/16 AMPatients therefore felt that the item on medication should be split in to two to reflect two very different concerns about medication (see Table P9. When you out “getting anxious” umm, it kinda combines with “the way I look” also. What I’ve just said you know, people pre-guessing exactly what is wrong with you, because you’re not in a wheelchair. 52.11. 21/07/16 AMAlthough patients felt that some items should be split, they felt that two items could be combined, namely the items on weight and on embarrassment, as having two items provided excessive emphasis on this aspect of quality of life deficit.P8. There’s a stigma about asthma isn’t there. 52.35. 21/07/16 AMAnother patient reflected that they felt self-conscious as a result of having asthma, which stemmed from the public’s lack of understanding of the disease.P16. What about night times? 28.20. 22/07/16P16. Well sometimes, I have er, so I don’t disturb the wife, I go downstairs, you know I use my pumps and all that, but I go downstairs, so I don’t wake her up. You know, I do get umm tight chest night times, and I’m woken up. 28.32 22/07/16P16. If I’m tired, you know, and I wanna go to sleep, and you can’t go to sleep, and sometimes it does get to you, you know. Well upset I suppose. 29.16 22/07/16.P14. Mines worse if I’ve got a chest infection as well, and then I’ve got my nebuliser right beside my bed. 29.32 22/07/16.In addition to changes to the structure of the questionnaire, patients also made changes to wording within items. Patients pointed out that a question about sleep did not ask about periods during the night when the patient was unable to sleep.The word ‘night time’ was therefore used with sleep as an example of what happens at night.Other changes involved amplification. For example, in the original scale there was an item ‘I get tired’. The final version is “Getting tired. For example, feeling tired for no reason, waking in the morning feeling tired.”P14. The one in the clinic feels like, it’s very kind of like medical, and have you done any exercise? Have you lost sleep? Umm, it’s kind of, they are just trying to establish how bad your asthma is at that point before you go and see the Consultant. Whereas these ones feel more, how your quality of life in general is, which I’ve never been asked about. Which is something which really frustrates me and this is the first time I’ve been asked about it.Patients were asked to compare the final version of the SAQ with other questionnaires completed in clinic. Responses were positive, none negative.14:47. 22/07/16This study demonstrates that more than one type of qualitative research is need to achieve content validity. An initial questionnaire was written on the basis of interviews with 23 patients . That inPatients who are prescribed OCS have poorer health-related quality of life , and greAlthough the initial qualitative interviews led to a 15 item questionnaire, the outcome of the second phase of qualitative research was to produce a 16 item questionnaire. Patients changed the structure and balance of the items. Two of the original items were split into two creating four out of the original two items, but two of the original items were combined. Patients made other changes to content of the items, and they also made changes to the response scale. Although the unsuitability of the term ‘exacerbation’ has been noted before , we founThe SAQ is designed for clinical trial use in asthma where an assessment period of 2 weeks is appropriate for underlying biological changes. A 2 week assessment period is applied in a commonly used asthma specific questionnaire . Severe www.saq.org.uk.The recall period of 2 weeks is appropriate for a clinical trial, but patients also have a narrative they want to tell the clinician. Time estimation is influenced by interest and enjoyment , 20. TheEdwards et al.  list pro


Cardiovascular complications determine morbidity/mortality in chronic kidney disease (CKD). We hypothesized that progressive CKD drives the release of cathepsin-S (Cat-S), a cysteine protease that promotes endothelial dysfunction and cardiovascular complications. Therefore, Cat-S, soluble tumor-necrosis-factor receptor (sTNFR) 1/2 and glomerular filtration rate (GFR) were measured in a CKD mouse model, a German CKD-cohort  and two Swedish community-based cohorts . Association between Cat-S and sTNFR1/2/GFR was assessed using multivariable linear regression. In the mouse model, Cat-S and sTNFR1/2 concentrations were increased following the progressive decline of GFR, showing a strong correlation between Cat-S and GFR  and Cat-S and sTNFR1/sTNFR2 . In the human cohorts, an increase of one standard deviation of estimated GFR was associated with a decrease of 1.008 ng/ml  −1.576–(−0.439), p < 0.001) in Cat-S levels in MCKD; in ULSAM and PIVUS, results were similar. In all three cohorts, Cat-S and sTNFR1/sTNFR2 levels were associated in multivariable linear regression (p < 0.001). In conclusion, as GFR declines Cat-S and markers of inflammation-related endothelial dysfunction increase. The present data indicating that Cat-S activity increases with CKD progression suggest that Cat-S might be a therapeutic target to prevent cardiovascular complications in CKD. Cathepsin-S (Cat-S) is a cysteine protease with intracellular and extracellular proteolytic activities246789101113141516172Chronic kidney disease (CKD) is a systemic inflammatory state that dramatically accelerates cardiovascular morbidity and mortality20All experiments were performed in accordance with relevant guidelines and regulations and were approved by the regional Government of Oberbayern, Germany. Male C57BL/6 mice were obtained from Charles River  at the age of 7–8 weeks, mice were housed in groups of five in standard housing conditions with unlimited access to food and water for one week for acclimatization. CKD was induced by feeding an oxalate-rich diet, which was prepared by adding 50 μmol/g sodium oxalate to a calcium-free standard diet  as previously describedGlomerular filtration rate (GFR) was measured at different time points  using an automated miniaturized imager device . The mouse neck was shaved and the device was mounted on the shaved area using double-sided adhesive tape, then fluorescein-isothiocyanate(FITC)-sinistrin  was injected intravenously to each mouse at the dose of 150 mg/kg. The transcutaneous FITC signal was recorded continuously for a period of 1.5 h. Imaging data were analyzed using MPD Lab software (Medibeacon) and GFR was calculated from the decrease of fluorescence intensity over time using a two-compartment calculation algorithm as describedThe Munich CKD cohort (MCKD) consisted of 421 patients from the outpatient clinic at Klinikum rechts der Isar, Munich, Germany. Among them were 69 patients without kidney disease (CKD 0°) serving as controls and 352 patients normally distributed across stages I°-V° http://www.pubcare.uu.se/ULSAM). The analyses presented in this study are based on the fourth examination cycle of ULSAM, in which participants were approximately 77 years old (1998–2001). Of 1398 invited men, 838 (60%) participated. Of these, 89 were excluded due to missing data on Cat-S, GFR or co-variates, leaving 749 participants as the present study sample. All 70-year-old individuals living in Uppsala, Sweden, between 2001 and 2004 were eligible for the Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS) study . In the present study the second examination cycle of PIVUS was used (2006–2009), in which participants were 75 years old. Of 964 invited participants, 827 participated (86%). Of these, 23 participants were excluded due to missing data on Cat-S, GFR or co-variates, leaving 804 participants as the present study sample. All participants gave written informed consent and the ethics committee of Uppsala University approved both study protocols. The studies adhere to the declaration of Helsinki.The Uppsala Longitudinal Study of Adult Men (ULSAM) was initiated in 1970. All 50-year-old men born between 1920 and 1924 and living in Uppsala, Sweden, were invited to participate in a health survey aimed at identifying cardiovascular risk factors  and/or apparent signs of kidney damage were present. For diagnosis of kidney damage, we defined proteinuria with a cut-off >150 mg/g creatinine (MCKD) or albuminuria >26.4 mg/g creatinine (ULSAM and PIVUS) on spot-urine specimen and/or histologically proven kidney disease and/or abnormalities detected in imaging techniques . Once the diagnosis of CKD was established, patients were assigned to a certain stage of CKD according to the KDIGO recommendation: CKD I° when eGFR >90 ml/min/1.73 m2 BSA, CKD II° 61–90 ml/min/1.73 m2 BSA, CKD 3° 31–60 ml/min/1.73 m2 BSA, CKD IV° 16–30 ml/min/1.73 m2 BSA and CKD V° 0–15 ml/min/1.73 m2 BSA. Patients with a single kidney (e.g. due to nephrectomy) were assumed to have CKD despite an eGFR >60 ml/min/1.73 m2 BSA. 69 patients in MCKD without a medical history for CKD and an eGFR >60 ml/min/1.73 m2 BSA were assigned to the group CKD 0°. Patients’ demographics of MCKD and PIVUS/ULSAM are given in We applied the criteria for CKD stages according to the current Kidney Disease: Improving Global Outcomes (KDIGO) guidelines® analyzer (Siemens) in ULSAM; with the use of an Architect ci8200 in PIVUS; or using a turbidimetric measurement in MCKD. Serum levels of Cat-S were measured by an ELISA . In the MCKD cohort, blood samples were frozen for a median of 515 days (range 340–677 days) until Cat-S levels were quantified in November 2015. In the ULSAM cohort, blood samples were frozen for a median of 10.0 years (range 8.7–12.4 years) and in the PIVUS study, for 2.0 years  until analysis of Cat-S. The intra-assay coefficient of variation was 7%. To date, there are no established reference values for circulating Cat-S in humans. Soluble TNFR-1 and TNFR-2 were measured as previously described® analyzer  and Cat-S/creatinine ratio (in μg/mol) was calculated.For biomarker analysis, plasma was used in MCKD and serum in PIVUS/ULSAM. Creatinine and blood-urea-nitrogen (BUN) were measured using photometric techniques . In MCKD, cystatin C levels were assessed using a nephelometric immunoassay ; or using a latex-enhanced reagent  detected using a BN ProSpec analyser (Siemens) in ULSAM; or with latex-enhanced reagents  detected using an Architect ci8200  in PIVUS. In MCKD, the eGFR equation was calculated based on serum creatinine and cystatin C concentrations, as publishedFor statistical analysis IBM SPSS 20  and Stata 12  were used. Continuous data are expressed as mean with standard deviation (SD), categorical variables are reported in absolute numbers and percentages. Normality of distribution for all parameters tested was tested using Shapiro-Wilk-test. Differences of biomarker concentrations between patient groups were evaluated using student’s t-test. Univariate correlations between Cat-S and eGFR, sTNFR1/2 were evaluated using Spearman-rank coefficient in the mouse model and Pearson-correlation coefficient in the human cohorts. Additionally in MCKD, correlations between Cat-S and blood creatinine, BUN and cystatin C were assessed using Pearson-coefficient. To adjust the association between Cat-S (dependent variable) and eGFR/sTNFRs (independent variables) for demographic  and inflammation parameters (CRP) multivariable linear regression modelling was applied in the human cohorts. To assess the association between Cat-S and eGFR, the latter was transformed into a standardized scale. Since sTNFRs (independent variables) were not sufficiently normally distributed, both were transformed into logarithmic scales in the referring linear regression model. In secondary analyses we also investigated the association between urinary Cat-S/creatinine ratio with eGFR using univariate Spearman-Rank correlation coefficient. All reported p-values are two-sided, with a significance level of 0.05. Statistical evaluation was performed similarly in all three cohorts included in the study.To address our hypothesis we first studied serum levels of Cat-S in a mouse model of progressive CKD2 BSA) was associated with a decrease of 1.008 ng/ml in Cat-S concentration , plasma Cat-S concentrations progressively increased from CKD I° to CKD V° , Fig. 2A2 BSA in ULSAM, ±19.3 ml/min/1.73 m2 BSA in PIVUS) resulted in a 0.664 ng/ml decrease of Cat-S serum concentrations  or estimated (human) GFR. This inverse correlation is identical to those of sTNFR1 and sTNFR2, two validated markers of systemic inflammation-related endothelial dysfunction.We hypothesized that the progression of CKD and its related systemic inflammatory state is associated with increasing levels of circulating Cat-S, a protease involved in the pathogenesis of cardiovascular disease and a potential therapeutic target to attenuate atherosclerosis in CKDThese results establish the impact of renal function on Cat-S concentrations in the circulation. We recently reported that Cat-S is filtered across the glomerular filtration barrierMarkers of systemic inflammation, such as urinary monocyte chemotactic protein-1, tumor necrosis factor-alpha (TNF-α), and interleukin-6 (IL-6) have been shown to correlate with the severity of CKD2867891011121819Interestingly, we observed that Cat-S and sTNFR1/2 concentrations differed between the three human cohorts in groups with similar eGFR (e.g. CKD III°). Therefore we wondered if other demographic/laboratory parameters besides kidney function might influence their blood concentrations. We reran an exemplary multivariable linear regression analysis focusing on parameters possibly influencing Cat-S in MCKD. We set Cat-S as the dependent variable and added independent variables as follows: eGFR, gender, age, BMI, total serum protein, serum CRP and prevalence of diabetes mellitus, arterial hypertension, vascular disease and tumor disease. In this analysis, besides eGFR only gender was weakly associated with Cat-S (p = 0.043), otherwise no significant data was obtained. Since the clinical samples were similar, we surmise that methodological rather than clinical circumstances lead to these findings. In particular, the sample material may have an influence on the results since plasma was used in MCKD and serum in PIVUS/ULSAM. Furthermore, samples were stored for a much longer period of time in PIVUS/ULSAM. Currently there are no reference values for Cat-S or sTNFR 1/2 in human material, and it would be important to determine in the future whether different value ranges exist for different sample materials and storage conditions.Our study has several strengths, including the use of both experimental and clinical data and the validation of results in independent clinical cohorts with a wide range of glomerular filtration rate. One limitation is that statistical analyses were not adjusted for multiple testing. However, the consistency of results from three different cohorts and a mouse model would argue against spurious association as an explanation of our findings. Other limitations include the lack of longitudinal data in the human cohorts and the use of different sample material in the three human cohorts, possibly limiting the comparability of the results obtained in the three cohorts. It is acknowledged that our data are cross-sectional in nature and only reflect the association between Cat-S and kidney function, with no outcome data provided. Hence, no clinical consequences can be drawn from our findings. However, the association of circulatory Cat-S with outcomes in CKD patients should be evaluated in future epidemiological studies. Lastly, additional markers of endothelial dysfunction and systemic inflammation that have been shown to be associated with CKD could not be measured in our cohorts, and might have been compared with Cat-S to validate the proinflammatory status.In summary, Cat-S, a cysteine protease released by activated immune cells, is consistently found at increased levels that correlate with the progression of CKD in mice and humans. It is tempting to speculate that Cat-S is a causative factor in this association, and a mediator of CKD-related cardiovascular morbidity and mortality. As pharmacological Cat-S inhibition has been shown to prevent macrovascular and microvascular disease in experimental animal models, there appears to be a valid scientific rationale to study whether Cat-S is associated with adverse outcomes in CKD and whether its inhibition can reduce cardiovascular morbidity and mortality in CKD patients.How to cite this article: Steubl, D. et al. Circulating cathepsin-S levels correlate with GFR decline and sTNFR1 and sTNFR2 levels in mice and humans. Sci. Rep.7, 43538; doi: 10.1038/srep43538 (2017).Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


It has been well documented that corin is a critical protease involved in the regulation of blood pressure and cardiac function. We performed a case-control study to determine whether serum corin is associated with the risk of chronic heart failure (CHF). We included 484 consecutive CHF patients and 484 control subjects to investigate the potential relationship between serum corin and CHF using logistic regression analysis. Compared with healthy controls, the CHF patients were more likely to have histories of hypertension and diabetes, and had higher levels of N-terminal pro-brain natriuretic peptide and lower levels of corin. The odds ratios of ischemic and non-ischemic HF were significantly reduced with the growing levels of serum corin after multivariate adjustment. Moreover, the decrease in serum corin levels seemed to be associated with the severity of CHF. In conclusion, our study suggested that serum corin levels were reduced in CHF patients and inversely correlated with the incidence of ischemic and non-ischemic HF. Corin is known as a transmembrane serine protease and has multiple physiological functions in the cardiovascular system. This protease mainly exists in myocardial cells and plays crucial roles in processing pro-natriuretic peptides, thereby regulating salt-water balance and vasodilation . RecentlChronic heart failure (CHF), a clinical syndrome characterized by reduced myocardial contractility, hemodynamic abnormality and neuroendocrine activation, is the major cause of mortality and morbidity in patients with cardiovascular diseases . Over thIn this study, there were 484 control subjects and 484 CHF patients, including 235 coronary heart disease, 97 valvular heart disease, 83 hypertensive heart disease, 42 dilated cardiomyopathy and 27 other cardiovascular diseases. The baseline characteristics of the study population are shown in Tables P for trend, < 0.001) after adjusting for hypertension, diabetes, eGFR and NT-proBNP.Participants were divided into quartiles of corin levels in control subjects to assess the association between serum corin and CHF. With the lowest quartile as a reference, the ORs of CHF were calculated and the results are presented in Table As shown in Table Our findings revealed that the decrease in serum corin levels seemed to be associated with the severity of CHF. The cardiac function in CHF patients was divided into 4 groups according to the NYHA classification. As shown in Figure We carried out this case-control study to determine the association of serum corin with CHF risk in a Chinese population. Our results showed that serum levels of corin were significantly decreased in CHF patients. The ORs of ischemic and non-ischemic HF were markedly reduced with the growing levels of serum corin following multivariate adjustment, which suggests that serum corin was inversely correlated with the incidence of CHF.Corin, which belongs to the transmembrane serine protease family, has a cytoplasmic tail and a single-span transmembrane domain near the N-terminus . AccumulThis study has several limitations. Firstly, it remains unknown whether reduced corin is the cause or the result of CHF, so the conclusions need to be further verified in prospective cohort studies. Secondly, this study was conducted in a Chinese population and the conclusions should be cautiously extrapolated to other ethnic groups. Thirdly, we cannot avoid selection bias, information bias and confounding bias in this study.In summary, our study demonstrated that serum corin levels were decreased in CHF patients and inversely correlated with the incidence of CHF.We consecutively recruited 484 CHF patients with different causes including ischemic, valvular, hypertensive, and cardiomyopathic etiologies between September 2015 and May 2017. The diagnosis of CHF was based on typical symptoms and signs and evidence of left ventricular enlargement and systolic functional impairment by echocardiography. A total of 484 control subjects were randomly selected from the healthy participants. This study was approved by the ethics committee of Soochow University and written informed consents were obtained from all participants.The clinical and biochemical data of patients were obtained from medical records. Hypertension was defined as systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg or receiving antihypertensive therapy. Diabetes was defined as fasting glucose ≥ 7.0 mmol/L or 2-hour postprandial blood glucose ≥ 11.1 mmol/L or use of antidiabetic agents. Hyperlipidemia was defined as triglyceride concentration > 1.7 mmol/L or total cholesterol concentration > 5.7 mmol/L or use of lipid-regulating drugs. The estimated glomerular filtration rate (eGFR) was calculated using the MDRD study equation, taking into account gender, age, race, and serum creatinine. Serum levels of corin and N-terminal pro-brain natriuretic peptide (NT-proBNP) were measured using enzyme-linked immunosorbent assay kits  according to the manufacturer's instructions.2 test. Odds ratio (OR) and 95% confidence interval (CI) were calculated to determine the association between serum corin and CHF risk. Multiple logistic regression analysis was conducted to adjust for hypertension, diabetes, eGFR and NT-proBNP. A P value < 0.05 was considered statistically significant in this study.Data are presented as mean ± SD or percentages. All statistical analyses were performed using SPSS software. Continuous variables were analyzed by Student's t test, while categorical variables were compared by χ