Renal denervation (RDN) is one of the most frequently used invasive methods for the treatment of arterial hypertension. However, recent randomized sham-controlled studies raised concern about the efficacy and predictability of response. We retrospectively analyzed outcomes of patients, who underwent RDN in our hypertension center between November 2010 and April 2014 and report here outcomes twelve months after procedure based on 24-hours ambulatory blood pressure monitoring. We defined ten-mm Hg decrease in office systolic blood pressure (SBP) as a cut-off for response and looked for possible predictors of this response using binary multiple regression analysis. 42 patients were included. Their mean age was 59.6 ± 9.2 years and 24% were female. Baseline office SBP and diastolic blood pressure (DBP) were 164.1 ± 20.3 and 91.8 ± 12.4 mm Hg respectively. Mean 24 h-SBP significantly decreased from 149.8 ± 13.3 mm Hg to 141.2 ± 14.6 mm Hg. Mean 24 h-DBP significantly decreased from 83.3 ± 11.7 mm Hg to 78.8 ± 11.2 mm Hg. A higher level of mean 24 h-DBP and office DBP was shown to be predictive for response in office BP and a higher level of mean 24 h-DBP for response in 24 h-SBP and 24 h-DBP. Further properly designed randomized trials are warranted to confirm this finding as well as further investigate the role of diabetes mellitus and arterial stiffness in RDN. However, reported responses vary from large falls in BP to unchanged or small increase in BP even within a given study population4. This suggests, that specific patient characteristics may predict the response to RDN. Establishing such predictors is very important for clinicians since significant fall in BP after RDN could cause more morbidity due to hypotension, whereas poor response would not be expected to reduce cardiovascular events, which is the primary purpose of BP reduction. The randomized and sham-controlled SIMPLICITY-HTN 3 trial could not show any benefit of RDN compared to sham-group with optimal medical treatment5 and raised doubt about the effectiveness of RDN, though reliable data support the “proof of concept” of RDN7. Recently published sham-controlled Spyral HTN ON-MED and OFF-MED studies demonstrated clinically relevant fall in 24-hours ambulatory systolic BP (SBP) with 7.4 mm Hg after six months in the ON-MED trial and 5.5 mm Hg after three months in the OFF-MED trial9. In the sham-controlled, prospective, double-blind Radiance-HTN solo trial, where an intravascular applied ultrasound was used for renal artery nerve ablation, 24-h-SBP reduction of 5 mm Hg was observed10. Both studies showed a clear tendency for the effectiveness of the RDN procedure. However, the magnitude of response was unpredictable with some over-responder and only about 70–80% presenting with any BP reduction after RDN.Arterial hypertension has a major disease burden. Percutaneous renal denervation (RDN) has been shown to effectively reduce blood pressure (BP) in different previous trials11. Based on ABPM readings, more data are needed from a “real-world setting” dealing with reliable predictors of the response to RDN. In this retrospective analysis, we sought to identify such baseline parameters in a cohort of patients with refractory hypertension, who underwent RDN in our centre. We considered changes in 24 h-BP measured with ABPM in order to avoid shortcomings related to office BP-based assessment of treatment effect.In the light of current data, identification of the predictors for response to RDN seems to be crucial in order to select the patients appropriately. The response should be evaluated according to change in mean 24 h-SBP and diastolic BP (DBP) obtained with ambulatory blood pressure monitoring (ABPM), due to known shortcomings of office BPIn total, 81 patients underwent RDN in our nephrology and hypertensiology department at Charité University Berlin, Campus Benjamin Franklin between November 2010 and April 2014. Complete demographic, clinical and procedure-related data and follow-up data including the course of BP values assessed with ambulatory blood pressure monitoring over 24 hours (24 h-ABPM) was available for 42 subjects, who were included in our retrospective analysis. According to the chosen response definition, twenty-one patients showed BP-response after RDN. Mean patient age, BMI, kidney function, amount of albuminuria, office SBP and DBP, heart rate and the number of antihypertensive medications at baseline and after twelve months did not differ significantly in both groups. In the responder group, the mean 24 h-SBP and -DBP at baseline were significantly higher compared to the non-responder group. In the non-responder group the number of patients with diabetes was significantly higher than in the responder group. Details of demographics and clinical data of the whole collective, responder and non-responder group are presented in Table During RDN 9.9 ± 3.6 ablations were performed. As shown in Table We observed a significant decline in mean 24 h-SBP and 24 h-DBP in the whole group and the responder group twelve months after RDN. Non-responder did not show any significant change in 24 h-SBP and 24 h-DBP. Details for whole group, responder and non-responder are shown in Table In the univariate analysis significantly different parameters between responder and non-responder group  and mean 24 h-DBP  compared to non-diabetics. Both mean 24 h-SBP and 24 h-DBP did not change significantly twelve months after RDN in diabetic patients  to assess the real effect of RDN on BP. Furthermore, in the case of electrical RDN, the ablation procedure was performed with the latest generation multielectrode catheter and generator9. Acknowledging the sophisticated trial design and improvements in ablation techniques, our patients had similar BP response after RDN compared to patients from above mentioned modern RDN-trials. This circumstance underlines the reliability of our data. Worth mentioning, baseline 24 h-DBP in SPYRAL HTN-ON and -OFF MED trials was substantially higher than in our analysis.In this study, we performed a retrospective analysis regarding the BP-lowering effect of RDN-procedure in our center. We saw a clinically relevant reduction in 24 h mean SBP (8.6 mm Hg) and mean DBP (4.5 mm Hg). Observed amount of BP-reduction is comparable with the findings of recent randomized sham-controlled trials, which were explicitly designed to eradicate known limitations of RDN trials13. We observed a statistically significant independent impact of baseline office DBP and mean 24 h-DBP on response to RDN using multiple binary regression analysis. Significant predictive effect of mean baseline 24-h DBP also remained, when the BP-lowering effect was assessed as a continuous variable using multiple linear regression analysis.We choose to dichotomize the BP-response after RDN and set the cut-off by ≥10 mm Hg fall in office SBP as already done in previous studies14. Randomized sham-controlled SIMPLICITY HTN 3 trial confirmed these findings. Various registry analyses including experiences from different countries also found baseline BP as a major predictor of BP-lowering effect after RDN and confirmed data coming from proof-of-concept studies and randomized trials by the evidence from real-life setting21. Noteworthy, baseline SBP predicted lowering effect in SBP and baseline DBP predicted lowering effect in DBP in all previously mentioned studies. In contrast, we observed baseline office DBP and 24 h-DBP being predictors for the fall in SBP (office and 24 h-ABPM). To our knowledge, this finding has not been reported yet and thus extends available evidence. A possible biological explanation could be that higher DBP might reflect arterial vessels without severe and irreversible wall damage. Profound arteriosclerosis leads to increased arterial stiffness, higher pulse wave velocity (PWV), lower DBP and increased prevalence of isolated systolic hypertension (ISH)22. In this case, sympathetic overdrive is probably not a dominant driving mechanism of refractory arterial hypertension and thus associated with impaired response to RDN. Growing evidence supports this hypothesis that patients with advanced arterial stiffness and thus severe arterial wall damage as indicated by increased PWV23, aortic calcifications24 or ISH25 showed attenuated BP response after RDN.Virtually all previously published RDN studies identified baseline BP as the major primary determinant of BP response after RDN: Symplicity HTN-1 Investigators reported the issue for office BP response already in the initially published resultsOne of the major causes of arteriosclerosis is diabetes mellitus. However, the impact of diabetes mellitus on BP response failed the statistical significance in multiple regression analysis, though it has shown a statistically significant negative impact on the BP response after RDN in univariate analysis among our patients. Further analysis of the subgroups with and without diabetes mellitus revealed that the former had significantly higher mean baseline SBP and DBP in ABPM, which could attenuate the effect of diabetes mellitus in the statistical analysis. Furthermore, patients with diabetes had also numerically more ISH compared to the group without diabetes. Lower baseline DBP and higher prevalence of ISH in non-responders and diabetic patients could be an expression of increased arterial stiffness and thus poorer response to RDN in our collective.8. These phenomena could be in part eliminated by ABPM11.One of the strengths of our analysis is that the response to RDN was assessed with office BP measurements and ABPM, though patients were classified as responder or non-responder according to the amount of office SBP change. However, grouping in responder and non-responder according to office BP response reflected the response of 24-h ambulatory SBP and DBP in our analysis very well. As already shown, office BP might have some potential confounding characteristics such as “regression to the mean” phenomenon and white coat hypertension, which significantly influence the amount of BP change over time10.We acknowledge several limitations of our analysis. Our findings were obtained from a single centre and analysed in a retrospective fashion. Thus, looking for potential predictors of response to RDN our findings reflect associations and can only generate a possible hypothesis, which should then be tested in appropriately designed prospective studies. Relatively small number of the included patients and open non-blinded design of the analysis might not be able to cover the abundance of confounding factors in RDN as we have learned from previous studies. Keeping the potentially higher risk of confounding in mind, our results show a similar response to RDN compared to recent second-generation sham-controlled randomized studiesTesting patient compliance was not a part of clinical routine during the follow up after the RDN in our collective. Thus, confounding of the BP-lowering effect of RDN by varying medication intake cannot be ruled out. It is a common problem of all RDN studies or analyses, which included patients on antihypertensive medications without compliance testing as an inclusion criterion or as a part of follow up. We cannot distinguish the true resistant hypertensive patients from the patients who are incompliant to their antihypertensive drugs. Among the non-responders in our study collective, the BP increased over time. A possible explanation of this finding could be the higher amount of incompliant patients, who took their medication in preparation to RDN and shortly after and then reduced or stopped it.18. Study findings could thus not be generally translated to response in ABPM and other cut-offs for a definition of responder vs. non-responder to RDN. Hence, we additionally looked for response predictors for change in mean 24 h-SBP and mean 24 h-DBP in ABPM and could demonstrate that higher baseline 24-DBP, but not baseline office DBP, significantly predicted a higher decrease of mean 24 h-SBP and 24 h-DBP 12 months after RDN. In our analysis, we showed the trend for diabetes mellitus to be a predictor for negative RDN response, which failed to remain statistically significant in the multiple logistic regression. This could be due to a relatively small study collective and further prospective studies directly approaching this issue with more patients are needed.The cut-off margin for responder was defined for office BP based on previous studies26.Recently released new guidelines on the management of hypertension by European Society of Hypertension and European Society of Cardiology do not recommend to use RDN in the clinical routine as hypertension treatment method anymore. One of the concerns leading to this recommendation was insufficient data about the suitable subpopulation of hypertensive patients and lack of predictors for RDN responseThe primary conclusion and clinical implication from our study are that DBP, measured in office and with ABPM, seems to be a predictor of response to RDN. Given that lower DBP could be a reflection of increased arterial stiffness and more advanced arterial wall damage, our data add to the available evidence pointing to impaired response to RDN in patients with increased arterial stiffness. Further properly designed randomized trials are warranted to confirm this finding as well as further investigate the role of diabetes mellitus and arterial stiffness in RDN.This retrospective analysis was performed according to the Declaration of Helsinki and written informed consent was obtained from all patients included. The local ethics committee  approved the study. There is no restriction on the availability of additional materials or information, which can be any time obtained by sending a query to the corresponding author via email.Patients were considered to have resistant hypertension, when the mean of three measurements of office systolic blood pressure was >140 mm Hg and/or of office DBP >90 mm Hg respectively and the mean SBP >130 mm Hg and mean DBP >80 mm Hg with 24 hours ambulatory blood pressure monitoring. 81 patients with resistant hypertension underwent RDN between November 2010 and April 2014. All of them were treated with at least three antihypertensive drugs including a diuretic at maximally tolerated dosages before performing the RDN. Common secondary causes of hypertension such as sleep apnea syndrome, hemodynamic significant renal artery stenosis, hyperaldosteronism, hypercortisolism, abnormality of thyroid function and pheochromocytoma were excluded prior to RDN.Further exclusion criteria were pregnancy, age below 18 years, implanted peacemaker or intracardiac defibrillators, severe cardiac valve abnormalities and renal artery diameter <4 mm or length of renal artery <20 mm. Renal artery anatomy was checked before intervention by either CT-angiography or MR-angiography.For RDN, the Symplicity RDN Catheter System  was used via the right femoral approach. RDN procedure was performed in both renal arteries during the same session with a minimum of five ablation points in each renal artery. The RDN procedure was performed under general anesthesia. We defined the bilateral presence of single renal artery without any anatomical abnormalities as “standard anatomy”; any other case was defined as “non-standard” anatomy.Routine clinical follow-up visits were performed after two days, one month, three months, six months, nine months, and twelve months. During each visit routine blood tests including assessment of kidney function and albuminuria were taken, information about current medication was collected and office blood pressure measurement, as well as ABPM were performed. ABPM was performed using Spacelabs 90207-2 device . The interval between 0600 to 2200 was defined as daytime (readings every 20 minutes) and the interval between 2200 and 0600 was defined as night-time (readings every 30 minutes). The cuff was placed on the non-dominant upper arm and patients were instructed to keep their arm calm during the measurement. 42 patients with complete data for ABPM readings at baseline and after 12 months were included in this retrospective analysis.Whenever a reduction in office SBP achieved ≥10 mm Hg after twelve months compared to baseline, the patient was considered to be a responder to RDN.Isolated systolic hypertension was defined as the presence of SBP >140 mm Hg with simultaneously DBP ≤90 mm Hg detected with office measurements or with ABPM.Continuous variables are expressed as mean with standard deviation. Presence of normal distribution was assessed with the Kolmogorov Smirnov test. In case of normal distribution, we used the t-test for comparison. In case of non-normal distribution, we used the Mann-Whitney-U test for comparison.χ2-test.Discrete parameters are expressed as the number of patients and percentages. The differences were compared using A multiple binary logistic regression analysis with stepwise forward inclusion model was applied to determine the predictors of RDN response after twelve months.The level of significance used for all tests was a two-sided p-value of 0.05.


Regional citrate anticoagulation (RCA) was recommended as the first treatment option for adults by the Kidney Disease Improving Global Outcomes Kidney Foundation in 2012, for the characteristic of sufficient anticoagulation in vitro, but almost no anticoagulation in vivo. Traditionally, the substitute for RCA is calcium-free. This study investigated a simplified protocol of RCA for continuous hemofiltration (CHF) in children using a commercially available substitute containing calcium.+, ionic calcium (iCa2+) and HCO3− concentrations, pH, and the ratio of total calcium to iCa2+ (T/iCa2+). In addition, in vivo and in vitro iCa2+, treatment time, sessions with continuous transmembrane pressure >200 mm Hg, and sessions with clotting and bleeding were recorded.An analytical, observational, retrospective study assessed 59 pediatric patients with 106 sessions and 3580 hours of CHF. Values before and after treatment were compared, including Na2+ achieved the target (0.25–0.35 mmol/L), and in vivo, 95.4% of iCa2+ achieved the target (1.0–1.35 mmol/L). There were 8 sessions with a transmembrane pressure >200 mm Hg and 3 sessions with filters clotted. After treatment, there were 2, 1, and 2 sessions with T/iCa2+ > 2.5 (implying citrate accumulation), iCa2+ < 0.9 mmol/L, and iCa2+ > 1.35 mmol/L. No sodium disorders were recorded. There were fewer cases of acidemia and more cases of alkalemia after treatment compared to before.The average treatment time was 33.8 ± 10.1 hours. In vitro, 88.5% of iCaRCA-CHF with a substitute containing calcium and close monitoring could be a safe and effective treatment for children. In addition, the calcium test site in vitro and the adjustment of citrate should be given strict attention. As a kind of extracorporeal circulation technology, CRRT requires anticoagulation validly. The requirement for anticoagulation during CRRT is stricter for critically ill pediatric patients compared to stable or adult patients because of higher bleeding risk, longer CRRT duration, and slower blood flow. In RCA, anticoagulation occurs only in the extracorporeal circuit via the infusion of citrate, which chelates ionized calcium (iCa2+), resulting in very low Ca2+ levels in vitro. In addition, the levels of blood calcium and coagulation factors are restored after the blood is returned to the patient by supplying enough calcium.Regional citrate anticoagulation (RCA) was recommended by the Kidney Disease Improving Global Outcomes Kidney (KDIGO) Foundation in 2012 as the first treatment option for adult patients with acute renal failure without contraindications.–11 However, this technique is complicated by the lack of commercially available physiological fluids, the various protocols that use different solutes and strategies, and the meticulous adjustment of citrate and calcium perfusions based on blood flow. Because 4% citrate solution contains high levels of calcium and sodium ions, the substitute should contain less sodium and less or no bicarbonate to avoid acid–base imbalances and hypernatremia. In addition, traditionally, the substitute for RCA had to be calcium-free. But, RCA reagents have not been commercially available in China. Efforts to prepare calcium-free substitutes have highly increased the risk of pollution, error, and blood infection, as well as the workload of nurses. Hence, the application of RCA has been severely restricted.In recent years, many studies have shown that RCA in CRRT could be used safely and effectively to treat children.Port formula A solution  is widely used in China as a substitute for heparin anticoagulation. Commercialized hemofiltration basic solution (HBS) contains the same formula as port formula A and meets the basic requirements for RCA (less sodium and no bicarbonate), except that it contains calcium. Thus, this study investigated whether RCA for continuous hemofiltration (CHF) with a commercially available substitute solution containing calcium HBS and a simplified protocol in our hospital is safe and effective in children.22.1The study was approved by the ethical committee of Children's Hospital of Chongqing Medical University (File No. 2015.83). The study included 59 children who were admitted to our pediatric intensive care unit (PICU) at the Children's Hospital of Chongqing Medical University from September 2015 to July 2017. The inclusion criteria of the patients were as follows: all patients were critically ill; a course of RCA-CHF was administered; and the HBS was used as the substitute solution. Patients with hepatic failure or serum lactate >3.4 mmol/L were excluded from this study.2.2The ACH-10 or Plasauto ∑ blood purification device  was used for all patients. Filters  were selected according to patient body weight. Blood pathways were set up via arteriovenous connection, double-lumen central venous connection, or dual-channel venovenous modality. Venous or artery access was obtained by catheters, depending on the age and weight of the child.+ 113 mmol/L, iCa2+ 1.6 mmol/L, Mg2+ 0.797 mmol/L, Cl− 118 mmol/L, and anhydrous glucose 10.6 mmol/L).Before treatment, the extracorporeal circulation tubes and filters were prerinsed with 3 L of saline containing heparin (40 mg/L), to be fully anticoagulated and to exhaust all air, and then with normal saline to drain the heparinized saline. If the volume of the extracorporeal circulation was >10% of the child's blood volume or the child had unstable hemodynamics, then erythrocyte suspension, plasma, or albumin was supplemented. Commercially available HBS  was used as the substitute fluid  was pumped into the extracorporeal blood circulation by infusion pump  through a T-junction connected at the primer of the artery pipeline. Calcium gluconate (10%) was pumped into the extracorporeal blood circulation by an Agilia infusion micropump  through a T-junction connected at the end of the vein pipeline. If the double-lumen central venous catheter was used both for blood taking and returning, then the calcium gluconate was pumped into the body through other venous lines.: blood flow rate = 3–5 (mL/kg/minute); displacement solution rate (mL/hour) = 35 mL/kg; citrate 4% rate (mL/hour) = blood flow rate (mL/minute) × (1.5–2); sodium bicarbonate 5% rate (mL/hour) = displacement solution (mL/hour)/(80–100); and calcium gluconate (10%) rate (mL/hour) = blood flow rate (mL/minute) × (0.1–0.2). However, from August 2015, the initial parameters were slightly modified as follows: blood flow rate (mL/minute) = 35 (mL/kg/minute); displacement solution rate (mL/hour) = 35 mL/kg; citrate 4% rate (mL/hour) = blood flow rate (mL/minute) × 1.8; sodium bicarbonate 5% rate (mL/hour) = displacement solution (mL/hour)/100; and calcium gluconate (10%) rate (mL/hour) = blood flow rate (mL/minute) × 0.1. For example, for a child weighing 10 kg, the initial parameters would be calculated as follows: blood flow rate = 5 × 10 = 50 mL/minute; displacement solution rate (mL/hour) = 35 × 10 = 350 (mL/hour); citrate (4% citrate) rate (mL/hour) = 50 × 1.8 = 90 mL/hour; and sodium bicarbonate 5% rate (mL/hour) = 350/100 = 3.5 (mL/hour).The initial parameters were set and simplified by the following formula2+E), targeted 0.25 to 0.35 mmol/L, and was tested in the extracorporeal circulation pipeline at the site after infusion of the postfilter substitute  within the physiological range  was >2.5, and hypocalcemia could not be corrected by administering calcium gluconate. Hemofiltration was ended for any of the following reasons: achievement of therapeutic goals; coagulation of the filter; transmembrane pressure continuously >200 mm Hg; or continuous treatment for 72 hours (to replace pipeline and filter).A blood gas analysis and test of electrolytes were conducted every 30 minutes after the start of the treatment, both in vivo and in vitro, until the anticoagulation targets of calcium were achieved, and then routinely every 4 to 6 hours to maintain target concentrations. Another anticoagulation protocol, or stopping the CHF, was conducted if the ratio of total calcium to ionic calcium  2 score, reason for CRRT, laboratory data , transmembrane pressure, and bleeding or clotting Table .2.4t test, or expressed as median (first and third quartile), and compared using the Mann–Whitney U test, as appropriate. Statistical analyses were performed with IBM SPSS version 21 software. A P-value < .05 was considered statistically significant.Enumeration data were analyzed using the chi-squared test. Continuous variables consistent with normal distribution were reported as mean ± standard deviation and compared using the 3The study population included 59 pediatric patients with 106 admissions. The median age was 25.2 months (9.6–108.0 months) , and the median weight was 11.5 kg (8.0–24.0 kg) . The RCA treatment duration was 33.7 ± 10.1 hours . The total treatment time was 3580 hours.2+ in vivo and in vitro. During treatment, 563 (88.4%) sessions of iCa2+ in vitro achieved the target (0.25–0.35 mmol/L), with 26 (4.1%) sessions achieving <0.25 mmol/L, and 48 (7.5%) sessions achieving >0.35 mmol/L. In addition, there were 608 (95.4%) sessions where iCa2+ in vivo achieved the target (1.0–1.35 mmol/L), with 19 (3.0%) sessions achieving <0.9 mmol/L, and 10 (1.6%) sessions achieving >1.35 mmol/L.We retrospectively collected data from 637 sessions of iCa3.1+, iCa2+, and HCO3− concentrations, pH value, T/iCa2+ ratio, and iCa2+ in vivo before and after treatment. After treatment, the average concentrations of iCa2+, T/iCa2+, Na+, and HCO3−, and pH were all significantly higher than before treatment  with T/iCa2+ > 2.5, which usually indicated citrate accumulation.–19 This suggested that most children could tolerate a sodium citrate concentration of 4 mmol/L in the extracorporeal circulation. In addition, there were very few calcium disturbances, with only 1 session of iCa2+ < 0.9 mmol/L and 2 sessions of iCa2+ > 1.35 mmol/L. There were less cases of acidemia and more cases of alkalemia after treatment compared to before, with HCO3− < 22 mmol/L (11 cases vs 52 cases), pH < 7.35 (6 cases vs 24 cases), HCO3− > 27 mmol/L (44 cases vs 14 cases), and pH > 7.45 (18 cases vs 3 cases). These results may be due to several factors. First, severe illness or acute renal failure of the patients was easily complicated by acidosis. Secondly, the dose of sodium bicarbonate may need to be further reduced, especially in cases of alkalemia. Although the average iCa2+, T/iCa2+, Na+, HCO3− concentrations, and pH were all significantly higher after treatment compared to before treatment, the average was still within or near the normal range. This indicates that it was safe to use RCA with a substitute containing calcium for CHF in children within 32.4 ± 11.6 hours.In summary, our results showed that RCA with a substitute containing calcium could be safely used for CHF in children. To achieve the target concentration (0.25–0.35 mmol/L), we had to use more sodium citrate to chelate the extra calcium ions in the substitute containing calcium. The actual flow of sodium citrate (mL/hour) was related to the blood flow rate, as determined by the recommended formula: 1.8 × blood flow rate (mL/kg/minute). In this study, the concentration of sodium citrate in vitro was higher (4 mmol/L) than that reported in other studies using calcium-free substitutes (2.5–3.5 mmol/L).–10 we had only 8 sessions (7.5%) with a transmembrane pressure >200 mm Hg and 3 sessions (2.8%) of clotted filters. This suggests that the filters may not meet the limit of the filter life, and the relatively short turnaround time might be more related to early achievement of the treatment goal.We performed this study to clarify that a substitute containing calcium could effectively maintain the anticoagulant state of the extracorporeal circulation, without affecting total coagulation. In this study, there were 106 filters with a total time of 3450 hours. Moreover, although the average treatment time (33.8 ± 10.1 hours) was shorter compared to other studies (39.8 ± 4.8 hours),In total, 637 pairs of calcium ions were collected during the treatment, including 563 (88.4%) in vitro that achieved the target (0.25–0.35 mmol/L) and 608 (95.4%) in vivo that achieved the target (1.00–1.35 mmol/L). Therefore, this study showed that RCA-CHF with a calcium substitute is safe and effective in children.4.1When using a calcium-free substitute, the postfilter is always placed in the blood collecting location  had the following initial flow rate parameters: blood 100 mL/minute; 4% sodium citrate 180 mL/hour; filtered solution 1.5 L/hour; and 10% calcium gluconate 10 mL/hour. Thirty minutes after beginning treatment, the calcium concentration in vitro was 0.55 mmol/L, which finally dropped to <0.35 mmol/L until the flow of 4% sodium citrate rose to 230 mL/hour. The filter duration was only 12 hours, perhaps because the in vitro calcium concentration at >0.35 mmol/L lasted for 6 hours. In this study, the practical flow rate of 4% sodium citrate was higher compared to other studies. This might be because there was more calcium due to ∼0.8 L HBS . Therefore, we had to either reduce the flow rate of the filtered solution or increase the flow rate of the 10% calcium gluconate.There has been no consensus regarding RCA-CHF in children with a substitute containing calcium. The present study is limited by a small sample size, leading to low statistical power in the results. In addition, the results were not adjusted for multiple confounders such as life-style, age, and environmental factors. To confirm our results, a larger patient population should be included in future studies.Based on our findings, RCA-CHF with a substitute containing calcium can be safely and effectively used in children with close monitoring. In particular, the calcium test site in vitro and the adjustment of citrate should be given close attention.Conceptualization: Fang Zhou.Data curation: Hongxing Dang.Methodology: Ke Bai.Supervision: Chengjun Liu.Writing – original draft: Ke Bai.Writing – review & editing: Feng Xu.


To assess the association between the levels of interleukin 17 (IL-17) and T-helper 17 count and symptom severity and etiology of chronic heart failure.+IL17+) Th17 cells and CD4+ helper T-cells in peripheral blood mononuclear cells of 42 patients with CHF and 42 matched controls. A multiple regression model assessed the predictors of peripheral IL-17 expression and Th17 count in patients with CHF.This single-center prospective case-control study, conducted from December 1, 2015 to January 1, 2017 in Tehran Heart Center, evaluated gene expression of IL-17, relative count of  functional class (class IV) than in controls and patients with class I. Th17 cell population expanded in patients with CHF, more prominently in patients with class IV than in controls and patients with class I, regardless of the ischemic or non-ischemic CHF origin. Multiple regression model showed that NYHA was the only meaningful predictor of IL-17 levels and Th17 count.We demonstrated the lymphocytic origin of IL-17 production in advanced CHF and the ability of disease severity to predict IL-17 levels.Oxford Centre for Evidence-based Medicine level of evidence: 3. The hallmark feature of congestive/chronic heart failure (CHF) is progressive myocardial fibrosis and cardiac remodeling . After mAlong with disease progression and progressive expression of proinflammatory cytokines, loss of forkhead box P3 (FOXP3) expression gives rise to maturation of regulatory T-cells without immunosuppressive phenotype that retain their profibrotic features. According to Bansal et al , the incLi et al  demonstrThis was a single-center prospective case-control study conducted from December 1, 2015 to January 1, 2017 in Tehran Heart Center, a national cardiology referral center.β = 0.84) and significance threshold of 95% (Zα/2 = 1.96), we used standard deviations (SD) and mean differences from a similar study  analyses were 95% and 89%, respectively.Adopting a statistical power of 80%  from referrals to the Tehran Heart Center as the case group. A total of 42 age- and sex-matched healthy individuals  were included from Iranian Blood Transfusion Bank during the same period as the control group .The diagnosis of CHF in the case group was made on clinical grounds and the patient’s most recent echocardiography (performed within a maximum of 6 months), and if not available echocardiography performed at the time of sampling, in which the left ventricular ejection fraction (LVEF) had been less than 45% and signs of structural heart disease, including but not limited to left ventricular eccentric hypertrophy, left ventricular remodeling, dilation, hypokinesia, etc. were evident . PatientPatients were excluded if they were in decompensated heart failure phase at the time or within the last 1 month of sampling, or if they had experienced acute coronary syndrome within the last 6 months. Additional exclusion criteria were: 1) current or recent (within the last 1 month) history of infections or presence of fever, 2) co-morbid malignancies, 3) use of non-steroidal anti-inflammatory agents, corticosteroids, or biological drugs at the time of sampling, 4) a recent (within last 1 month) change in medication regimen, and 5) history of chemotherapy with cardiotoxic agents or clear history of exposure to cardiotoxic/profibrotic chemicals , or 6) history of congenital heart defects (repaired or unrepaired). Following the establishment of described preliminary eligibility criteria, patients were invited to participate in the study. Fifty of the contacted patients visited our center and provided their latest echocardiography reports or underwent echocardiography. Patients with isolated diastolic dysfunction, ie, constrictive cardiomyopathy (1 patient with Tb pericarditis) and post-chemotherapy CHF (3 patients), were excluded from the case group. Further 4 patients refused to give blood sample after echocardiography and were excluded. Details on case selection criteria are depicted in Patients with ischemic etiology of CHF were defined based on evidence of coronary artery disease identified through catheterization techniques or myocardial perfusion studies (n = 30). The etiology for CHF in the rest of the patients was identified through detailed clinical history taking. Those not fulfilling the criteria for ischemic CHF, and with otherwise non-significant history, were categorized as patients with CHF of non-ischemic origin. Thirty patients had ischemic CHF, while 12 patients had non-ischemic CHF. None of the patients had undergone open heart surgery, resynchronization therapy, or had cardioverter-defibrillators implanted. Thirty patients had both systolic and diastolic heart failure and none of the patients had co-morbid atrial fibrillation. Patients were also classified into four functional classes according to NYHA classification. Six patients belonged to class I, ie, they had no limitation in physical activity, 11 to class II, ie, they had signs of fatigue, palpitation, dyspnea during less-than-ordinary activities, 12 to class III, and 13 to class IV, ie, they experienced dyspnea and fatigue during activities less-than-ordinary living chores or at rest, respectively.Blood samples for the control group were randomly selected from samples obtained by the Iranian Blood Transfusion Bank during the same period when case collection was performed. Ninety individuals were initially selected from a total of ~ 1500 referrals, and were age- and sex- matched with the cases based on their records. These individuals were contacted by telephone, provided information about the aim of the study, and asked whether they opt for their sample to be used for this purpose. A detailed medical history was then obtained. Controls were excluded if they had any history of coronary artery disease, hypertension, diabetes, or other cardiac risk factors. Disease-free status of individuals with incomplete medical records was confirmed through outpatient visit and echocardiography. This led to inclusion of a final number of 42 age- and sex-matched healthy individuals as control group. Mean systolic/diastolic blood pressure of controls was 135 ± 28 mm Hg /83 ± 21 mm Hg.This study was approved by local ethics committee and institutional review board of Tehran University of Medical Sciences, under ID: 2034, in July 2015. The study protocol and aim of the study was clarified to all study participants. Signed informed consent forms were obtained from all enrolled case participants, to perform sampling, echocardiography and necessary procedures (at the expense of the investigators) and for publication of the results as papers.6/mL of the cellular suspension. RNA pellets were melted in nuclease-free DEPS water (30 μL) were stored at -70°C. Quality of extracted RNA was determined using Nanodrop ND-1000 instrument , measuring optical density (OD) of the samples at 260 nm and 280 nm. Preparations with an OD ratio 260/280 less than 1.8 were discarded. Phenolic contamination was assessed using OD ratio of 260/230 nm, which was above the optimal .An amount of 5 mL of whole blood was obtained from cases and controls and PBMCs were isolated through Ficoll–Paque density gradient centrifugation . Total cellular RNA was isolated with 12000 rpm (RPM) centrifugation, using RNX solution , and an amount of 5-10 × 101 µg of total RNA from each sample was reverse-transcribed to complementary DNA (cDNA) using High Capacity cDNA Reverse Transcription Kit  according to the manufacturer’s instructions. An amount of 500 ng total RNA, 2μL 10X Buffer M-MuLV, 1 μL Random hexamer , 1 μL Oligo d(T)18 primers , 0.5μL M-MuLV Reverse Transcriptase (200u/µL), 0.5 μL RNase inhibitor (40u/µL), 2μL dNTP Mixture, and nuclease-free water were used for each reaction in a total volume of 20 μL. The mixture was incubated at 25°C °for 10 min, followed by 42°C° for 60 min and finally 5 min at 85°C°. cDNA solutions were stored at 80°C until they were used in further analyses.−ΔΔCT) formula  method. Quantitative PCR reactions were performed with 20-μL reaction mixtures, using TaqMan Universal PCR Master Mix  and 1-μL primer/probe pairs . Difference in expression of IL-17 between cases and controls were normalized against β-Actin (as housekeeping gene), via ABI Prism7900 Sequence Detection System . Threshold cycle (CT) during the exponential phase of amplification was determined by real-time monitoring of fluorescent emission after cleavage of sequence-specific probes  by nuclease activity of Taq polymerase . Results were calculated using the comparative Ct  supplemented with 1% penicillin- streptomycin-L-glutamine (Sigma-Aldrich). Isolated PBMC were incubated at 37°C, with 1.5% phytohemagglutinin  . After 48 hours of incubation with PHA and exposure to humidified (95% H2O + 5% CO2) atmosphere, the supernatant was collected and stored at -70°C until enzyme-linked immunosorbent assays (ELISA).PBMC were resuspended in complete medium (CM) in 10We measured TGF-β1 in the supernatant of PHA-stimulated PBMCs using specific commercial ELISA according to manufacturer’s instructions . Relative concentrations were determined by measuring optical density at 450 nm in a spectrophotometric microtiter plate reader.6 cells were incubated in each well of a 24-well plate with phorbol myristate acetate (PMA) (50 ng/mL) (Sigma-Aldrich) and ionomycin (1 μg/mL) (Sigma-Aldrich), at 37°C and CO2 5% for 5 hours. Cultures were excubated at 30 minutes to add Brefeldin A (3.0 μg/mL)  to inhibit endoplasmic reticulum transportation of cytokines. After 5 hours, cells were extracted and expanded to 50 µL solution at 1 × 106 concentration.To stimulate cytokine production, 2 × 106 cells from each tube of cultured PBMC was suspended in a 5% Fetal Calf Serum (FCS) buffer. Anti-cell-surface antibody, anti-CD4-fluorescein isothiocyanat (FITC)  was added to the staining buffer to reach the volume of 50 µL and further 50 µL of the cellular suspension was prepared. The mixture was incubated in a dark room at 4°C for at least 30 minutes before being washed and resuspended in staining buffer.In order to perform cell surface staining, an amount of 1 × 10Following extracellular staining with CD4-FITC, cellular suspension was mixed in IC Fixation buffer, incubated at dark room at 20°C, mixed with 2 mL of Permeabilization buffer, and centrifuged at 300-400 g at room temperature, with all steps being repeated twice. Finally, fluorescent anti-Human IL-17A PE solution  was added to the cellular precipitate and incubated for further 30-60 minutes in dark room at 4°C. The suspension was then mixed with perm buffer before being centrifuged at 300 g. The resulting cellular cocktail was resuspended in staining buffer and was immediately used to obtain flow cytometry data on a Fluorescence Activated Cell Sorter (FACS) Calibur . Other analyses were performed using the free software flowjo 7.6 .t test or Mann-Whitney U-test were used for between-group comparisons. Pearson correlation was used to identify correlations between baseline characteristics of patients, including age and disease duration, with variables of interest. Comparisons between NYHA functional class groups were made using one-way ANOVA analysis, with Bonferroni correction for multiple comparisons. The corrected P above the cut-off of 0.05 was considered significant. Post-hoc analysis was performed using Tukey's honestly significant difference (HSD) when the Leven’s test satisfied the assumption of homogeneity of variance or the Games Howell test when data did not meet the homogeneity criteria.Normality of distribution was determined by Kolmogrov-Smirnov test. Independent post-hoc plotting of the residua squares against predicted values. P < 5% were considered significant for the model as a whole, and for each variable. Statistical analyses were performed using SPSS Statistics for Windows, Version 23.0. .Multiple regression analysis was used to assess significant predictors of baseline and stimulated expression levels of IL-17 and Th17 count. We considered NYHA functional class , sex and ischemic vs non-ischemic origin of the CHF (as dichotomous parameters), age and disease duration  in univariate analyses against baseline and stimulated IL-17 expression and Th17 count . VariablP < 0.001). One-way ANOVA revealed a significant difference in IL-17A expression among patients with different NYHA groups  = 35.44, P < 0.001). Tukey’s post-hoc analysis revealed higher expression in patients with class IV and class III compared to patients with class I . Patients with classes III and IV combined had higher levels of IL-17A expression than controls , but not compared with patients with classes I and II (P = 0.21) (IL-17A was higher at baseline level (before stimulation with PHA 1.5%) in patients with CHF compared to controls (I and II . Patient = 0.21) .P = 0.001 and <0.001, respectively). One-way ANOVA analysis showed that stimulated IL-17A expression was different in patients with different NYHA stages  = 27.78, P < 0.01). Tukey’s post-hoc analysis revealed differences in IL-17A expression between NYHA class IV and I (P = 0.027) , while there was no difference between the two groups separately (P = 0.12)IL-17 after stimulation was higher in patients in combined class III and IV compared to controls  (P = 0.0= 0.027) . Both gr+IL17+) were expanded in patients with CHF (P < 0.001). This increase was significantly different between all NYHA classes  = 14.01, P < . 05) and according to post-hoc Tukey between classes IV and II (P = 0.041). The difference was also significant between the control group and patients in class III (P = 0.006) and IV (P < 0.001) (P = 0.001) and also in patients with non-ischemic origin than in controls (P < 0.001), there was no difference between ischemic and non-ischemic group (P = 0.08) (Th17 cells (CD4< 0.001) . While T = 0.08) .P < 0.01, and Pearson correlation coefficient: 0.37, P = 0.012, respectively) and controls . IL-17A at baseline and after stimulation correlated with disease duration in CHF patients . Male patients with CHF had a borderline lower expression of IL-17 and Th17 count compared to women .Baseline and stimulated IL-17A expression showed significant correlation with age in both patients .Finally, we included the significant factors predicting IL-17 expression and Th17 count: age, sex, disease duration, NYHA functional class, and ischemic vs non-ischemic origin of CHF into a multiple regression model. It showed that the NYHA function class was the only meaningful predictor of baseline and stimulated IL-17 and Th17 levels, considering other variables: age, sex, disease duration, and CHF etiology as covariates , compared to both controls and patients in functional class I and II. These results suggest that peripheral IL-17 production is associated with CHF progression, and that Th17 cells are perhaps the main source of IL-17 in late stages of CHF. Also, according to our previous results investigating Treg and Th1 population in patients with CHF ,13, the As CHF progresses, the Th17/Treg ratio progressively increases to support the profibrotic state, with activation of p38/mitogen-activated protein kinases . Yan et Restoring the balance between Th17/Treg should be able to reverse the positive feedback loop described above. Even in rats with established ischemic cardiomyopathy, physical training was able to restore the Treg population and mitigate the production of IL-6, TNF-α, and later IL-17 in peripheral blood . Catechipost-hoc power of the comparisons between patients with ischemic and non-ischemic CHF was 84.01%, 89.0%, and 89.5% for baseline IL-17A, stimulated IL-17A, and Th17, respectively. Meanwhile, the low number of patients with non-ischemic CHF does not affect the assumption that with a larger group of CHF patients, IL-17 could be found to be preferentially expressed in either of the two groups.Finally, we found no difference between patients with ischemic and those with non-ischemic origin of CHF in IL-17 levels or Th17 cell count. It might be postulated that the late increase in IL-17 happens regardless of the initial insult and as a product of Th17/Treg induction dysregulation. In line with this, IL-17 was able to drive myeloid cell infiltration and remodelling in models of inflammation-induced dilated cardiomyopathy , and eveResults of our study are limited in validity by two main sources: 1) selection of the case group (selection bias) and 2) measurement bias. Our effort was focused on selecting patients with CHF in whom the inflammatory/immune status was not disrupted by any other accompanying condition. Meanwhile, we could not control for the anti/pro-inflammatory effects of diuretics, diabetes medication, and digitals in general inflammatory milieu of the body, cytokine production, and T-cell population. Also, we did not perform perfusion scan in all patients, which is considered a gold standard to discriminate left-sided from right-sided heart failure. Echocardiography is generally acceptable to measure volume and pressure of heart chamber and differentiate systolic from diastolic dysfunction. As for measurement bias, we were unable to differentiate between local (within cardiac muscle) and peripheral source of IL-17 production. We know that in late stages of CHF, infiltrating lymphocytes are also a major source of cytokine production and contribute to cardiac dysfunction and failure. We were unable to differentiate between these two sources.Nonetheless, our results reiterate the importance of IL-17A as a principal dual-effect, profibrotic and proinflammatory, cytokine in late stages of CHF. It would be also useful to use other cell surface markers of T-cells to identify cell-specific targets for development of biologic agents to combat cardiac remodeling in advanced CHF.


Based on data of the SPRINT trial, American hypertension guidelines recently reduced the blood pressure goal from 140/90 mmHg to 130/80 mmHg for subjects with chronic kidney disease (CKD), whereas European guidelines recommend a systolic blood pressure (SBP) of 130–139 mmHg. The present analysis investigates whether a SBP < 130 mmHg is associated with an additional benefit in renal transplant recipients. We performed a retrospective analysis of 815 renal transplant recipients who were stratified according to mean office SBP values < 130 mmHg, 130–139 mmHg or ≥140 mmHg. Patient and graft survival was defined as composite endpoint, follow-up was limited to 120 months. Mean SBP of the follow-up was significantly associated with the composite endpoint (n = 218) with better survival for a SBP < 130 mmHg and 130–139 mmHg compared to ≥140 mmHg (p < 0.001). The differences in the combined endpoint remained significant in Cox regression analysis adjusted for age, gender and eGFR , but not for graft survival alone. Renal transplant recipients with SBP < 130 mmHg had a lower mortality than those with the conservative blood pressure goal <140 mmHg. These data suggest that the new AHA BP targets are safe for renal transplant recipients and – with all limitations of a retrospective analysis - might even be associated with improved outcome. The cardiovascular risk of the transplant population exceeds the risk of the general population by far3. Hypertension has a prevalence of 80% in renal transplant recipient and represents one of the crucial determinants for cardiovascular events4. The optimal blood pressure (BP) target for this population remains elusive. To date, there are no randomized trials on the management of hypertension after kidney transplantation5. Current guideline recommendations are conflicting. The 2009 KDIGO guidelines on renal transplantation recommend a systolic blood pressure (SBP) goal of <130 mmHg. This recommendation was based on former hypertension guidelines of the general population suggesting this goal for chronic kidney disease (CKD)6. Since that time several international hypertension guidelines - including the European and the American ones – liberalized BP targets for non-proteinuric CKD to <140 mmHg8.Cardiovascular events are the leading cause of death and a major reason for graft loss after renal transplantation9. Interestingly, 28% of the SPRINT population suffered from CKD. In this subgroup intensive blood pressure control led to a 27% reduction of mortality. In November 2017, the American Heart Association (AHA) therefore adapted their blood pressure targets. For subjects at high cardiovascular risk – including CKD – the new SBP target is <130 mmHg10. The new guidelines from the European Society of Hypertension were published after the AHA guidelines in 2018 and recommend a systolic target blood pressure of 130–139 mmHg and a diastolic blood pressure <80 mmHg for CKD11. Thus, there is currently no consensus on the ideal blood pressure in subjects with impaired kidney function and thereby renal transplant recipients (3).The SPRINT trial led to a reversal of the liberalization of BP targets in CKD. A mean SBP < 130 mmHg was associated with a substantial reduction of cardiovascular and overall mortality compared to a conventional BP management in a cardiovascular high risk populationIt is not clear, which guidelines should be regarded suitable for renal transplant recipients and whether these subjects benefit from an intensive BP control. The aim of the present retrospective analysis of three transplant centers in Germany is to investigate whether an intensive BP control is associated with a better graft and patient survival than conservative BP control.858 subjects were screened for inclusion. 43 subjects were excluded for reasons of incomplete BP documentation. 815 patients were enrolled and stratified according to mean SBP over the complete follow-up . Mean BP was 133.2 ± 11.8 mmHg in the overall follow-up period. As presented by Table During the follow-up a total of 118 patients returned to dialysis and 110 patients died. Kaplan Meier analysis revealed significantly different cumulative survival curves in dependence of BP. The lowest SBP was associated with best survival rates, the highest BP with lowest survival rates (p < 0.001). The composite endpoint of patient and graft survival differed significantly among the groups in an analogous manner . Outcome was worst, if mean SBP was ≥140 mmHg in the first 12 months after transplantation. Supplementary Fig. 12. A well performed retrospective analysis – with all its inherent limitations - in a large cohort of subjects is therefore currently the best way to address this question of daily clinical interest.“It is unlikely that there will be randomized controlled trials in kidney transplant recipients to determine whether blood pressure lowering reduces cardiovascular disease events, or prolongs patient or graft survival.” Almost 10 years after the publication of this statement in the KDIGO guidelines on renal transplantation, this prediction is still true13. The present study shows for the first time that a SBP target <130 mmHg is associated with an even better outcome. In all Kaplan Meier and Cox regression analyses cumulative survival regarding both the primary composite and the individual secondary endpoints was best in the group with strict BP control (<130 mmHg), followed by conservative BP control (130–139 mmHg) and worst in those subjects with uncontrolled hypertension. The post-hoc log-rank testing of the two lower BP groups proved that the additional benefit on the composite endpoint was statistically significant suggesting that the new blood pressure target of the AHA guidelines might be suitable for renal transplant recipients as well. Moreover, this analysis uncovered that this additional benefit is primarily driven by the reduction of mortality and not the reduction of graft loss. This finding resembles the outcome of the SPRINT CKD population. Intensive BP control resulted in a significant reduction of mortality but only to a trend in renal endpoints like doubling of creatinine or initiation of dialysis14. The SPRINT CKD population had a very low grade of proteinuria with a mean urinary albumin-creatinine ratio of only 13 mg/g14. Several trials in non-transplant CKD populations have demonstrated that intensive compared to conservative BP lowering does only provide additional GFR-sparing benefits in proteinuric CKD.Former retrospective analyses have convincingly shown that a SBP < 140 mmHg is associated with improved patient and graft survival15. In summary, data of the non-transplant CKD population suggest a convincing cardiovascular benefit by intensive BP control, whereas the additional effects on slowing the progression of renal disease are restricted to proteinuric subjects. The present population had a low level of proteinuria (>200 mg at month 12), which may explain why the trend to improve graft survival did not reach statistical significance.The African American Study of Kidney Disease and Hypertension (AASK) trial had a large impact on the liberalization in the CKD population. A blood pressure target <130 mmHg did not result in a better conservation of renal function than a goal <140 mmHg over a period of 3–6 years in a population of almost 1100 subjects with CKD. At closer view, however, proteinuric patients actually did benefit from the intensive blood pressure control, whereas only non-proteinuric subjects did not. The AASK trial thereby confirmed the historical findings of the Modification of Diet in Renal Disease (MDRD) studyAs illustrated by Fig. But is BP indeed the chicken or could it be the egg? As demonstrated in SPRINT, a lower BP can result in a reduction of mortality. A “better” allograft function, however, could result in lower BP as well. A retrospective analysis is never able to prove causality. In order to minimize this possibility, adjustment by baseline eGFR was performed in the Cox regression. Noteworthy, the benefit in both the composite endpoint and mortality remained, whereas only the benefit in graft survival lost statistical significance. These data indicate a major “chicken” role of BP control on patient survival and a minor causal role on graft survival. The second cox regression model additionally including live donor transplantation and donor age as covariates still showed significant differences among the three groups. Thus, these differences are unlikely to be explained by the heterogeneity of groups.16. The Collaborative Transplant Study revealed an association between BP and outcome as well. The present study, however, differs from these historical ones in two crucial aspects. First, it compares a SBP < 130 with <140 mmHg for the first time. Second, it contains an adjustment for several parameters including baseline eGFR, thus making a causal relationship between BP control and improved outcome very probable.Our data are in line with previous observations in the literature: Thus, a 10 mmHg increase of SBP was associated with an increase in the risk of graft loss by 12%17. In analogy to the SPRINT trial, we did primarily focus on systolic and not on diastolic BP in the present analysis, since diastolic BP decreases with increasing arterial stiffness.The second mode of stratification showed that the mean SBP of the first 12 months predicts outcome. In analogy with the first analysis, there were significant differences in both the primary and the two individual secondary endpoints death and graft survival. Still, a SBP < 130 mmHg performed best. This finding underlines the importance of BP control early after transplantation. Interestingly, one-year BP was recently identified as a major risk factor for deteriorating kidney function after heart or liver transplantation as well16. The present study population performed somewhat better with two thirds reaching this goal. Nevertheless, is it reasonable to call for a more challenging BP goal, when one third of our patients still do not reach the conservative one? Yes indeed, since “what is better is the enemy of what is good.” Moreover, a more ambitious BP goal is likely to increase the rate of subjects reaching at least <140 mmHg.What are the consequences of these data for clinical practice? In 2004 50% of the American transplant recipients did not reach the BP goal <140 mmHgThe study is primarily limited by its retrospective character. The adjustments for eGFR in cox regression and the confirmatory Kaplan Meier analysis using a second stratification approach attenuate this limitation as far as possible. Nevertheless, a retrospective analysis can never prove causality. Moreover, data on proteinuria were not available for the complete study population.The present retrospective study analyzed the application of the new hypertension guidelines to renal transplant recipients for the first time. Renal transplant recipients who achieve a mean SBP < 130 mmHg had a significantly lower mortality than with the conservative goal <140 mmHg. This finding remained unchanged after adjustment for baseline allograft function. These data suggest that the new BP targets are safe for renal transplant recipients and – with all limitations of a retrospective analysis - might even be associated with improved outcome.Patients who underwent kidney transplantation at two transplant centres of the Charité – Universitätsmedizin Berlin, Germany (Campus Benjamin Franklin and Campus Virchow Klinikum) and at the University Hospital Knappschaftskrankenhaus Bochum between 1997 and 2011 were screened for inclusion in this retrospective study. Patients were selected from the outpatient clinics of these transplantation centres. Data for analysis were collected from patients undergoing routine examinations based on clinical indications in a retrospective manner, thus making an approval from the local ethical board unnecessary.Inclusion criteria were renal transplantation between 1997 and 2011 and documented follow-up examinations including laboratory and BP values in the outpatient clinic for at least 12 months after transplantation with at least 4 documented visits in the outpatient clinic. Data were documented from single measurements of 7 visits during follow-up: 3, 6, 12, 36, 60, 84 and 120 months after transplantation.BP measurements took place in the outpatient clinics of the three transplant centers according to each center’s standard. Both manual auscultatory BP measurement and oscillometric blood pressure measurement by automated devices were applied. Measurements took place in separate rooms of the outpatient clinic by a nurse, who stayed in the room. The nurse usually refrained from repeated measurements. Thus, the analysis was based on single office BP values. The population was characterized for epidemiological parameters, cardiovascular comorbidities, renal disease, and transplant related parameters. The presence of a concomitant disease was presumed if such a diagnosis (e.g. hypertension or coronary artery disease) was found in the medical history of the patient. Antihypertensive or antidiabetic medication allowed to categorize a patient as having hypertension or diabetes mellitus. Graft loss was defined as reinitiating any type of renal replacement therapy.Death or graft loss was defined as primary composite endpoint. Subjects were stratified according to their SBP in two statistical approaches. First, the stratification was based on the mean SBP of the above mentioned visits during the complete follow-up (3–120 months). The second analysis investigated the impact of the first year’s BP on outcome parameters. Hence, mean SBP of the first 12 months posttransplant was used for stratification. The timepoint of 12 months was selected since graft function, antihypertensive and immunosuppressive medication have usually reached a “steady state” at this time. Subjects were divided into three groups: The first one achieving the new AHA goal SBP < 130 mmHg, the second one fulfilling the European guidelines (SBP 130–139 mmHg), and the third one failing to reach the criteria of any of these guidelines (SBP ≥ 140 mmHg). Data about the diastolic blood pressure were documented and analyzed but patients were divided in the groups based only on SBP.2-test. Intergroup differences of BP and pulse pressure were examined by analysis of variance (ANOVA). Cumulative patient and graft survival was calculated by Kaplan Maier analyses after stratification of patients by their mean SBP over the follow-up period. Cox regression analyses were performed for the primary composite endpoint and the individual secondary endpoints. They were adjusted for all the parameters that showed a significant intergroup difference at baseline . Cox’s proportional hazards model was used as multivariate analysis to estimate hazard ratios (HR) with 95% confidence intervals (CI) for the study outcomes. Kaplan Maier analyses were repeated using a stratification by mean SBP of the first 12 months posttransplant. Post-hoc log- rank test was used to determine significant differences. P < 0.05 was regarded statistically significant. All statistical analyses were done using SPSS Statistics 21  and Prism 6 .Continuous data are presented as mean ± standard deviation, discrete data as median and range. Data was tested for normal distribution by the Kolmogorov-Smirnov test. Comparison of categorical parameters was performed by Fisher’s exact test and Pearson-ΧSupplement


Indoxyl sulfate (IS), a product metabolized from tryptophan, is negatively correlated with renal function and cardiovascular diseases in patients with chronic kidney disease (CKD). We investigated the association between serum IS levels and endothelial function in patients with CKD. Fasting blood samples were obtained from 110 patients with stages 3–5 CKD. The endothelial function, represented by vascular reactivity index (VRI), was measured non-invasively using digital thermal monitoring. Serum IS levels were determined using liquid chromatography–mass spectrometry. Twenty-one (19.1%), 36 (32.7%), and 53 (48.2%) patients had poor (VRI < 1.0), intermediate (1.0 ≤ VRI < 2.0), and good (VRI ≥ 2.0) vascular reactivity. By univariate linear regression analysis, a higher prevalence of smoking, advanced age, higher systolic, and diastolic blood pressure (DBP), elevated levels of serum phosphorus, blood urea nitrogen, creatinine, and IS were negatively correlated with VRI values, but estimated glomerular filtration rate negatively associated with VRI values. After being adjusted by using multivariate stepwise linear regression analysis, DBP and IS levels were significantly negatively associated with VRI values in CKD patients. We concluded that IS level associated inversely with VRI values and had a modulating role in endothelial function in patients with stages 3–5 CKD. For a majority of patients with chronic kidney disease (CKD), cardiovascular disease (CVD) is the main cause of mortality not fully related to traditional risk factors such as age, hypertension (HTN), and diabetes mellitus (DM), but also non-traditional factors including inflammation, abnormal bone and mineral metabolism, and endothelial damage or dysfunction ,2. EndotIndoxyl sulfate (IS), initially only known as a gut-derived protein-bound uremic toxin, accumulates as renal function decreases and accompanied by a negative correlation with the level of kidney function . Besidesp = 0.020). Systolic blood pressure , diastolic blood pressure  and serum blood urea nitrogen , creatinine (p = 0.001), phosphorus (p = 0.016), and IS (p < 0.001) levels increased significantly, whereas estimated glomerular filtration rate  decreased significantly as VRI decreased among patients with CKD. With respect to renal function defined by CKD stage, there were more patients at more advanced CKD stages with lower VRI values (p < 0.001). The proportion of patients with a smoking habit also increased as VRI decreased (p = 0.022). Among the patients with CKD, 54 had DM (49.1%) and 91 had HTN (82.7%). Prescribed medications for the patients included angiotensin receptor blocker , β-blocker , α-blocker , calcium channel blocker , statin , and fibrate . There were no significant differences with respect to sex, the presence of DM and HTN, or the use of medications among the three groups of patients.The clinical characteristics and medications used for patients with CKD are presented in r = −0.264, p = 0.005), SBP , DBP , smoking habit , serum phosphorus level , logarithmically transformed BUN , log-creatinine , and log-IS level  were negatively correlated, whereas eGFR  was positively correlated with VRI values in patients with CKD by univariate linear regression analysis  and serum log-IS level  were significantly and independently negatively associated with VRI values in patients with CKD by multivariate stepwise linear regression analysis  and were carried out following the rules of the Declaration of Helsinki. All patients were required to provide informed consent before being investigated in this study.A total of 110 patients with CKD were enrolled from October 2017 to February 2018 at a medical center in Hualien, Taiwan, After reviewing their medical records, HTN or DM were respectively defined as SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg, the prescription of any anti-HTN medications or fasting plasma glucose level ≥ 126 mg/dL, or the administration of oral hypoglycemic medications or insulin. The body weights and heights of the participants were measured in light clothing and without shoes to the nearest 0.5 kilograms and 0.5 cm, respectively. Body mass index (BMI) was expressed as weight (kg)/height(m)2, 29–15 mL/min per 1.73 m2, or <15 mL/min per 1.73 m2, individually.Fasting blood samples (approximately 5 mL) of patients were immediately centrifuged and examined by an auto-analyzer  for the measurements of serum BUN, creatinine, albumin, globulin, fasting glucose, total cholesterol, triglycerides, low-density lipoprotein cholesterol, total calcium, and phosphorus levels. The Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation was applied to calculate eGFR using the mean value of measurements at least 3 months apart. The participants were divided into different CKD stages according to the Kidney Disease Outcomes Quality Initiative criteria . Patient® C18(2)  ; the temperature, flow, and injection were respectively set at 40 °C, 0.8 mL/min, and 30 µL. The mobile phase consisted of a binary gradient applied as follows: the initial composition (95% (A) water + 0.1% formic acid/5% (B) methanol + 0.1% formic acid) was kept constant for 1 min; solvent B was then increased linearly up to 70% over 12 min and kept constant for 2 min. For column re-equilibration, solvent B was reduced to 50% over 1 min and kept constant for 2 min.This study used a Waters e2695 HPLC system consisting of a single quadrupole mass spectrometer . The analytical column was Phenomenex Luna® 3.0 software  was used for data acquisition and processing. The retention time for IS was approximately 13.86 min. According to Shu et al. [Liquid chromatography–mass spectrometry analysis of the serum IS level was performed using a modified method ,38. Pretu et al. , this meAfter overnight fasting and resting supinely at an ambient temperature of 22 °C–24 °C for 30 minutes, BP cuffs were placed on the subject’s right upper arm and skin temperature sensors were affixed to both of the subject’s index fingers. An FDA-approved device  with DTM for the measurements of the endothelial function was applied to the patients . The meap-value of < 0.05 was considered statistically significant.Continuous variables were analyzed by the Kolmogorov–Smirnov test, and variables were expressed as means ± standard deviation or medians with interquartile ranges depending on whether they exhibited normal distribution. Differences among groups  were analyzed using Kruskal–Wallis analysis or one-way analysis of variance followed by the Fisher’s protected t test for parameters with and without normal distribution. Because fasting glucose, triglyceride, BUN, creatinine, globulin, total calcium, and IS levels were not shown to have normally distribution, these variables were logarithmically transformed before further analysis. Variables correlated with VRI values were evaluated by univariate linear regression analysis and variables with significant results in the univariate linear regression analysis, including age, smoking, SBP, DBP, Log-BUN, Log-creatinine, eGFR, phosphorus and Log-IS were further analyzed with multivariate stepwise linear regression analysis. SPSS for Windows was used for analysis . A


The relationship between benzodiazepines, opioids and tricyclic antidepressants and trauma is of great importance because of increased consumption and the growing evidence of a positive association among older adults. The objective of this study was to determine the effect size of the association between the consumption of psychotropic medications /opioids and falls in patients who have suffered trauma by studying the role of other variables in this relationship.From 2011 to 2016, the presence of benzodiazepines, opioids and tricyclic antidepressants and other drugs in 1060 patients admitted for trauma at a level I trauma hospital was analysed. Multivariate models were used to measure the adjusted effect size of the association between consumption of benzodiazepines, opioids and tricyclic antidepressants and falls, and the effect of age on this association was studied.p < 0.001. Once other covariates were introduced, this association was not observed, leaving only age, gender (woman) and, to a lesser extent, sensory conditions as variables associated with falls. Age acted as an effect modifier between benzodiazepines, opioids and tricyclic antidepressants and falls, with significant effect sizes starting at 51.9 years of age.A total of 192 patients tested positive for benzodiazepines, opioids and tricyclic antidepressants, with same-level falls being the most frequent mechanism of injury in this group (40.1%), with an odds ratio of 1.96 (1.40–2.75), The association between the consumption of benzodiazepines, opioids and tricyclic antidepressants and falls in patients admitted for trauma is conditioned by other confounding variables, with age being the most influential confounding variable. The abusive consumption of substances such as alcohol, cannabis or cocaine poses a substantial morbidity and mortality burden . HoweverWhile the short-term therapeutic efficacy of benzodiazepines, opioids and tricyclic antidepressants is not in doubt, there are risks associated with their use. In this sense, the association found between the consumption of benzodiazepines and falls and fractures is especially noteworthy –12, as iFalls are one of the most important causes of mortality and disability among older people . In addiA high prevalence of traumatic episodes highlights the need to investigate its causes, which may guide us towards possible intervention strategies ,19,20. AIn short, although the literature has highlighted the relationship between the consumption of psychotropic medications and trauma, there is a lack of evidence on the impact that the consequences of the consumption of benzodiazepines, opioids and tricyclic antidepressants  or other variables independent of the consumption of psychotropic medications  may have on this relationship. Additionally, studies that have explored the prevalence of the consumption of benzodiazepines, opioids and tricyclic antidepressants and other substances in trauma patients find a high percentage of falls associated with people who consume these substances ,25 but dA cross-sectional analytical study was based on data obtained from a secondary prevention SBIRT-based program for traumatized patients associated with alcohol and/or other drugs at the Trauma Hospital of Granada. The research was approved by the Granada Provincial Research Ethics Committee (CEI-Granada) and conducted according to the principles expressed in the Declaration of Helsinki; including informed consent obtained from the participants or their relatives or guardians in minor participants.The population for this study was 1060 patients admitted for trauma in the aforementioned hospital, in the periods in which the programme was active, comprising 34 non-consecutive months during which it received public financial support: from November 2011 to October 2012, June 2013 to November 2013 and June 2014 to February 2015.®). Review of the patient’s medical records and direct questioning were used to distinguish between patients who screened positive for positive results for benzodiazepines and opioids as a result of emergency treatment of their injuries and patients who had taken these substances before they sought medical attention. Alcohol was considered positive if the blood alcohol level exceeded 0.3 g/L on admission or if, given the narrow detection window, the patient self-reported alcohol consumption.The presence of benzodiazepines and analogues , prescription opioids, tricyclic antidepressants and drugs of abuse  was detected by urinalysis via fluorescence immunoassay , severity of the trauma measured by the injury severity score (ISS) , hospita® For the data analysis, the presence of benzodiazepines, opioids and tricyclic antidepressants was dichotomized as positive or negative. Trauma severity was classified according to the ISS as mild (1–8), moderate (9–15) or severe (≥16). As a dependent variable, the mechanism of injury was used, categorized into 2 strata: same-level falls versus other mechanisms.For the descriptive study, after verifying the lack of normality in the distribution of the continuous variables, the distribution of these variables was compared using the Mann-Whitney U test. To examine the association of categorical variables, the Pearson Chi-squared test was used.For the analytical analysis, the strength of the association between the consumption of benzodiazepines, opioids and tricyclic antidepressants and falls was quantified by applying a binary logistic regression model where negative outcomes for psychopharmaceuticals and other non-fall injury mechanisms were considered as reference categories. This allowed obtaining crude odds ratios (ORc) and adjusted odds ratios (ORa). For ORa, the independent variables psychiatric disorder, cognitive decline, hypertension, osteoporosis, diabetes, impaired balance, musculoskeletal conditions, heart disease, sensory conditions, obesity, alcohol consumption, cannabis consumption, cocaine consumption, amphetamine consumption and methadone consumption were added to the model. In addition, exploratory analyses were performed to determine which factors acted as effect modifiers. These analyses were developed according to the method of Hayes and colleagues ,29 throuIn the comparison of the demographic and clinical characteristics between the groups consuming or not consuming benzodiazepines, opioids and tricyclic antidepressants , age wasp < 0.001). Regarding the other variables, we did not find differences in trauma severity; however, there was a higher percentage of osteoporosis in the group positive for benzodiazepines, opioids and tricyclic antidepressants (4.7% versus 1.6% in the non-consumer group). Regarding musculoskeletal deficiency, 3.1% (6 patients) of those who consumed psychopharmaceuticals had some deficiency, compared to 0.8% (7 patients) of non-consumers. Regarding sensory conditions, 3.1% (6 patients) of those who consumed psychopharmaceuticals had some type of condition, compared to 2.6% (23 patients) of non-consumers.We also found differences in the distribution of the mechanism of injury, with a much higher percentage of falls in the group of psychopharmaceutical consumers compared to non-consumers  in the group positive for psychotropic medicines.p < 0.001. However, when all variables are introduced into the multivariate analysis, this association is not observed, leaving only a significant relationship of age and gender with falls, with an ORa (95% CI) of 1.04 (1.03–1.05), p < 0.001, and 3.00 (2.16–4.17), p < 0.001, respectively. In addition, the relationship between trauma and sensory conditions was also maintained; however, it loses strength, and the consumption of cannabis appears to be a protective factor against sensory condition symptoms.p = 0.066. However, age exerted a significant interaction on the effect of psychotropic medication consumption on falls (p = 0.025), with conditioned effect values that increased with age, with significant values starting at 51.9 years , .9 years .When determining the relationship between the consumption of benzodiazepines, opioids and tricyclic antidepressants and falls, assessing the impact of other variables in this association, our main finding is that although the crude association shows a clear relationship between most variables that, a priori, could be linked to this mechanism of injury, this association is not observed after introducing all these factors in a multivariate model. Only the variables age, gender, and sensory conditions remain significantly associated, and negatively so with cannabis consumption. The study of mediation/moderation showed that of these variables, age modified the effect of benzodiazepines, opioids and tricyclic antidepressants in falls, becoming significant after 51.9 years of age. These results suggest that the consumption of benzodiazepines, opioids and tricyclic antidepressants is not directly related to a greater number of falls compared to other mechanisms of injury in trauma patients, as noted by some studies , but theNumerous studies have confirmed the association between psychotropic medication use and falls in elderly people ,16,31–33Our descriptive study shows that the age of consumers of benzodiazepines, opioids and tricyclic antidepressants that have suffered trauma, average of 48 years of age, is clearly higher than that of the rest of the patients, a finding that coincides with those of the Spanish Monitoring Centre for Drugs and Drug Addiction (Observatorio Español de la Droga y las Toxicomanías) and other studies that place the age of onset of the use of these substances at 45 years of age, much higher than that of other substances of abuse ,34,35. FIn line with the findings of the Report on Drug Use in Spain, published in 2015 , our datNotably, in our sample, there was a significantly higher number of drugs other than alcohol in psychotropic medication users. The use of central nervous system depressants to reduce the effect of stimulants such as cocaine and methamphetamine has also been found in previous studies .The main limitations of this study include the impossibility of extrapolating the results to patients who suffer trauma and are not hospitalized. Furthermore, the retrospective collection of some of the variables used in the study, through a review of patient medical records, could lead to underestimations of some pathologies, such as those that are still latent and have not been diagnosed, for example, obesity, whose detection sensitivity through this method is questionable. On the other hand, patients who were admitted with blood alcohol levels of 0.3 g/L or lower have not been considered positive for alcohol. This is because it is the legal limit allowed in our country for novice and professional drivers. However, the concentration of alcohol in the blood related to an increased risk of trauma in the elderly may not coincide with that legally established for driving due to the special susceptibility of this age group .Despite these limitations, this study presents important strengths. It is noteworthy that this study was carried out within a project in which a systematic screening of substances in patients admitted for trauma was carried out. In this study, positive tests for benzodiazepines and opioids were prospectively excluded when these drugs were administered as part of the prehospital or emergency treatment, thus avoiding false positives. Although there may be some cases that the use of benzodiazepines in prehospital care for serious trauma could have masked the previous consumption of non-prescribed benzodiazepines , we believe that our approach is more adequate than systematically discarding these benzodiazepine positive screenings. On the other hand, the design of the present study allowed us to avoid selection biases present in other studies in which consumption was detected by means of questionnaires  or throuIn conclusion, we can affirm that despite the crude data suggesting a relationship between the consumption of benzodiazepines, opioids and tricyclic antidepressants and falls in patients who have suffered trauma, this relationship is influenced by other variables that confound or modify the effect of this relationship. However, the conditional effect that age exerts on this association only begins to be significant after 51.9 years of age. The influence of benzodiazepines, opioids and tricyclic antidepressants on trauma risk cannot be called into question given the methodology and population used in this study; however, future research conducted in this regard should account for the importance of non-causal associations that could be generated if the roles of the variables used in this study are not considered.S1 Data File(SAV)Click here for additional data file.


This small scale cross-sectional study was done to identify the common systolic blood pressure pattern (dipping or non-dipping) among type 2 diabetic men with coexisting hypertension and erectile dysfunction(ED). A recent study in the same setting showed that prevalence of ED was high among diabetic men and co-existing hypertension was identified as an independent risk factor. There was a postulation about an association between ED and non-dipping nocturnal blood pressure pattern. So ambulatory blood pressure measurements (ABPM) was obtained for participants to test this prediction. Data was analysed using SPSS 25 Version.Among 29 participants who underwent ABPM, 21 showed non-dipping pattern of nocturnal systolic blood pressure . Mean SBP of participants was 125.55 +_14.1 and Mean DBP was 81.5 + _12.82. There was no statistical difference observed in mean SBP and DBP between patients with dipping nocturnal SBP and non-dipping pattern (P > 0.05). Variability of SBP was high among the participants (Mean SD-11.96 +/_2.74) and DBP also showed relatively high variability (SD-9.28 +/_2.9). Mean dipping percentage of the SBP during sleep was 5.54 +/_6.66. A significant difference in heart rate (HR) between patients with non-dipping and dipping pattern was noted (P-0.034). Hypertension is a well-recognized risk factor for development of Erectile Dysfunction (ED). A recent study from the diabetic centre of Northern Sri Lanka from which this study population was selected, revealed that the prevalence of ED among type 2 diabetic men was very high and co-existing hypertension was identified as an independent risk factor for ED . StudiesThis is a cross sectional study among type 2 diabetic men with ED and co-existing hypertension to find out the common nocturnal systolic blood pressure pattern.Sampling: 30 patients were selected randomly(simple random sampling) from the 113 diabetic men with ED and co existing HT from a previous study [Study Period: August 2018–September 2018. Extension of the ethical clearance was obtained from ethical review committee, Faculty of Medicine, University of Jaffna (J/ERC/17/88/DR/0054) in July 2018 as part of the recent prevalence study conducted in the same setting.Operationalization: ambulatory blood pressure monitoring (ABPM) was done by using machine Scanlight III Vers B. ABPM device was programmed to perform the measurement per 30 min in daytime (06:00–22:00 h) and per 60 min in Night time (22:00–06:00 h).Dipping of SBP pattern was calculated as follows: (1 − (Mean systolic BP in night time/Mean SBP in day time)) × 100. After that participants were classified into dippers if night time SBP dropped more than 10% , 9 and iData were analysed by using SPSS version 25.0. Continuous variables are presented as mean ± standard deviation (SD) and for categorical variables percentage calculated with 95% CI. Comparison of means between non-dipping group and dipping group was made using t test and P value of < 0.05 was considered as statistically significant.Among 30 type 2 diabetic men with ED and co-existing hypertension, 29 completed ABPM. Mean age of study participants was 51.24 ± 6.04 with minimum age 38 and maximum age 59. Among 29 participants 21 of the diabetic men with ED and coexisting hypertension showed non-dipping pattern of systolic blood pressure(SBP)  . Even though exact mechanism of the nocturnal hypertension is not fully understood studies suggested that increased sympathetic activity and decrease parasympathetic activity throughout the night is a possible explanation , 12. A sNon-dippers with essential hypertension is associated with “more advanced left ventricular hypertrophy, left ventricular mass and left ventricular mass index, carotid artery wall thickness, carotid artery atherosclerotic plaques, silent cerebral infarct, stroke, cognitive impairment and micro-albuminuria” . During In addition we also noted variability of SBP and DBP was high among the participants as well (Mean SD of SBP-11.96 +/_2.74 and Mean SD of DBP-9.28 +/_2.90 respectively). Other risk factors for ED such as dyslipidemia, BMI, medication adherence, obstructive sleep apnoea, alcohol intake, and smoking are associated with ED  and mighAs we expected diabetic men with ED and co existing blood pressure showed more non-dipping pattern of systolic blood pressure during sleep. Sympathetic over activity could be possible explanation for this findings and the non-dipper status has no correlation with blood pressure variability and the level of blood pressure. Further methodologically well-defined comparative study is recommended to test the hypothesis of non-dipping pattern is more associated with ED.Above findings need to be interpreted cautiously as we have not done a comparative study instead we just observed among a selected type 2 diabetic men with ED and coexisting hypertension and it showed non-dipping pattern of nocturnal SBP. Due to constrains of resources this preliminary study is limited to 30 in number. Actual estimation of sample size with a comparison group could improve the validity of the study. Also collection of other covariates and multivariate analysis could have been done to improve the validity of the study. Also worth note that diabetic patients are not routinely screened for ED until our first prevalence study (Reference


Purpose: To study the hemodynamic parameters in ophthalmic artery (OA) using color Doppler imaging in subjects with primary open-angle glaucoma (POAG), normal-tension glaucoma (NTG) and age matched normals. Methods: Sixty-eight eyes of 68 subjects  constituted material for this prospective observational study. They were divided into three groups; Group A had 24 patients with POAG, Group B had 18 patients with NTG and Group C had 26 normal subjects. They underwent CDI of OA. The outcome variables were peak systolic velocity (PSV), end diastolic velocity (EDV), resistivity index (RI) and pulsatility index (PI). Data were compiled and analyzed using one-way ANOVA analysis.Results: The mean ± SD age of POAG patients, NTG patient and normal subjects was 59.95 ± 7.35, 58.11 ± 9.97 and 57.73 ± 5.39 years, respectively. The mean intra ocular pressure (IOP) was 29.8 ± 5.0, 15.9 ± 2.4 and 16.6 ± 1.7mm Hg in Group A, B and C, respectively. In group A, the mean PSV, EDV, RI and PI were 18.2 ± 3.80, 3.71 ± 1.40, 0.93 ± 0.12 and 2.8 ± 0.42. In group B, 26.6 ± 1.72, 4.93 ± 1.32, 0.84 ± 0.02 and 1.32 ± 0.20 and in group C, 35.4 ± 3.04, 8.08 ± 0.69, 0.77 ± 0.03 and 1.80 ± 0.17, respectively. All the values were found to be statistically significant (p < 0.05). Lower PSV and EDV were found in POAG and NTG patients, while RI was higher than in normal subjects. Conclusion: The hemodynamic parameters are significantly affected in POAG and NTG patients. The PSV and EDV are decreased and RI is increased. EDV is more sensitive for the assessment of hemodynamic changes.  Intraocular pressure (IOP) is known to be a major causative risk factor. Vascular factors have also been implicated in the pathophysiology of glaucoma [2]. The association of glaucoma with vascular diseases like diabetes, hypertension, and migraine, has been reported [3-5]. The association of glaucoma with specific circulatory events such as systemic hypotension and peripheral vasospasm indicates that vascular factors play an important role in the pathogenesis of glaucoma . The recent application of Color Doppler Imaging (CDI) to the orbit potentially allows us to measure the velocity in the central retinal artery (CRA) and in the short posterior ciliary arteries (SPCAs) [8]. Glaucoma, a chronic progressive optic neuropathy, is the second leading cause of blindness worldwide [9]. Maximum velocity is produced when Doppler angle is 0° and the sound beam is parallel to the direction of blood flow [10]. Peak systolic velocity (PSV) and end diastolic velocity (EDV) can be measured from the spectral display. The resistive index (RI) can be calculated according to the method of Pourcelot as RI = PSV – EDV divided by PSV [11].CDI allows information about the flow of blood to be superimposed in color on a B-mode gray-scale ultrasound image, which enables the direct visualization of specific vessels that can be interrogated to produce a spectral waveform. Flow velocity, known as Doppler shift frequency or simply, true Doppler shift, is strongly dependent on the insonation angle i.e. the angle between the emission sound beam and flow direction at sampled artery . NTG was diagnosed in patients who had reproducible localized VFD and glaucomatous optic nerve damage with multiple IOP readings lower than 21mm Hg [1]. The eye with greater glaucomatous damage was chosen in glaucoma patients, being randomly selected in the healthy individuals.POAG was diagnosed in patients who had reproducible localized visual field defects (VFD) and glaucomatous optic nerve damage with multiple intraocular pressure (IOP) readings over 21mm Hg [The procedures were in accordance to the Declaration of Helsinki and the International Code of Medical Ethics and were approved by the institutional ethical review committee. Each subject was required to sign an informed consent statement before enrolling in the study and prior to any study measurements were taken.12]. The outcome variables of this study were the following basic hemodynamic parameters: peak systolic velocity (PSV), which is the highest velocity of blood flow during the systolic phase of cardiac cycle, end diastolic velocity (EDV), which is the velocity of blood flow at the end of diastolic phase of cardiac cycle, resistivity index (RI), which is derived as RI = PSV-EDV/ PSV, pulsatility index (PI), which is derived as PI = PSV-EDV/ MFV, where MFV is the mean blood flow velocity . All CDI studies were performed on a Prosound Alpha 6 (Hitachi Aloka Products) ultrasound machine by a single experienced sonographer who was unaware of the subject’s clinical status. High frequency linear probe of 1-15 MHz was used. All examinations were carried out in the supine position with eyes closed. Blood flow in the retro bulbar orbit was detected by production of color pixels on visual display unit. In general, optic nerve was identified using a B scan, which is an important landmark for the detection of OA. The OA is situated either above or below the optic nerve into the posterior orbit before passing forward in the nasal orbit in a horizontal plane slightly superior to that of the optic nerve . OA seems to be the most suitable vessel to investigate vascular aspects of Glaucomatous Optic Neuropathy (GON) [18]. Studies have confirmed that measurements of the hemodynamic variables of this vessel are reproducible and more reliable than the SPCAs and other vessels . Although an indirect measure of blood circulation, the CDI can be used as a device to measure hemodynamic parameters of retro bulbar vessels. Hence, we studied the hemodynamic parameters of healthy and glaucomatous eyes in OA using CDI. We compared the findings of our study with the ones in related articles to draw conclusions . With the mechanisms of glaucoma still so poorly understood, CDI may play a role in the hemodynamic pathophysiology of the disease, as well as in evaluating the effects of various medical and surgical therapies . RI is considered to reflect vascular resistance peripheral to the location where the measurement is made, but is not equivalent to vascular resistance because it depends on both vascular resistance and vascular compliance; only in high vascular compliance is RI an adequate measure of vascular resistance [35].PSV reflects the strength of vessel perfusion, whereas EDV reflects the blood perfusion of distal organs and is a sensitive indicator of increased downstream impedance [The possible mechanism of changed hemodynamic parameters in Glaucoma can be observed below.36]. Reduced blood flow velocities could be a sign of inadequate mechanisms of auto regulation in glaucomatous patients. This might also be due to increasing distal end resistance of the optic disc as a result of increased IOP. The POAG eyes with high IOP have significantly reduced ocular blood flow [37]. As reported, the increased RI may perhaps be caused by long standing vascular compromise in NTG and raised IOP in POAG [38]. In support of the relationship between these vascular changes and glaucoma, an increased correlation between ocular perfusion pressure (OPP) and retro bulbar blood flow velocities have been demonstrated [39-40]. Thus, EDVs are thought to be more sensitive for hemodynamic changes than the PSVs [40].The association of lower EDV with higher RI can be attributed to the increase in vascular resistance that affects diastolic blood flow velocity more than systolic velocity, which further aggravates the ischemia of organs [Due to short duration of follow up, glaucoma progression analysis could not be performed in our study. Thus, a correlation between hemodynamic parameters and progression of visual fields could not be established. Financial support and disclosureNone.