We found a progressive increase in serum OGN according to the severity of kidney impairment in T2D patients  ng/mL; mildly impaired kidney function: 19.15 (15.78–25.90) ng/mL; moderate impaired kidney function: 21.80 (15.06–29.22) ng/mL; p = 0.006). Circulating OGN was an independent estimator of mildly impaired kidney function risk in T2D patients. We suggest that serum OGN could act as an albuminuria-independent biomarker of incipient kidney dysfunction in T2D patients.Osteoglycin (OGN) could be a biomarker of mild kidney function impairment in type 2 diabetes (T2D). Our study aimed to determine the association between serum OGN and impaired kidney function risk in T2D patients and to analyze its potential role as an estimator of kidney disturbances in this population. This cross-sectional study included 147 T2D patients , and 75 healthy controls . Circulating OGN levels were determined by ELISA. Linear regression modeling was performed to determine the variables influencing circulating OGN, and an ROC curve was plotted to assess the usefulness of OGN as an estimator of diabetic kidney disease risk. Circulating OGN was significantly increased in T2D patients compared to controls (18.41 (14.45–23.27) ng/mL vs. 8.74 (7.03–12.35) ng/mL;  Osteoglycin (OGN), also known as osteoinductive factor or mimecan, is a secretory protein belonging to class III of the small leucine-rich proteoglycans . OGN is Diabetic kidney disease (DKD) is one of the most frequent complications of type 2 diabetes (T2D). The classic description of DKD involves progressive stages of glomerular hyperfiltration, microalbuminuria, overt proteinuria, and a decline in the estimated glomerular filtration rate (eGFR) . It was Few and contradictory results are known regarding OGN levels in T2D patients with DKD ,20. In tHence, we determine the serum OGN levels in T2D patients with mildly decreased eGFR, in order to assess their significance as a biomarker of impaired kidney function.2; mean eGFR 100 ± 7) (n = 62) and mildly decreased eGFR  (n = 85). Patients with liver, gastrointestinal, and thyroid disease; cancer; dialysis; or renal transplantation were excluded.This cross-sectional study included 222 participants, 147 T2D patients , and 75 healthy controls . T2D was diagnosed according to the American Diabetes Association criteria from 2017 . The recSerum samples from healthy controls were supplied by the SSPA Biobank from blood donors of the Andalusian Regional Government Health Service. Healthy donors did not have metabolic diseases as diabetes or infectious, neoplastic, hepatic, cardiovascular, gastrointestinal, central nervous system, or renal diseases . All samples used for the study were managed by the SSPA Biobank of the University Hospital Clínico San Cecilio of Granada. Informed consent was obtained from each patient.This study was conducted with the approval of the Ethics Committee of the University Hospital Clínico San Cecilio of Granada and conformed to the principles of the World Medical Association Declaration of Helsinki  on 26 April 2017).2). The systolic and diastolic blood pressure was measured using a standard electronic sphygmomanometer. Hypertension was defined as values ≥140/90 mmHg and/or antihypertensive treatment. Dyslipidemia was characterized by serum levels of low-density lipoprotein cholesterol (LDL-c) >100 mg/dL, high-density lipoprotein cholesterol (HDL-c) <50 mg/dL, triglycerides (TG) >150 mg/dL, and/or current treatment with lipid-lowering drugs. Patients reported their alcohol use, smoking status, and level of physical activity in response to specific health questionnaires [The height, weight, and waist circumference were measured according to standard procedures. The body mass index (BMI) was calculated by the Quetelet formula, weight (kg)/stature , glycated hemoglobin (HbA1c), TG, HDL-c, LDL-c, calcium, and phosphorus were measured using standard automated laboratory techniques. The eGFR was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation . The albThe calciotropic hormone profile included serum intact parathormone (iPTH) and 25-hydroxyvitamin D (25(OH)D) as determined with the two-site immunoassay  and the chemiluminescence immune assay , respectively.The OGN was determined in duplicate by the enzyme-linked immunosorbent assay (ELISA) method developed by Cloud-Clone Corp. , following the manufacturer’s protocol. Precision testing was performed by the determination of the intra-assay and inter-assay coefficients of variation of OGN .Fibroblast growth factor 23 (FGF-23) was measured in duplicate using ELISA (Biomedica). The intra- and inter-assay coefficients of variation of FGF-23 were <6% and <8%, respectively.t-test for continuous and normally distributed variables. The Mann–Whitney U test and Kruskal–Wallis test were used to compare the variables that were not normally distributed. When the comparison between groups required an adjustment by covariates, an analysis of covariance (ANCOVA) was performed. The χ2 test was used to compare categorical variables between groups.Analyses were performed using SPSS version 22.0 software . The data were expressed as the means ± standard deviation (SD) for the normally distributed variables and as the median with the interquartile range (IQR) for variables that were not normally distributed. The data for categorical variables are presented as percentages. A Shapiro–Wilk test was used to test the normality of the distribution of the continuous variables. The mean values between groups were compared using the unpaired Student’s Associations between continuous variables were described by Spearman’s correlation coefficients. Multiple linear regression modeling was performed to determine the variables independently associated with the OGN (dependent variable), including the quantitative and qualitative variables linked in the bivariate analysis and other variables biologically associated with OGN as independent variables. To identify OGN as an independent predictor of impaired kidney function, multiple logistic regression modeling was performed, including mildly decreased eGFR as a dependent variable. The independent variables included in the model were the established factors related to impaired kidney function risk in addition to the OGN level. The usefulness of serum OGN as an estimator of impaired kidney function risk was assessed using a receiver operating characteristic (ROC) curve. The area under the curve (AUC) indicates the probability of predicting an event. AUC values greater than 0.75 indicate good predictive performance.p < 0.05 (two-tailed) and p < 0.10 for multiple linear regression analysis.The statistical significance was set at The clinical, anthropometric, and biochemical parameters of T2D participants according to normal or mildly impaired kidney function are summarized in The recruited groups were homogenous, and there were no differences between them in sex, weight, height, BMI, waist circumference, or diabetes duration. Regarding age, there was a significant difference between groups. Most of the clinical parameters were also comparable between groups except for hypertension, dyslipidemia, and CVD. The biochemical parameters differed between the groups in terms of the serum levels of iPTH, FGF-23, and OGN.n = 136, 57% males) than in control subjects  (18.41 (14.45–23.27) ng/mL vs. 8.74 (7.03–12.35) ng/mL; p < 0.001). When T2D patients and control subjects were further divided according to sex, the significant differences in OGN levels remained for both males (16.68 (13.44–20.77) ng/mL vs. 8.79 (7.64–11.17) ng/mL; p < 0.001), and females (19.88 (15.70–26.30) ng/mL vs. 8.70 (6.65–12.41) ng/mL; p < 0.001). We found that the OGN levels were significantly higher in females than in males in the T2D group (19.88 (15.70–26.30) ng/mL vs. 16.68 (13.44–20.77) ng/mL; p = 0.009), but no differences were found for the healthy controls according to sex  and mildly decreased  eGFR revealed significant differences between all groups (p < 0.001). The control group showed lower levels of serum OGN (8.74 (7.03–12.35) ng/mL). T2D patients with normal eGFR showed lower circulating OGN levels compared to T2D patients with mildly decreased eGFR (16.14 (12.13–20.48) ng/mL vs. 19.59 (15.70–25.90) ng/mL; p = 0.013) (p = 0.017).The comparison of serum OGN levels between control subjects and T2D patients with normal (= 0.013) B. After 2). In this subgroup , the highest levels of OGN were observed (21.80 (15.06–29.22) ng/mL) with significative differences compared to normal eGFR group (p = 0.022).In the group of T2D patients with mildly decreased eGFR, there is a 20.5% of T2D patients with a moderate decrease in eGFR (<60 mL/min/1.73 mp < 0.001), iPTH , and FGF-23  and a negative correlation with eGFR  in T2D patients  in addition to the diabetes duration, insulin treatment, UACR, presence of osteoporosis, and presence of CVD as independent variables. The results showed that the variables independently associated with the OGN serum level were age and FGF-23, as shown in p < 0.061). The comparison of serum OGN levels in T2D patients according to the prevalence of CVD after age and sex adjustment revealed significant differences between both groups (p = 0.041). T2D patients with CVD  showed lower circulating OGN levels compared to T2D patients without CVD : (17.88 (15.39–20.38) ng/mL vs. 21.15 (19.44–22.86) ng/mL).The presence of CVD was not independently associated with serum OGN level, although it bordered on significance  compared to that in controls subjects  although not significantly (1.16 (0.63–2.05) pmol/L vs. 1.02 (0.47–1.85) pmol/L; p = 0.186). When T2D patients were divided according to eGFR values, we observed higher circulating FGF-23 levels in the group with mildly decreased eGFR  compared to those with normal values  (p = 0.028) (n = 46) compared to those with normal eGFR values (n = 43): (1.55 (0.93–2.36) pmol/L vs. 0.84 (0.44–1.90) pmol/L; p = 0.005). No significative differences were found between T2D patients according to the prevalence of CVD independently of the kidney function.The serum FGF-23 levels were higher in T2D patients (= 0.028) . When pap = 0.021), the serum OGN level was an independent estimator of impaired kidney function risk ; p = 0.029) in T2D patients. Logistic regression modeling was performed to assess the variables related to impaired kidney function risk in T2D patients. The independent variables included in the model were age, hypertension, dyslipidemia, HbA1c levels (categorized according to the cutoff point of 7%), tobacco use, years of diabetes duration, presence of CVD, presence of osteoporosis, and UACR in addition to the OGN serum level. We found that, in addition to age ; ROC curve analysis was performed to assess the usefulness of the serum level of OGN as an estimator of impaired kidney function risk. Two different models were assessed, including the main impaired kidney function risk factors  with and without the serum OGN level .p < 0.001 for both).The AUC of the model without OGN was 0.748, whereas the AUC of the model including OGN was 0.782  are mainly related with renal rather than vascular damage. Endorsing our findings, a recent study observed increased immunostaining of OGN in human atherosclerotic carotid plaques from patients with lower eGFR values [On the other hand, the fact that prevalent CVD is so close to significance as a predictor variable of OGN as shown in our results suggests that there may be a relationship between OGN levels and CVD. The role of OGN in CVD is controversial to date. Some studies’ results have reported a close relationship between OGN levels and the risk of suffering CVD although the mechanism of action of OGN is unclear. In this line, a couple of studies found an association between high serum OGN levels and poor coronary collateralization in patients with coronary artery disease ,41, as wR values . HoweverAlthough future longitudinal studies are needed, our preliminary results place OGN as a promising biomarker that deserves future research to confirm its potential role as an early predictor of kidney damage in daily clinical practice.Our cross-sectional study has some limitations. First, the cross-sectional design precludes any determination of causality in our findings. Thus, we cannot assure whether FGF-23 influences the increase in OGN levels or the other way around. Second, we do not have many biochemical determinations in the control group, which could provide valuable information for the comparative study of OGN between T2D and control subjects. Finally, our study was conducted in a specific population of Caucasian T2D and healthy subjects, which prevents guaranteeing the same results in other ethnic or study groups. The strengths of this study lie in the evaluation of circulating OGN in T2D patients with an exhaustive evaluation of the biochemical and clinical parameters. In addition, we considered potential confounders, such as age, sex, diabetes duration, and current medications.The main findings of this study suggest that the elevation of OGN related to mildly impaired kidney function could involve a specific role of OGN in this process acting as an albuminuria-independent biomarker of incipient impaired kidney function in T2D patients. Future longitudinal studies are required to understand the mechanisms through which the upregulation of OGN influences the risk of impaired kidney function in T2D patients and to confirm the potential usefulness of serum OGN as a potential biomarker of kidney status in clinical settings to establish preventive and therapeutic approaches in the T2D population.


Patients and Methods. This was a case-control study, carried out in the nephrology department of the Aristide Le Dantec University Hospital in Dakar. All records of patients with lupus nephritis over a 10-year period, from January 01, 2007, to December 31, 2016, were included. Results. During the study period, out of 64 lupus nephritis records collected, 28 patients had hypertension, for a hospital prevalence of 43.75%. The mean age of the patients was 30.64 years ± 10.44. There were 24 women and 4 men. The mean systolic blood pressure was 156 mmHg (110–220) and the mean diastolic blood pressure was 100 mmHg (80–130). The mean serum creatinine was 29.48 mg/l ± 24.99. The mean proteinuria was 4.50 g/24 h ± 2.87. Hypertriglyceridemia was observed in one patient. Hypercholesterolemia was present in 3 patients. HDL levels were normal in all patients and elevated LDL levels were noted in all 4 patients. None of our patients had diabetes. Class III was found in 11 cases, class IV in 14 cases, pure class V in 2 cases, and class II in 1 case. Hypertension was associated with the presence of proliferative glomerulonephritis . Conclusion. Hypertension is common in lupus nephritis. The presence of a proliferative glomerulonephritis is a risk factor for the development of arterial hypertension. Screening and adequate management of hypertension are essential for the prevention of the progression of chronic kidney disease in lupus.Studies report a high prevalence of hypertension in lupus, reaching up to 74%. The incidence of hypertension in SLE patients is increased with the severity of the kidney damage. This work was carried out with the objective of determining the prevalence of hypertension in lupus nephritis and to seek the existence of an association between the presence of a proliferative glomerulonephritis and hypertension.  Several studies report a high frequency of hypertension in lupus, reaching up to 74% in some cohorts –4. The iLupus is the cause of major and accelerated atherosclerosis, possibly through nephropathy but also through chronic inflammation and metabolic complications, immunosuppressive treatments, and corticosteroids. A recent meta-analysis clearly confirms that SLE patients have a cardiovascular risk almost twice that of the general population, this being much more marked for the youngest patients .Hypertension is one of the important determinants of the progression of atherosclerosis in lupus. In addition, hypertension is recognized as one of the factors contributing to the progression of chronic kidney disease (CKD). Hypertension in lupus nephritis is not well described in sub-Saharan Africa. This work is carried out with the objective of determining the prevalence of hypertension in lupus nephritis and to seek the existence of an association between the presence of a proliferative glomerulonephritis and hypertension.p < 0.05. The 95% confidence interval of the odds ratio was calculated using the semi-exact method.This was a case-control study carried out in the nephrology department of the Aristide Le Dantec University Hospital in Dakar. All records of patients with lupus nephritis over a 10-year period, from January 01, 2007, to December 31, 2016, were included. The cases were chosen by taking all the files of patients who presented hypertension. The patients who did not have hypertension were the controls. Patients who had a proliferative glomerulonephritis were the exposed. The patients who did not present a proliferative glomerulonephritis were the unexposed. The diagnosis of lupus nephritis was made after a concordant renal puncture biopsy associated with proteinuria greater than 0.5 g/24 h or with active urine sediment . For eacl ± 24.99. The mean proteinuria was 4.50 g/24h ± 2.87. Hypertriglyceridemia was observed in one patient. Total hypercholesterolemia was present in 3 patients. HDL levels were normal in all patients and elevated LDL levels were noted in all 4 patients   and the mean diastolic blood pressure was 100 mmHg (80–130). The mean serum creatinine was 29.48 mg/patients . None ofp=0.002) .The association of lupus nephritis and hypertension is well reported , 11. SevThe incidence of hypertension in patients with lupus nephritis was also increased with both the severity of the kidney damage and the loss of kidney function. In our study, there is an association between hypertension and the presence of a proliferative glomerulonephritis. Okpechi et al. had also found this association between hypertension and the existence of a proliferative glomerulonephritis . These rHowever, hypertension associated with lupus can occur independently of the nephropathy . For exaRAAS is also implicated because of its role in blood pressure balance and homeostasis. Angiotensin II can stimulate the production of endothelin-1 (ET-1), a peptide whose role in blood pressure control results from a balance between its vasoconstrictor and natriuretic actions in the renal medulla. Plasma ET-1 levels are increased in patients with lupus , and serα (TNFα) have been implicated in the pathogenesis of lupus. Likewise, studies report a correlation between cytokines such as IL-6, TNFα, and C-reactive protein and blood pressure in patients with essential hypertension [It is widely recognized that immune dysregulation and chronic inflammation have a role in the pathophysiology of hypertension in lupus. . This isrtension . Inflammrtension  and the rtension .Hypertension is common in lupus nephritis. The presence of a proliferative glomerulonephritis is a risk factor for the onset of hypertension. Screening and adequate management of hypertension are essential for preventing the progression of chronic kidney disease in Lupus.The limitation of our study was the lack of match on age and sex ratio between cases and controls. But we can see in our study that the cases and controls were comparable on age. Corticosteroid therapy could not be a confounding factor as hypertension was diagnosed before the patients were started on corticosteroids.


Foot process effacement and mitochondrial fission associate with kidney disease pathogenesis. Electron microscopy is the gold-standard method for their visualization, but the observable area of electron microscopy is smaller than light microscopy. It is important to develop alternative ways to quantitatively evaluate these microstructural changes because the lesion site of renal diseases can be focal.We analyzed elastica-Masson trichrome (EMT) and periodic acid-Schiff (PAS) stained kidney sections using structured illumination microscopy (SIM).2-(1/16)2 in the power spectra (PS) included information for normal periodic structures of foot processes. Foot process integrity, assessed by PS, negatively correlated with proteinuria. EMT-stained sections revealed fragmented mitochondria in mice with mitochondrial injuries and patients with tubulointerstitial nephritis; Fourier transform quantified associated mitochondrial injury. Quantified mitochondrial damage in patients with immunoglobulin A (IgA) nephropathy predicted a decline in estimated glomerular filtration rate (eGFR) after kidney biopsy but did not correlate with eGFR at biopsy. PAS-stained sections, excited by a 640 nm laser, combined with the coefficient of variation values, quantified subtle changes in the basement membranes of patients with membranous nephropathy stage I.EMT staining revealed three-dimensional (3D) structures of foot process, whereas ponceau xylidine acid fuchsin azophloxine solution induced fluorescence. Conversion of foot process images into their constituent frequencies by Fourier transform showed that the concentric square of (1/4)Kidney microstructures are quantified from sections prepared in clinical practice using SIM.  Various studies have shown that changes in cellular microstructures play important roles in the pathogenesis of renal diseases. For example, structural defects in podocyte foot processes can result in loss of the proper glomerular filtration barrier, whereas mitochondrial fragmentation can cause mitochondrial dysfunction and oxidative stress.,,et al.,et al.The highest achievable resolution of a conventional optical microscope cannot surpass the diffraction limit (approximately 200–250 nm).,et al.et al.Immunofluorescent staining is the standard sample preparation method for SRM analyses. However, antibodies are expensive. Organelle-specific fluorescent dyes are alternative tools for labeling cellular microstructures. For example, phalloidin, paclitaxel, and MitoTracker  can label f-actin, tubulin, and mitochondria, respectively.Here, we analyzed kidney cellular microstructures using SIM for HE-, PAS-, periodic acid methenamine silver (PAM)–, and EMT-stained paraffin-embedded sections prepared in daily clinical practice. Additionally, by applying Fourier transform (FT), we developed a method to quantify structural changes in the foot processes and mitochondria of kidney biopsy specimens.2 per year) was estimated using a mixed-effects linear regression model including all available data on eGFR after kidney biopsy, with individual patients regarded as a random effect. The correlation between mitochondrial damage indices and clinical measurements was then analyzed using a robust linear regression model. All patients provided written informed consent and the ethics committee at the Osaka University Graduate School of Medicine approved this study . Images for the foot process analyses , dehydrated in an increasing ethanol concentration solution series, and embedded in paraffin. HE, PAS, or EMT staining was performed on 2-μm–thick kidney sections using standard procedures described in analyses c, coeffianalyses c and d w,Escherichia coli O111:B4, Sigma-Aldrich). Kidney samples were obtained 18 hours after LPS injection.Six-week–old male Sprague-Dawley rats and 8-week–old male C57BL/6 mice were purchased from Japan SLC Inc.  and maintained at the animal facility of Osaka University School of Medicine.For the ischemia reperfusion kidney injury model, bilateral renal pedicles were clamped for 30 minutes and kidney samples were obtained 15 minutes after reperfusion. Tissues were fixed with 4.0% paraformaldehyde in phosphate-buffered saline (pH 7.4), dehydrated, and embedded into paraffin.Bright field microscopy images were obtained with a Nikon ECLIPSE E600  using an oil-immersion objective lens (100×).For electron micrographs, kidneys were dissected and fixed in 4.0% glutaraldehyde, post-fixed in 1.0% osmium tetroxide, and embedded in Epon-Araldite.Kidney sections stained with HE, PAS, PAM, and EMT were analyzed by N-SIM SRM (Nikon) with no additional florescent dye. To confirm that the structures visualized in the tubular area of the EMT-stained sections were mitochondria, we performed sequential staining for cytochrome c oxidase polypeptide IV  before EMT staining.Emission spectra of EMT staining dyes were measured with a SH-9000Lab plate reader . Ponceau xylidine acid fuchsin azophloxine solution  and aniline blue  were diluted 50 times in distilled water and 8% acetic acid, respectively. The ranges of emission wavelengths for the spectra analyses were determined according to the emission filters equipped on the N-SIM. Spectra from the corresponding solvents were subtracted from the spectra of the ponceau xylidine acid fuchsin azophloxine solution, and aniline blue.https://github.com/NephrologyOsakaUniv/SuperResMicroscopy_2021. To analyze the integrity of the basement membrane, ROIs were traced in ImageJ2.To quantitatively analyze damage in podocyte foot processes and mitochondria, 128 × 128–pixel regions of interest (ROIs) corresponding to 4.13 × 4.13 μm were manually isolated from the original images. FT, inverse FT, and spectrum magnitude analyses were performed using NumPy 1.16.5, a library for scientific computing in Python. Circular cutouts of the mitochondrial images were also performed by NumPy in Python. Codes are available at the following website: P < 0.05.Statistical analyses were performed with Stata/SE (version 16) software package  for eGFR slope estimation and analysis of association between mitochondrial damage indices and clinical measurements. GraphPad Prism8  was used for the others. Correlation between foot process integrity assessed by SIM and proteinuria was analyzed using simple linear regression. Comparisons between two groups were performed with the Mann–Whitney U test. Statistical analyses for variation of ratio were evaluated with chi-square test. Univariate and multivariate association between mitochondrial damage indices and clinical measurements were analyzed by robust linear regression analyses. Results were considered statistically significant at Using SIM, we sought to visualize cellular microstructures of glomeruli in HE, PAS, PAM, or EMT-stained paraffin-embedded samples prepared as part of daily clinical practice. Staining protocols are summarized in To analyze which dye in the EMT staining procedure  caused fWe assessed whether EMT-based 3D SIM imaging could detect pathological changes in podocyte foot processes in two patients, one with MGA whose proteinuria was 0.49 g/gCr, and the other with minimal change nephrotic syndrome (MCNS) whose proteinuria was 13.2 g/gCr and whose foot process effacement was confirmed by electron microscopy . Althoug2-(1/16)2 adequately included information that represented normal foot process structures (2-(1/16)2, we analyzed the integrity of the foot process in patients with MGA, MCNS, and IgAN  of patients with MGA and TIN were manually cut out from 561-nm–excited EMT-stained section images [Herein, we have shown that EMT-stained kidney sections are useful for quantifying the integrity of podocyte foot processes and tubular mitochondria, whereas PAS-stained sections are appropriate for analysis of basement membrane microstructures. Because our method does not require additional sample preparation, we obtained the microstructural information from human specimens without loss of samples. Moreover, we developed a novel FT-based quantitative method to evaluate the integrity of foot processes and mitochondria, the morphological changes of which directly cause kidney diseases. Subtle changes in the basement membrane in MN stage I were quantified by calculating CV values. Hence, microstructural information of the kidney was obtained from sections prepared as part of a routine clinical practice for a renal disease patient.,Electron microscopy is the gold standard method for detailed analysis of cellular microstructures. Although SRM can surpass the diffraction limit of visible light, electron microscopy can achieve much higher resolution because the electron beam wavelength is much shorter than visible light.et al.et al.et al.et al.Several methods have been applied to quantify injured foot processes. For example, Deegens There were several limitations associated with our study. First, SIM is not currently available or present in many general hospitals. Therefore, collaboration between hospitals and research facilities that have SIM is required for the broad application of our strategy. Second, we analyzed only relatively thin sections  because our facility routinely uses 2 μm-thick sections for the preparation of kidney biopsy samples. As many conventional histology stains can result in uneven staining in thick specimens, fluorescent labeling of abundant reactive entities, which can covalently stain thick sections, may be helpful in the analyses of thick samples.In conclusion, we developed a novel strategy to facilitate the quantification of microstructural changes in kidney biopsy specimens. PAS- or EMT-stained sections prepared during daily clinical practice are sufficient to extract information regarding podocyte foot processes, mitochondria, and basement membranes. Meanwhile, electron microscopy and SRM can play complementary roles in better understanding kidney disease pathology.10.13039/501100001691JSPS KAKENHI 18K15974.Supported by a grant from


Background: Women had worse outcomes after acute myocardial infarction (AMI), and physiologically, women had lower hemoglobin values. We examined whether there were sex-related differences in the relationship between hemoglobin levels and adverse outcomes in patients with acute myocardial infarction.Method: We conducted a post-hoc analysis of data from the Acute Coronary Syndrome Quality Improvement in Kerala (ACS-QUIK) Study. We explored the relationship between baseline hemoglobin level and 30-days adverse outcomes by logistic regression model, generalized additive model (GAM) and two-piecewise linear regression model. We used multiple imputation, based on five replications and a chained equation approach method in the R multiple imputation procedure, to account for missing data. The primary outcome were 30-day major adverse cardiovascular events (MACEs) defined as death, reinfarction, stroke, and major bleeding. The secondary outcomes were 30-day major bleeding, 30-day stroke and 30-day cardiovascular death (CVD death).Results: Twenty thousand, five hundred fifty-nine patients with AMI were included in our analysis. Baseline hemoglobin level was associated with major bleeding , CVD death , and MACEs . There was no significant relationship between baseline hemoglobin level and stroke incidence in both men  and women . Baseline hemoglobin level was associated with major bleeding  in male patients, however we did not find the same relationship in female patients . GAM and two-piecewise linear regression model showed the relationships of hemoglobin level with major bleeding, CVD death, and MACEs were non-linear (non-linear P < 0.05), and the threshold value were 13, 14.8, and 14.3 g/dL for MACEs and CVD death, respectively.Conclusion: Baseline hemoglobin level was one of the independent predictors of prognosis in South Asia patients with acute myocardial infarction. Moreover, its impact on prognosis was largely different depending on the patients' sex. In previous studies, the prevalence of anemia in patients with acute coronary syndrome was 10–32% . Many copatients –11. Leonpatients . In a repatients . Accordipatients . Women apatients .In high-income countries, the decline of mortality rates was observed in patients with ACS since 1970s . HoweverRecent studies did not have data on South Asian populations, and most of the data sources came from 10 years ago , 20. Conpost-hoc analysis of data from the Acute Coronary Syndrome Quality Improvement in Kerala (ACS-QUIK) Study . The design and results of ACS-QUIK have been reported before  , stroke,H-test, according to the distribution type.We used a normality test to determine whether baseline hemoglobin levels followed a normal distribution. The baseline characteristics of patients were presented as means and standard deviations (SDs) or interquartile ranges (IQRs) for continuous variables depending on whether data distribution was normal [as assessed by normal quantile–quantile (Q–Q) plots and Lilliefors (Kolmogorov-Smirnov) normality test] while categorical variables were expressed as percentages. We compared categorical variables using chi-square tests and continuous variables using one-way analysis of variance (ANOVA) and the Kruskal–Wallis http://www.R-project.org) and EmpowerStats . P < 0.05 (two-sided) were considered statistically significant.We investigated the relations between baseline hemoglobin level and 30-day adverse outcomes using the baseline hemoglobin level as both continuous and categorical variables by logistic regression model that adjusted clinically meaningful variates and statistically significant covariates. We presented the non-adjusted model, minor adjusted model which adjusted for demographic data, including cohort, intervention, age, male sex and full adjusted models which adjusted for cohort, intervention, age, male sex, ST-segment elevation myocardial infarction (STEMI), heart rate, weight, smoking or tobacco, hypertension, peripheral arterial disease (PAD), prior transient ischemic attack (TIA) or stroke, diabetes, cardiac arrest, Killip class, left-ventricular ejection fraction (LVEF) category, minutes from symptom onset to arrival, angiography, percutaneous coronary intervention (PCI), and inhospital medications. We used multiple imputation, based on five replications and a chained equation approach method in the R multiple imputation procedure, to account for missing data . In logiP < 0.01, Lilliefors (Kolmogorov-Smirnov) normality test]. At baseline , P = 0.04, CVD death, OR: 0.79, 95%CI , P < 0.01, MACE, OR: 0.82, 95%CI , P < 0.01]. However, in the full adjusted model baseline hemoglobin level was not statistically significant in relation to Stroke .We presented the non-adjusted model, minor adjusted model, and full adjusted model in the P < 0.01], CVD death , and MACE .The equivalent degrees of freedom of GAM were 7.7, 6.6, and 4.6 for major bleeding, CVD death, and MACEs, respectively. Generalized additive model showed non-linear relationships between baseline hemoglobin level and major bleeding, CVD death, and MACEs . Then weP < 0.01], but not in the female population . However, in female patients, the risk of stroke increased as hemoglobin increased, but it was not statistically significant . The risk of stroke in male patients did not change with changing of hemoglobin level . The risk of CVD death was significantly reduced when the hemoglobin level was below 14.9 g/dL as hemoglobin level increased  of the male patients. On the other hand, the risk of CVD death of female patients lowered  when the hemoglobin level was above 9.2 g/dL. As the level of hemoglobin increased before the inflection point, the risk of MACE in men was significantly reduced , while women had no significant impact .As is shown in P for interaction is 0.03, <0.01, <0.01, <0.01, <0.01, and 0.02). For stroke, the significant variables of the interaction test were weight and LVEF category (P for interaction is 0.02 and 0.02). We observed that high hemoglobin levels were a risk factor for stroke in low-weight populations , while high hemoglobin was a protective factor for stroke in high-weight populations . For MACE, the significant variables of the interaction test were heart failure (P for interaction is 0.05).As showed in As showed in Anemia was associated with multiple comorbidities, such as diabetes , heart fBrener et al. only described the non-linear relationship between baseline hemoglobin level and prognosis, but their study did not elaborate on the independent effects of different hemoglobin levels on prognosis . The maiThe relationship between baseline hemoglobin level and adverse outcomes approximated a J-shaped curve , and we Different levels of hemoglobin had different effects on the cardiovascular system. Low hemoglobin levels mean a reduction in the ability of the blood to carry oxygen. The delivery of oxygen depended primarily on hemoglobin and cardiac output. In the condition of AMI, the systolic and diastolic functions of ventricles were affected by local myocardial hypoperfusion due to the involvement of the coronary arteries, resulting in decreased cardiac output. Conversely, if tissue oxygen demand was insufficient, heart rate increased faster to increase cardiac output, which would increase cardiac workload and might exacerbate myocardial supply and demand mismatch. Additionally, high hemoglobin levels might directly contribute to the formation of acute thrombosis and increase the risk of thrombosis in patients with polycythemia . At the Low hemoglobin levels could also lead to an increased risk of bleeding. A low baseline hemoglobin level might be a sign of occult gastrointestinal bleeding, inflammatory status, or hemorrhagic quality. In addition, hematocrit levels could affect primary hemostasis. It was shown that an increase in the hematocrit level on the one hand could lead to an increase in platelet deposition on the arterial wall, and on the other hand led to an increase in blood viscosity and an increase in shear force. In this case, the function of platelets might be activated by adenosine diphosphate released by red blood cells , 44.Many studies reported that low hemoglobin levels were associated with bleeding and the women have a higher bleeding risk in ACS , 44. Howpost-hoc analysis of a pre-defined registry with a study population from the south Asia. The results of this study might not be applicable to Western countries due to differences in the ethnicity and treatment of AMI patients.There were still many limitations in our research. Although we adjusted a lot of variables, but limited to the original database, we were unable to adjust all the variables that need to be adjusted. Several variables in the Global Registry of Acute Coronary Events (GRACE) score, such as excessive deletion of creatine kinase isoenzymes in the heart, ST segment depression, were not included. Moreover, the raw data did not collect the cause of patients' hemoglobin declines. Therefore, we did not know whether the reason for the decrease in hemoglobin levels in patients was related to adverse outcomes. There were 1,741 patients with no medication data, and although we used the method of multiple imputation, we were not able to completely avoid this possible bias. This study was a The level of baseline hemoglobin was an independent predictor of prognosis in patients with acute myocardial infarction in South Asia. Moreover, its effect on prognosis was largely dependent on the sex of the patient. Low hemoglobin levels could increase the risk of adverse outcomes in patients with acute myocardial infarction. Male patients with low hemoglobin levels were at high risk of bleeding and should consider conservative antiplatelet and anticoagulation strategies.https://biolincc.nhlbi.nih.gov/studies/acs_quik/.Publicly available datasets were analyzed in this study. This data can be found here: XH and XW designed the study and provided methodological expertise. JP and XW drafted the manuscript. XW, JP, PC, KZ, and XH drafted the tables and figures and performed statistical analysis. JP was mainly responsible for the revised manuscript. All authors have read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Growing evidence suggest that type 2 immune effectors play a role in solid organ transplantation. The aim of this study was to evaluate the impact of blood count eosinophils (BCEo) on immunological outcomes in kidney transplant recipients with stable graft function after 3 months post-transplant.de novo donor specific antibodies after excluding common causes of increased BCEo..We performed cause-specific Cox model considering BCEo, the use of calcineurin inhibitors and systemic corticoids as time-dependent explicative variables on a prospective cohort of 1013 kidney transplant patients who experienced kidney allograft rejection and/or the appearance of BCEo ≥ 0.3 G/L was associated with a 3-fold increased risk of rejection independent of immunosuppressive regimen after 3 months post-transplant in patients without pre-transplant DSAs and with CNI-based immunosuppression. No association between BCEo either with donor specific antibodies or graft survival was noticed.These observations in this large cohort support the hypothesis of eosinophils in allo-immunity in human and claim for further mechanistic research.This study was supported by the French National Research Agency, The “Institut de Recherche en Santé Respiratoire des Pays de la Loire” and the University hospital of Nantes. We searched in Pubmed, Embase, Web of Science relevant articles encompassing the following terms: “eosinophilia”, “transplant rejection”, “graft rejection”, “kidney transplantation”, “kidney graft rejection”. Mechanistic studies in mice model of transplantation (skin and heart) showed a cytotoxic role of eosinophil participating in acute and chronic rejection. In human, whereas the role of eosinophils in transplantation remains unclear, some case reports and/or studies in a few patients have shown a positive correlation between eosinophilia and solid organ rejection a few days before it occurs. In this study, we evaluated the association of time-dependent variation in blood count of eosinophils (BCEo) and allograft rejection and the appearance of Our data thus revealed that a BCEo ≥ 0.3 G/L threshold could be an interesting and routine biological marker for monitoring immunological outcomes along with other routine parameter such as DSAdn in kidney transplant recipients without pre-transplant DSAs and with CNI-based immunosuppression at steady state .In clinical practice after eliminating common causes of an increase in BCEo  and/or proteinuria > 1 g/24 h and/or hematuria (> 10 red blood cells/mL) and/or an increase of 25% in serum creatinine compared to baseline. Though, multicentric studies challenging BCEo > 0.3 G/L threshold but also evaluating the optimal time points of BCEo titration are needed. At last, these observations open new perspectives and directions that raise the question of the involvement of eosinophils and type 2 immunity in kidney allograft rejection.Alt-text: Unlabelled box1Type 2 inflammation is mainly characterized by a high rate of IL-4, IL-5 and IL-13 secretion leading to IgE synthesis, an increase in blood count eosinophils (BCEo) and eosinophil and mast cell/basophil tissue infiltration. Type 2 inflammation is mostly associated with parasitic infection and atopic/allergic diseases in vivo results in a drastic decrease in eosinophil infiltrate and in complete or partial rejection inhibition in cardiac and skin graft models The implication of eosinophils in acute and chronic rejection has been shown in an experimental mouse model to depend on the cytotoxic effect of cationic and basic proteins released after eosinophil degranulation in the graft de novo anti-HLA donor-specific antibodies (DSAdns) in a prospective cohort of 1013 kidney recipients with stable renal function at 3 months post-transplant.In humans, whereas the role of eosinophils in transplantation remains unclear, some case reports and/or studies in a few patients have shown a positive correlation between eosinophil infiltrate in graft biopsies and acute rejection in cardiac, lung, liver and kidney transplantation models, which is often associated with an increase in relative blood BCEo  a few days prior, suggesting that blood eosinophilia is predictive of an immunological event occurring in the graft 22.1www.divat.fr, French Research Ministry: RC12_0452, last agreement No. 13 334, No. CNIL for the cohort: 891735)]. First, a total of 5984 KTRs with medical follow-up in Nantes University Hospital were screened. Adult (≥ 18-year-old) KTRs alive between January 2008 and December 2018 with stable graft function at 3 months post-transplant were selected (n = 1682). Stable graft function at 3 months post-transplant was defined as creatinine < 150 µmol/L and proteinuria < 1 g/24 h under standard immunosuppression  or mTOR inhibitors and antimetabolite +/- corticosteroids). We established a baseline period at 3 months post-transplant to obtain the steady state of BCEo. Indeed, high-dose of systemic corticosteroids , immunosuppressive drugs  and induction therapy are given within the first 3 months after transplantation and the impact of immunosuppressive drugs  combination on BCEo is yet not well established. Among those 1682 KTRs, patients with pretransplant DSA or who had undergone simultaneous kidney-pancreas transplantation were excluded. Patients with post-transplant haematologic disorders, active parasitic infection and HIV infection were also excluded since those factors are known to increase BCEo (n = 1393) Daily practice clinical and biological data were extracted from the prospective cohort of kidney transplant recipients (KTRs) [DIVAT cohort from Nantes University Hospital (Données Informatisées et VAlidées en Transplantation) (2.2i.e. number of kidney transplantation) and the number of HLA-A/B/DR mismatches. As the baseline period began at 3 months post-transplant, the previous immunization status was defined as positive if a rejection episode or HLA antibody (IgG) was registered before the baseline period. All the rejection episodes were histology proven rejection (HPR). HPR was divided into 3 subsets according to the Banff consensus: T-cell-mediated rejection (TCMR) and Classical risk factors likely to influence graft immunological outcomes were extracted from the database. Donor features included age, sex, living or deceased donor status, cold ischemia time and extended criteria donor (ECD) data ,21. The Routine blood eosinophil counts after 3 months post-transplant and all subsequent counts using automated flow cytometry  were noted. All eosinophil counts in this study refer to blood eosinophil counts. Classical and available risk factors likely to influence blood eosinophil count changes were extracted from the database. HIV-positive patients, patients diagnosed with post-transplant lymphoproliferative disorders (PTLDs), active parasitic infections or acute allergic process which could cause an increase in BCEo de novo DSA with time-dependent variation in BCEo were used to define analysis outcomes.The appearance of kidney allograft rejection  and the appearance of 2.3Surveillance kidney transplant biopsies were routinely taken during patient follow-up at 3 months post-transplant for 50.2% of the KTR and for 52.9% KTR at 12 months post-transplant. For cause kidney transplant biopsies were also taken during follow-up either in case of a serum creatinine increase of 25% serum creatinine baseline or proteinuria ≥ 1 g/24 h or hematuria (10 red blood cell/mL) or DSAdn against class I and/or class II HLA of IgG isotype with MFI ≥ 2000. Kidney transplant biopsies were carried out by experimented nephrologists with a biopsy gun . The biopsies were immediately fixed in 10% formalin and subsequently embedded in paraffin, and the produced slides were stained with hematoxylin and eosin (HE), May Grünwald Giemsa (MGG) and Masson trichrome. All kidney transplant biopsies were analyzed according to the Banff classification 2.4Declaration of Helsinki and approved by the National French Ethics Committee (DIVAT (Données Informatisées et VAlidées en Transplantation) ). All participants enrolled in this study signed informed consent forms.This study was performed in accordance with the 2.5The analysis was performed in 2 steps. Step 1 was an explanatory variable reduction process based on clinical ground and statistical methods. The principal explanatory variable of interest was multiple eosinophil counts during follow-up. All other predictors of the survival outcome in the raw dataset were selected by 2 independent nephrologists. Variables with small variance and/or redundant variables  were removed. Ten predictors were included in the multivariable regression model: ECD, recipient features , previous immunization status  and the rank of transplantation. Step 2 involved a multivariable regression model to investigate the etiologic relationship between the dynamic eosinophil count during follow-up and kidney allograft rejection and DSAdn appearance. The outcomes were survival data with multiple changes updated during the patient follow-up. We used a time-dependent covariate cause-specific Cox regression model (competitive risk model for aetiologic purpose) ,24. Threa priori relevant blood eosinophil threshold based on available data mostly from a priori threshold of 0.3 Giga/L  was thus used to categorize BCEo defined as follows: high (≥ 0.3 Giga/L) or low (< 0.3 Giga/L). This a priori threshold was confirmed fisrt by inspecting Martingale residuals according to continuous blood count eosinophils, then by plotting the spline function of blood eosinophil according to hazarad ratio using cause-specific multivariable Cox model  and at last by performing time-dependent multivariable analysis of immunological event onset (rejection and/or DSA) in KTRs during follow-up according to BCEo as categorical variable  (Table S1). The statistical significance  was set at 0.05. All analyses were performed using R software version 4.0.3 using Thernau et al package .The proportional hazards assumption and the log-linearity assumption of the Cox model were evaluated by Schoenfeld and martingale residuals, respectively 2.6None of the funder had any role in the present study.33.1The demographic characteristics of the patients are described in 3.2p = 0.004) in patients without pre-transplant DSA and with CNI-based immunosuppression. No association was observed with BCEo ≥ 0.3 G/L when stratifying by HPR subsets , probably due to a lack of power since only 15 patients experienced a rejection episode 3 months post-transplant and had a BCEo ≥ 0.3 G/L (data not shown). The use of CNIs as maintenance therapy at eosinophil measurements significantly reduced the risk of a rejection episode by 76% , whereas the use of corticosteroids as maintenance therapy at eosinophil measurements was significantly associated with an increased risk of rejection  probably due that patients at higher risk of rejection  are more frequently under long-term OCS course compared to other KTR where corticosteroids withdrawal occurs early in our practice (Patients with a higher eosinophil count (≥ 0.3 Giga/L) at a given follow-up time after 3 months had a 3-fold higher risk of experiencing a rejection episode during the follow-up period than patients with a lower eosinophil count (< 0.3 Giga/L) at the same time point, independent of other confounding factors  suggesting that BCEo could be associated with DSAdn appearance in a specific subpopulation of KTR. Nevertheless, the use of CNIs as maintenance therapy at eosinophil measurements significantly reduced the risk of developing DSAdn by 71% , whereas the use of corticosteroids as maintenance therapy at eosinophil measurements increased the risk of DSAdn appearance . Not surprisingly, HLA antibody positivity before transplantation or 3 months post-transplant and extended criteria donors were significantly associated with an increased risk of developing DSAdn   to KTRs with a low eosinophil count (n = 13) by age (+/- 5 years) and sex to take into account immunosenescence. We did not detect the presence of eosinophils in the graft and thus no correlation with the blood eosinophil count in either subgroup (high or low eosinophil count)  in KTRs with a high eosinophil count compared to those with a low eosinophil count. Within the rejection group, we matched KTRs with a high eosinophil count (l count) .Table 3C4First described in 1879 by Ehrlich Eosinophils are mainly associated with type 2 inflammatory diseases but have also been described in organ transplantation, mainly in the lung and liver. In lung transplantation, a BCEo ≥ 0.4 G/L, though arbitrary, is used as a biological sign suggesting acute lung rejection in the presence of a 10% FEV1 decrease during patient follow-up In liver transplantation, BCEo has long been associated with acute cellular rejection Despite being less frequent, several studies also reported the appearance of eosinophils in the peripheral blood  and kidnMany confounding factors  could impact the relative and absolute BCEo thresholds, thus questioning their robustness in predicting HPR in solid organ transplantation. Importantly, steroids are clearly one of the main factors that downregulate eosinophils In the literature, the results regarding a correlation between the number of eosinophils in the graft and in the blood are controversial. Whereas some report a direct correlation ,43,49, oe.g., amino acid starvation or a decrease in partial pressure in oxygen) γ or by the iNOS pathway in a mice model of lung transplantation The question is then “What could trigger eosinophilia?” and, by extension, “What could trigger type 2 immunity 3 months post kidney transplantation?”, particularly in the blood. Contrary to common paradigms, type 2 immunity is not limited to allergic, parasitic or fungal hypersensitivity. Recently, specific stimuli in the cell microenvironment were shown to strongly polarize innate immunity to a type 2 response . These stimuli act alone or in synergy and consist of either protease-activated receptors (PARs) via the serine/cysteine protease activity of antigens and/or tissue damage release of DAMPs and/or metabolic changes leading to the oxidative stress response . In clinical practice after eliminating common causes of an increase in BCEo  Our data thus revealed that a BCEo ≥ 0.3 G/L threshold could be an interesting and routine biological marker for monitoring immunological outcomes along with other routine parameter such as DSAdn in kidney transplant recipients without pre-transplant DSAs and with CNI-based immunosuppression at steady state (LC conceptualized, created the methodology, curated data and formal analysis, wrote the original draft, reviewed, and edited. LB created the methodology, curated data and formal analysis. CK managed the data and reviewed the manuscript. KAR, ML and AM reviewed and edited the manuscript. MG conceptualized, created the methodology, reviewed, and edited the manuscript. SB conceptualized, created the methodology, curated datas, wrote, reviewed, and edited the manuscript. All the authors red and approved this manuscript.Pr. Gilles Blancho; Dr. Julien Branchereau; Dr. Diego Cantarovich; Dr. Anne Cesbron; Dr. Agnès Chapelet; Pr. Jacques Dantal; Dr. Florent Delbos; Dr. Clément Deltombe; Dr. Anne Devis; Dr. Lucile Figueres; Dr. Claire Garandeau; Dr. Caroline Gourraud-Vercel; Pr. Maryvonne Hourmant; Dr. Christine Kandell; Pr. Georges Karam; Dr. Aurélie Meurette; Dr. Anne Moreau; Dr. Simon Ville; Dr. Alexandre Walencik.The authors of this manuscript have no conflicts of interest to disclose as described by EBioMedicine.


The sample consisted of 13 patientssubmitted to percutaneous renal biopsy, with 65 evaluations. The patientswere evaluated in five moments in the 24 hours after the procedure, using aninstrument developed by the researchers based on five outcomes  and 11 indicators. The Generalized Estimation EquationTest was used to compare the scores of the indicators. The project wasapproved by the institutional ethics committee. in the 65 evaluations, a statistically significant difference was identifiedin the reduction of the scores of the following nursing outcomes: Bloodcoagulation, “hematuria” indicator; Circulation status, in the “systolicblood pressure and diastolic blood pressure” indicators and Comfort status:physical, in the “physical well-being” indicator. the evaluated patients did not show major complications. The clinicalindicators signaled changes in circulation status, with reduced bloodpressure, as well as in blood clotting observed by hematuria, but withouthemodynamic instability. The comfort status was affected by the rest timeafter the procedure. The major ones includemacroscopic hematuria and retroperitoneal hematoma requiring blood transfusions,surgical interventions or invasive procedures. Minor complications consist oftransient macroscopic or microscopic hematuria, without the need for transfusion orother interventions, nephrectomy and bladder obstructionThe clinical evaluation of the patient submitted to PRB by the nurse includes themonitoring of signs and symptoms, aiming to identify early potential complicationsto avoid and/or decrease their incidence, as well as facilitate patient recovery.The use of a classification system, based on a standardized language, allows nursesto diagnose, plan, intervene and evaluate the results obtained. -The Nursing Outcomes Classification (NOC)-In this sense, a number of studies also pointed out that the NOCA systematic review on standardized language identified 312 articles, most of them onthe NOC with a focus on the reliability or validity of its terms and nurses’perception of their potential to be used in the practice. However, only six studiesused this classification in the clinical nursing practiceThus, the study was developed in a real clinical setting and aimed to evaluate thecomplications of PRB based on outcomes and clinical indicators of the NOC.This is a longitudinal study with prospective data collectionPatients were recruited for the study occurred according to the marking schedulebiopsies, informed daily to the researchers, by the research field nurses. Patientsof both genders, aged 18 years old or over and submitted to PRB, were included.Those who were submitted to more than four punctures during the procedure and/or useof a larger needle (14G) were excluded, due to the fact that these patients havemedical indication to continue resting in bed rest for 24 hours after the procedure.Bedridden patients or who were unable to walk were also excluded, because theevaluation of the “Comfort status: Physical” nursing outcome is related to thepatient leaving the bed. -,The sample was calculated using the WINPEPI program, version 11.43. The same wasestimated for the outcome of the main complications of PRB, knowing that bleeding isthe most frequent of them. The NOCData collection took place from February to May 2018. The data collection instrumentwas built by the researchers and consisted of sociodemographic and clinicalcharacteristics of the patients, description of the biopsies performed and NOCnursing outcomes and indicators-The selection of indicators and outcomes was carried out by the researchers based onthe literatureFor each indicator of the NOC-All the patients were evaluated at five different times by the researchers in a totalperiod of 24 hours: immediately before the procedure (A0), to know the baselinestatus of the patient; immediately after PRB A1); at the eighth hour after theprocedure (A2); at the 12th hour (A3) and at the 24th hour after PRB (A4). Theinterval between evaluations was determined based on studies on bed rest time afterPRB, which indicate that complications are more frequent in the first hours and upto 24 hours after the procedure; at the Excel for Windows and analyzed in theStatistical Package for the Social Sciences, version 21.0. Thecontinuous variables were described as mean and standard deviation or as median andinterquartile range, according to data distribution. The categorical variables weredescribed by means of absolute and relative frequencies. To compare the mean scoresof the nursing indicators over time, the Generalized Estimation Equations model) was applied with Bonferroni adjustment to locate the differencesbetween the means. The level of significance adopted was 5% (p<0.05).The data were organized in The project was submitted to Brazil Platform and approved by the institution’sResearch Ethics Committee (Protocol No. 170430). The specialists who participated inthe selection stage of the clinical indicators used in the study consented to theirparticipation by submitting their answers using an online form. The patients whotook part in the study signed two copies of the Free and Informed Consent Form.Of the 13 patients submitted to BRP, the following were identified: seven (54%) malepatients were identified and seven white-skinned (54%), with a mean age of 46.6 (±12.3) years old. Eight (61.5%) were hypertensive, four (30.8%) diabetic and six(46.2%) kidney transplant recipients. Four (30.8%) of the patients had alreadyperformed the procedure on another occasion .The performance of 53.8% of the procedures occurred in the Outpatient SurgicalCenter, with patients coming from their home and who remain for 24 hours underobservation after the interventions. The predominance of procedures performed atthis site is of native kidneys, due to the need to investigate the etiology of renalfunction loss. Regarding the needles gauge used, 12 (92.3%) were of 16G gauge, bothin native kidney and graft .The Blood coagulation, Circulation status and Comfort status: physical nursingoutcomes were statistically significant. In the “bleeding, bruising, facialexpressions of pain and comfortable position” indicators, it was not possible toperform the statistical test due to lack of variability in their scores, whichremained high. In the “abdominal distension, skin and mucous membrane pallor andreported pain” indicators, there was no significant difference between the momentsevaluated, which also points to the absence of complications after the procedure.There was a significant change in the scores of four clinical indicators:“hematuria, systolic blood pressure, diastolic blood pressure and physicalwell-being”. As for “hematuria”, considering the scores obtained before PRB, it was observed thatthese were significantly higher than in the eight-hour period after the procedure.However, this indicator was the only one that could not be applied in the 65evaluations performed, as in some cases the patient did not show diuresis at thetime of the evaluation. This situation is justified by the fact that the samplestudied is composed by patients with chronic kidney disease, in which change inurinary volume is usually found. Another factor that interferes with urinary volumeis due to the patient’s fasting 4 hours before the procedure and 4 hours after, thatis, without fluid intake. Regarding “systolic blood pressure and diastolic blood pressure”, the scores at the8th hour and at the 12th hours after PRB were substantially lower than at the pre-and immediately post-procedure. In addition, “diastolic blood pressure” also had aconsiderably lower score at the 24th hour, when compared to the moment before theintervention. With regard to “physical well-being”, the scores at the 8th hour afterPRB were significantly lower than after the procedure, with a slight difference inthe 12th and 24th evaluations after, being less than one point on the scale of theNOCThis is the first study developed in a real clinical setting on the application ofthe NOC-,The stage of validation by expert consensus was essential for the development of thestudy, since the NOC-,-Thus, nursing outcomes and clinical indicators were selected for which conceptual andoperational definitions were built, according to the magnitude of the 5-point Likertscale of the NOC,-Regarding the characteristics of the patients, the study sample consisted,predominantly, by those with chronic diseases with chronic diseases, with half ofthe sample being kidney transplanted, which is corroborated by the literature,Biopsies were performed on both native kidneys and kidney grafts, which did notinterfere with the occurrence of complications, since all the patients remainedwell, without complications. Differently from the present study, the literature onrates of complications after PRB points out that those performed in native kidneysare higher compared to allografts, because the latter are easier to access, inaddition to allowing easier compression of the site, in bleeding cases-,,Also regarding the procedure, all the biopsies were performed with a smaller gaugeneedle, with 12 92.3%) with a 16G gauge needle and one (7.7%) with 18G gauge, whichis known to reduce the risk of bleeding, when compared to the use of larger gaugeneedles% with a Regarding the evaluation on the complications of the procedure, with a NOC-basedinstrumentIn the Blood coagulation nursing outcome, the “bleeding” clinical indicator remainedwith its scores practically unchanged over time, with a slight decrease occurringshortly after the procedure. As for the “bruising” indicator, no patient presentedthis complication, that is, the scores remained at their maximum value in allassessments. It is worth noting that the scores measured during the evaluations canvary from positive , negative (decrease) or, even,there may be no change. For certain situations in which the patient does not haveconditions for improvement, the goal ends up being to maintain the clinical statusat a certain magnitude of the outcome-,,,,-In addition to nursing care and monitoring of potential biopsy complications, it isrelevant to note that the technique used in performing the procedure, as well as theprediction of risk factors, are aspects that also minimize the chances of thepatient presenting complicationsRegarding the “hematuria” indicator, the scores before the biopsy and at the 24thhour were significantly higher than at the eighth hour. However, it should be notedthat this was the only indicator not measured in the total sample of patients(n=13), considering that two patients did not want or could not urinate in any ofthe five evaluated moments. In addition, at the 8th hour after the procedure, thelargest number of evaluations was performed with the tape test to check formicrohematuria and inspection in relation to the presence of macrohematuria (eightpatients), which justifies the fact that there was a greater difference at thismoment. According to the literature-As for the Circulation status nursing outcome, assessed by the “systolic bloodpressure and diastolic blood pressure” indicators, it is highlighted that the valuesfound at the eighth and 12th hours after the procedure were obtained in the earlyevening and during the night, which can explain the lower blood pressure values whencompared to the patient’s baseline (before biopsy) or with the evaluation performed24 hours after the procedure, which always happened during daytime hours when thepatient was awake. It is known that the pressure values are lower during sleep, butwithout other associated clinical repercussionsA number of studies indicate that blood pressure varies widely during 24 hours andduring sleep, in healthy individuals, there is a progressive decrease in theirvaluesIn the Blood loss severity nursing outcome, the scores for the “abdominal distensionand skin and mucous membrane pallor” indicators did not indicate a statisticallysignificant difference in any evaluation during the 24 hours after PRB. This pointsout to the unchanged status of the patient, that is, the absence of these signs andsymptoms after the procedure. This finding does not exclude the importance ofmeasuring these two indicators pointed out by specialist nurses as priorities forpatient assessment after PRB, since they are signs and symptoms that can indicatethe occurrence of major complications, when associated with other clinicalindicatorsRegarding the Pain level outcome, the “reported pain and facial expressions of pain”indicators showed high scores, demonstrating the absence of pain in all theassessments performed over the 24 hours. Thus, it is inferred that the patients werewell-assisted by the health team, with the implementation of comfort and analgesiameasures, when necessary. Pain management by the nurse is fundamental for the patient’s good recovery, since itis a symptom that can trigger psychological and physiological changes that canworsen their health situation. Thus, pain control and relief are essential, withappropriate pharmacological and non-pharmacological interventions for each caseAs for the Comfort status: Physical nursing outcome, the “physical well-being”indicator at the 8th hour after the procedure had a score significantly lower thanin the initial evaluations (p<0.044). Physical well-being refers to the generalstate of physical comfort and the perception of this well-being by the patientIt became evident that, as the hours passed, there was a change in the patient’sfeeling of comfort and physical well-being, possibly associated with the long restperiod after the biopsy, which includes movement restriction in the first hoursafter the procedure, in addition to bed rest for 24 hours. The set of outcomes and indicators applied in this study reflects the clinicalcondition of the patients after PRB, pointing to their care needsThe study presented as a limitation the fact that the evaluations at the eighth and12th hours always occur at night and/or at dawn, which may have interfered in theevaluation of some indicators, such as the measurement of blood pressure duringsleep. It was not possible to modify this logistics because the vast majority of thebiopsies, in the field hospital of the study, are performed in the afternoon shift.That is, the observation period of the patient, which begins with the procedure andprogresses for 24 hours and ends up only on the following day. Another limitationwas the difficulty of measuring the indicator of microscopic or macroscopichematuria, since not all patients urinated at the five moments evaluated. The outcomes and clinical indicators selected and evaluated in a real care settingare in line with the literature regarding possible complications of PRB, allowing usto conclude that the evaluated patients had no major complications. The clinicalindicators signaled changes in circulation status, with reduced blood pressure, aswell as in blood clotting observed by hematuria, but without hemodynamicinstability. The comfort status was affected by the rest time, after theprocedure.Thus, it is inferred that there has been effective monitoring of the patients afterthe procedure. The set of evaluated outcomes and indicators points out to thespecificity of the Nursing care in this setting of clinical practice and providessubsidies to qualify and enable a more reliable assessment of patients at risk ofcomplications after PRB, in addition to promoting patient safety in real clinicalsetting. Therefore, this study demonstrated the feasibility of applying the NOC in the Nursingpractice, which confirms the importance of taxonomies combined with the NursingProcess in the fields of care, teaching and research. The comparison of thesefindings with future research studies will allow for the refinement of the use ofthis taxonomy in the clinical setting of patients undergoing PRB.


In subgroup analysis, only 200 mg and 400 mg LCZ696 showed a significant BP reduction. There was no difference in the AE rate between the LCZ696 and placebo groups . Egger’s test revealed a potential publication bias for msSBP (p = 0.025), but no publication bias for other outcomes. Conclusion: LCZ696 may reduce blood pressure more efficaciously than traditional therapy in hypertensive patients without increasing adverse effects.Background: The management of hypertension remains suboptimal throughout the world. Methods: We performed a random-effects model meta-analysis of randomized controlled trials to determine the effectiveness and safety of sacubitril/valsartan (LCZ696) for the treatment of high arterial pressure. Relevant published articles from PubMed, Cochrane base, and Medline were examined, and the last search date was December 2020. Only published randomized controlled trials and double-blind studies were selected for further analysis. The mean reductions in systolic blood pressure (msSBP) and diastolic blood pressure (msDBP) in the sitting position, as well as the mean reductions in ambulatory systolic blood pressure (maSBP) and ambulatory diastolic blood pressure (maDBP), were assumed as efficacy endpoints. Adverse events (AEs) were considered as safety outcomes. Results: Ten studies with a total of 5931patients were included for analysis. Compared with placebo, LCZ696 had a significant reduction in msSBP (weight mean difference (WMD) = −6.52 mmHg, 95% confidence interval (CI): −8.57 to −4.47;  Hypertension is a well-known and modifiable risk factor for cardiovascular disease worldwide. A study showed that the number of patients will increase to 1.5 billion by 2025 . SacubitIn recent years, several randomized controlled trials (RCTs) have attempted to compare the antihypertensive efficacy and safety of LCZ696 in hypertensive patients ,14,15,16This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines . The incWe searched PubMed, Embase, and the Cochrane database throughout December of 2020 using the following key words in various combinations: “hypertension”, “high blood pressure”, “angiotensin receptor blockers”, “angiotensin receptor antagonists”, “angiotensin II receptor antagonists”, “angiotensin II receptor blockers”, “LCZ696”, “ARNI”, and “angiotensin receptor neprilysin inhibitor” and “randomized clinical trial”. Two investigators (SKC and LCC) independently reviewed the titles or abstracts of the studies to determine whether they met the inclusion and exclusion criteria. Disagreements were resolved via consensus and by a third investigator (LCC).2 statistics. Heterogeneity was interpreted as significant if I2 > 50%. All calculations were performed using R (ver 4.0.0) with the metafor package (Version 2.4-0) (Viechtbauer 2017), with a p < 0.05 taken as statistically significant.The following details were gained from all the included studies and were assumed as efficacy endpoints: patient characteristics, sex ratio, enrolled numbers, LCZ696 drug dose, mean reductions in systolic blood pressure (msSBP) and diastolic blood pressure (msDBP) in the sitting position, as well as mean reductions in ambulatory systolic blood pressure (maSBP) and ambulatory diastolic blood pressure (maDBP). The main outcomes were the difference in the means of the blood pressure between LCZ696 and traditional therapy (or placebo). Adverse events (AEs) were considered as safety outcomes. The summary adjusted odds ratio (OR) was derived by pooling each adjusted OR in the included studies. A subgroup analysis was performed based on the LCZ696 drug dose . Publication bias was determined by funnel plots; by visually inspecting the symmetry of the effect size distribution, and Egger’s test was also used for further confirmation. Fixed-effect or random-effect models were chosen according to heterogeneity, and inverse variance was used for weighted averages. We assessed the heterogeneity between studies using Cochran’s Q test and Ip = 0.01.The flow diagram of the study selection is shown in p < 0.001); while the WMD for msDBP was −3.32 mmHg . Thereby, evidencing that LCZ696 has greater antihypertensive efficacy with respect to angiotensin receptor blockers or placebo in hypertensive patients at 24–52 weeks.Both the msSBP and msDBP were calculated in all included studies. The systolic and diastolic blood pressure levels significantly decreased from the baseline after LCZ696 therapy . The poop < 0.001), and maDBP with WMD = −3.57 mmHg,   .p = 0.21). In the 200 mg dose of LCZ696 with comparators, the result showed a significant reduction in msSBP with WMD at −6.64 mmHg . In the 400 mg dose of LCZ696 with comparators, the result showed a significant reduction in msSBP with WMD at −6.41 mmHg  (p = 0.21). In the 200 mg dose of LCZ696 with comparators, the result showed a significant reduction in msDBP with WMD at −3.47 mmHg . In the 400 mg dose of LCZ696 with comparators, the result showed a significant reduction in msDBP with WMD at −2.90 mmHg   . In the  < 0.01) .Similar observations were also seen for maSBP and maDBP A,B.p = 0.90) (p = 0.86); 200 mg of LCZ696 showed an odds ratio of 1.12 ; while 400 mg of LCZ696 had an odds ratio of 1.06 . There was also no significant difference between all subgroups according to different LCZ696 doses. The commonly reported AEs in the LCZ696 groups were nasopharyngitis, headache, dizziness, upper respiratory tract infection, diarrhea, and hyperuricemia. All of which were minimal and mild.Several drug-related AEs were reported after therapy in nine studies. The pooled data showed no significant difference between the AE rates of LCZ696 and the placebo  . In subgThere were two cases of angioedema in the LCZ696 groups and one case in the olmesartan group, all of which were mild and resolved without hospitalization. Except for angioedema, there was one case of acute hepatitis that was attributed to LCZ696 , but theAll studies had randomized controlled and double-blind trials, and all the prespecified outcomes were reported. The ten trials were parallel group, multicenter trials. Overall, the included studies were of high quality. The Egger’s test revealed that there was a publication bias that existed in the estimates of pooled effect size of msSBP, but not in other outcomes. .In this meta-analysis, we found that LCZ696 reduced blood pressure more efficaciously than traditional therapy in msSBP, msDBP, maSBP, and msDBP, without increasing adverse events in hypertensive patients.In our meta-analysis, we explored the vasodilation and anti-hypertensive properties of LCZ696, based on a comparison with two comparator drugs belonging to the ARB class . We found that LCZ696 showed consistently better blood pressure control than traditional antihypertensive agents. There was a concordance in the blood pressure reduction in the LCZ696 group, including msSBP, msDBP, maSBP, and maDBP. Compared with the traditional angiotensin receptor inhibitor, which mainly acts to reduce the sympathetic drive, or inhibition of the renin-angiotensin-aldosterone system, LCZ696 inhibits both the renin-angiotensin-aldosterone system and the breakdown of serum natriuretic peptides, which results in further natriuresis and vasodilation .Our meta-analysis demonstrated that LCZ696 has a stronger blood pressure-lowering efficacy in msSBP and msDBP, compared with the corresponding dose of valsartan, olmesartan, amlodipine, or placebo. The blood pressure-lowering capability was dose-dependent, and the blood pressure control rate also increased with higher doses of LCZ696, achieving 54.2% in patients receiving under 400 mg of LCZ696 . CompareAmbulatory blood pressure measurement also showed a more efficacious blood pressure-lowering capability in the LCZ696 group, and the reduction was dose dependent. The general effects of blood pressure lowering with LCZ696 were maintained over the full 24-h dosing interval, with significantly greater reductions at night time . The nig1 receptor). The natriuretic peptide system plays a key role in the pathophysiology of the cardiovascular system, especially the atrial natriuretic peptide and brain natriuretic peptide [2) receptor [2 receptor stimulation can be produced if the AT1 receptor is blocked [2 receptors, and produces a positive biological response. These mechanisms appear to be responsible for the greater anti-hypertensive effect of LCZ696 compared to ARBs alone.LCZ696 inhibits both natriuretic peptide degradation and angiotensin 1 receptor 1  in the LCZ696 group were later confirmed to be unrelated to the LCZ696 treatment. All trials showed good tolerability, even when compared with placebo. There was also a comparable rate of drug discontinuation (approximately 1% per group) in both groups. Regarding serious adverse events, only one acute hepatitis case was attributed to LCZ696 because no other obvious etiology could be found. Generally, the adverse events of LCZ696 are few and it is well tolerated.The significant blood pressure-lowering potency and acceptable adverse events of LCZ696 provide an effective and safe alternative for those whose blood pressure are still difficult to manage. Although there are many agents approved for lowering blood pressure, a potent single pill treatment may improve medical compliance. Improved blood pressure control also contributes to fewer cardiovascular events, given the enormous number of people with hypertension worldwide. All guidelines have set up blood pressure targets for different groups of people, and a more effective blood pressure-lowering capability will help many patients achieve their goal. Without a doubt, better blood pressure control will decrease the mortality and morbidity in cardiovascular disease.These trials also have several limitations. Firstly, their follow-up periods were generally short, from 28 days to 8 weeks. Endurance should be tested in further trials with longer follow-up periods. Second, these 10 studies only included a total of 5931 patients, which is relatively low compared to the massive number of patients that currently have hypertension. Third, all these studies included patients from different habitants, races, and ages, so these different inclusion criteria may be difficult to apply to all patients. Fourth, the traditional medication literature only included valsartan, olmesartan, and amlodipine, which could not represent all the currently approved medications. There are also no comparisons between LCZ696 with beta-blockers or diuretics. Fifth, the study groups only included essential hypertension, so the result could not be applied to the treatment of secondary hypertension. Sixth, there is still considerable heterogeneity in this study. We assessed the published year and LCZ696 dose as potential sources of heterogeneity and examined these factors as potential moderators in the meta-analysis; none was found to be significantly associated with the effect sizes. There may be other clinical or methodological differences among the studies that contributed to the statistical heterogeneity. However, we found that the main limitation of the study by Kario et al. was the lack of an active comparator [Sacubitril/valsartan (LCZ696) as a single daily dose may reduce blood pressure more efficaciously than traditional therapy (or placebo) in hypertensive patients without increasing adverse effects.


For a one-point increase in the mental fatigue component of the CFQ scale, the risk of PEM increases by 34%. For an sBPaortic increase of 1 mmHg, the risk of PEM decreases by 5%. For a one unit increase in sympathovagal balance, the risk of PEM increases by 330%. Higher mental fatigue and sympathetic activity in rest are related to an increased risk of PEM, while higher central systolic blood pressure is related to a reduced risk of PEM. However, none of the between group differences were significant after FDR correction, and therefore conclusions should be treated with caution and replicated in further studies.Post-exertional malaise (PEM) is regarded as the hallmark symptom in chronic fatigue syndrome (CFS). The aim of the current study is to explore differences in CFS patients with and without PEM in indicators of aortic stiffness, autonomic nervous system function, and severity of fatigue. One-hundred and one patients met the Fukuda criteria. A Chronic Fatigue Questionnaire (CFQ) and Fatigue Impact Scale (FIS) were used to assess the level of mental and physical fatigue. Aortic systolic blood pressure (sBPaortic) and the autonomic nervous system were measured with the arteriograph and Task Force Monitor, respectively. Eighty-two patients suffered prolonged PEM according to the Fukuda criteria, while 19 did not. Patients with PEM had higher FIS scores ( Chronic Fatigue Syndrome (CFS) is characterized by a substantial deterioration of symptoms that could be provoked in response to physical exercise in patients with post-exertional malaise (PEM) . The NatThe exact mechanism that underlies PEM is as yet unknown. However, it has been reported that patients with CFS experience shortness of breath . DisruptIn addition, an attenuated adrenaline response to physical exercise has been observed in CFS, compared to healthy controls , along wA decrease in the ability of large arteries to adapt readily to an increase in the amount of blood ejected during heart muscle contraction has been reported. Aortic pulse wave, or pulse wave propagation velocity (PWV), and an indirect parameter, the augmentation index (Aix), constitute a relatively simple, non-invasive, and reproducible method to determine arterial stiffness . ArteriaThe Fukuda criteria can distinguish between CFS and chronic fatigue. However, a further subclassification of the former group into PEM positive and PEM negative subgroups has been suggested . In contThe current study took place from January 2013 to July 2018. The Ethics Committee, of the Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Torun approved the study . Written, informed consent was obtained from all the participants.A group of 131 patients with CFS between 25 and 65 years of age were recruited via telephone, e-mail, and mass-media advertisements. The main enrolment criteria included: (1) Fukuda criteria (2) Fatigue Severity Scale score higher than 36 points and persistent fatigue for more than 6 months (3) had suffered from one or more of four additional symptoms: post-exertional malaise, impaired memory and/or concentration, unrefreshing sleep, headache, sore throat, tender lymph nodes (axillary or axillary), muscle or joint pain, (4) perceived fatigue could not be explained by an underlying condition. On inclusion, all CFS patients received a pre-test health state assessment: basic neurological, psychiatric, clinical examination, and had been referred by a general practitioner and by the neurology and psychiatry departments. The exclusion criteria included: (1) any indication of underlying illness, (2) medical condition explaining fatigue, (3) psychiatric disorders. Hospital Anxiety and Depression Scale (HADS) has been performed to assess anxiety (HADS_A) and depression (HADS_D) symptoms intensity . Beck Den = 10), had an underlying psychiatric illness (n = 13), or had another diagnosis, or fatigue was not the primary complain (n = 7). 30 participants were excluded as they did not meet the Fukuda criteria  and were performed at approximately the same time of day.The Chalder Fatigue Questionnaire (CFQ) , FatigueThe Hospital Anxiety and Depression Scale (HADS) was performed to assess anxiety (HADS_A) and depression (HADS_D) symptoms intensity . The BecThe Epworth sleepiness scale (ESS)  was usedWe used subjective and objective tools to measure the function of the autonomic nervous system. The Autonomic Symptom Profile served to measure presence, frequency, and dynamics of autonomic symptoms severity . ScoringSecond, ANS functioning was automatically measured with a Task Force Monitor—TFM . Signals from a three-channel ECG were analyzed using the adaptive autoregressive model . Low frewww.tensiomed.com, accessed on 18 March 2021). This is a device that uses a simple upper arm cuff as a sensor, with the cuff pressurized to at least 35 mmHg over the actual systolic pressure. The device determines the PWVaortic and augmentation index according to the manufacturer’s instructions. Arteriograph measurement has been described extensively in previous papers [Arterial stiffness was measured using an oscillometric non-invasive Arteriograph . The DescTools package was used to calculate pseudo R2 for the model [p-value, applying an online calculator available at . The results contain p-values before as well as after correction.Histogram visual inspection and the Shapiro–Wilk test were applied to test the normality assumption. To examine between-group differences (patients with PEM vs. those without) Mann–Whitney U or independent he model . Dotwhishe model . Violin he model  with a ghe model . Effect One hundred and one patients met the Fukuda criteria for CFS and were included in the analysis . The patt = −2.19, p = 0.02, Hedges’ g = −0.57 , and higher mental fatigue   . Mean fap = 0.02, r = 0.24   . No sign6, 0.44) .p = 0.01, r = −0.26 , lower HFnu-RRI  and higher LF/HF-RRI . Also, LF/HF was higher in patients with PEM . In addition, patients with PEM had higher LFnu-dBP  and higher LF/HF-dBP   .R2 = 0.26) ( = 0.26) .The results of the present study have shown that CFS patients with PEM had significantly higher mental fatigue, overall fatigue being measured by FIS, which was one of the three fatigue scales used in the above research. Moreover, patients with PEM had lower central systolic blood pressure. However, no difference in levels of peripheral blood pressure was observed. Higher mental fatigue is related to a higher risk of PEM, while higher central systolic blood pressure is related to lower risk of PEM. However, none of the between group differences were significant after FDR correction, and therefore conclusions should be treated with caution and replicated in further studies.As has been noted in the introduction, 73.4% assessed PEM duration as equal to or longer than 24 h . As a reThe above findings are in line with previous research, which suggests that chronic vascular damage might cause a lack of exercise-induced vasodilation and be a potential cause of PEM . In CFS,In the current study, sympathetic nervous system function was more active during rest in the group with PEM, compared with the group without PEM. Moreover, indicators of parasympathetic nervous system activity were lower during rest. Findings in the PEM group are in line with the previous study by Frith et al. , where LWhat is surprising is that the current results, corrected for multiple comparisons, showed no significant differences between the subgroup with PEM and that without PEM, in terms of fatigue as measured by scales. This is in contrast to a previous study, where higher PEM intensity was related to higher frequency and intensity of symptoms, and greater problems with emotional regulation . HoweverIn the above study, PEM was measured subjectively. Further studies should incorporate a protocol based on repeated Cardiopulmonary Exercise Tests, to confirm objectively the presence of PEM in CFS patients. A difference in sample size between the subgroup with PEM and that without PEM was observed, which seems to reflect PEM prevalence in the general population. By increasing the sample size, a higher number of patients without PEM could be included as a control group. Sample size should therefore be increased in further studies on PEM in CFS. Meta-analysis showed that PEM occurs 10.4 times more frequently in CFS patients in comparison with other groups . CompariPatients with PEM had significantly higher mental fatigue and overall fatigue than those without PEM, as measured by FIS, one of the three fatigue scales used in the above research. They also had higher mental fatigue and sympathetic activity compared with parasympathetic activity during rest and lower central systolic blood pressure. However, none of these differences remained statistically significant after correction for multiple comparisons. Further studies should be conducted to confirm if higher mental fatigue and higher sympathetic activity, compared with parasympathetic activity at rest and lower central systolic blood pressure, are related to a higher risk of PEM.