This study was initiated to establish a renal thrombotic microangiopathy (TMA) scoring system based on clinical needs and investigate its predictive value for patients’ long-term outcomes.Kidney biopsy-proven Complement-mediated TMA (C-TMA) patients from January 2000 to December 2017 in Peking University First Hospital were retrospectively studied. Both acute and chronic TMA-related lesions, including 15 pathologic indices, were semiquantitatively scored. The interobserver and intraobserver reproducibility and correlation between the pathologic indices and clinical parameters were analyzed. Furthermore, the patients were divided into 2 groups by dialysis use at baseline, and the association of these pathologic indices with their prognostic outcomes was assessed between the two groups.Ninety-two patients with renal biopsy-proven C-TMA were enrolled. All fifteen included pathology indices showed good or moderate interobserver and intraobserver reproducibility and correlated well with several clinical parameters. Several clinicopathological indices were worse in the dialysis group than in the nondialysis group, such as serum creatinine, hemoglobin, platelet count, and estimated glomerular filtration rate. Moreover, morphologic features in the dialysis group presented with more severe vascular lesions. Interstitial fibrosis and chronic tubulointerstitial lesions were related to a trend of high risk of continuous dialysis in the dialysis group. Based on univariate and multivariable Cox regression analysis, more severe glomerular lesions, including glomerular mesangiolysis, glomerular basement membrane double contours and glomerular mesangial proliferation, were identified as risk factors predicting worse prognosis.Our renal C-TMA semiquantitative scoring system is reliable with good reproducibility and prognostic value in clinical practice, which needs further validation. Thrombotic microangiopathy (TMA) is characterized by various causes that induce microvascular endothelial injury followed by subsequent pathologic manifestations, including subendothelial edema and microthrombi formation, and clinically manifests as consumptive thrombocytopenia, microangiopathic hemolysis, and multiple organ ischemic damage . With thThe kidney is one of the most commonly involved organs with the most easily obtained biopsied samples, which makes it a feasible way to explore TMA pathologic changes, although associated studies are rare. The typical pathologic features of TMA include microvascular endothelial injury presented as subendothelial myxoid edema and secondary microthrombi as acute lesions in both glomeruli and arterioles/arteries, while the double-contours of GBM and onion skin lesions of arterioles/arteries are chronic lesions . InteresHerein, we aimed to identify different renal pathological features in TMA patients and propose a scoring system based on a well-defined Chinese cohort.Kidney biopsy-proven TMA patients from January 2000 to December 2017 at Peking University First Hospital were enrolled as shown in The research was in compliance with the Declaration of Helsinki, and the design of this work was specifically approved by the ethical committees of Peking University First Hospital .The clinical data were extracted from the electronic medical records of Peking University First Hospital, including age, sex, serum creatinine, proteinuria, serum albumin (ALB), hemoglobin, platelet count, lactate dehydrogenase (LDH) level, serum C3, serum C4, hematuria, and extrarenal organ involvement. The serum creatinine level, age, and sex were used for the GFR estimates following the CKD-EPI estimated glomerular filtration rate (eGFR) equation . ClinicaTherapeutic regimens included plasma therapy (plasmapheresis or plasma infusion), immunosuppressants (including glucocorticoids), and renin–angiotensin–aldosterone system (RAAS) inhibitors. No patient in our cohort received eculizumab due to inaccessibility in China.As end-stage kidney disease (ESKD) occurred at the onset of some patients in our cohort, the enrolled patients were grouped by dialysis use at baseline. The endpoints during follow-up were defined as in a previous report ,15,18,19Renal biopsy specimens were examined by direct immunofluorescence, light microscopy (LM), and electron microscopy and were fixed in 4% buffered formaldehyde for LM. Consecutive serial 3 µm sections were used for histological staining, including hematoxylin and eosin, periodic acid-silver methenamine, periodic acid-Schiff staining, and Masson’s trichrome. Immunofluorescence staining of the kidney was performed on fixed-frozen sections, including IgA, IgM, IgG, C1q, C3, albumin, and fibrinogen. A semiquantitative approach was used to score the immunofluorescence labeling (0–3).Two nephropathologists who were blinded to the patients’ data and scores of the other observer evaluated the biopsies separately. Differences in scoring between the pathologists were resolved by rereviewing the biopsies and thus reaching a consensus. Semiquantitative scoring was based on light microscopy, except for subendothelial edema on electron microscopy.Glomerular and arteriolar parameters were analyzed as semiquantitative variables and expressed as the percentage involvement of all scoreable glomeruli and arterioles based on Banff type .Supplementary Table S1).The scoring criteria were composed of the following three parts containing 15 indices (details are shown in Supplementary Table S1 (A).Part 1: Glomerular microangiopathic lesions, including acute glomerular microangiopathic lesions  and chronic glomerular microangiopathic lesions . The details are shown in Supplementary Table S1 (B).Part 2: Vascular microangiopathic lesions, including acute vascular microangiopathic lesions  and chronic vascular microangiopathic lesions . The details are shown in Supplementary Table S1 (C).Part 3: Chronic tubulointerstitial lesions, including tubular atrophy and interstitial fibrosis. The details are shown in Genomic DNA was extracted from peripheral blood cells of patients. An ultraviolet spectrophotometer was used to detect the RNA concentration, and agarose gel electrophoresis was used to measure the RNA quality. Whole-exome sequencing (WES) was completed by the Huada Gene Institute .t-test or one-way ANOVA for two or more independent samples as appropriate. Nonparametric variables are expressed as the medians with range (minimum–maximum) and compared using the Mann–Whitney U test or Kruskal–Wallis H test. Categorical variables are expressed as the percentages. The Kruskal–Wallis H test was used to compare quantitative versus categorical variables, and the chi-square test was used to compare categorical versus categorial variables. Reproducibility was assessed for each variable of the extended pathology dataset using intraclass correlation coefficients (ICCs) [SPSS software  was used for statistical analysis. Normally distributed variables are expressed as the means ± standard deviation (SD), and differences in quantitative parameters among groups are assessed with Student’s s (ICCs) . All of s (ICCs) ,23.p < 0.05 was considered to be statistically significant. The factors that were verified by univariate Cox regression analysis were entered into the multivariate Cox regression analysis based on the rationale of stepwise multivariable Cox regression analysis, which considered the pathology variables in addition to the initial age, sex, and associated disorders. Model a was adjusted for traditional clinical markers  [b was adjusted for variables based on the univariate analysis . Differences were considered significant when p < 0.05.The Kaplan–Meier curves were generated to analyze the risk factor for prognosis and compared by the log-rank test. The correlation analysis between pathological features and clinical data was based on the semiquantitative degree of the pathological lesions using Spearman’s test. The Cox proportional hazards regression model was used to quantify the relationship between exposures and the outcomes . The results were expressed as the hazard ratios (HRs) with 95% CIs. nd eGFR) , and ModThe study included 92 Chinese renal TMA patients . Their bThe median follow-up time was 35 months . The enrolled patients were grouped based on whether they were on dialysis or not at baseline. In the dialysis group, 26 patients  discontinued dialysis after a median of 2 months (range: 1–13 months). In the nondialysis group, one patient  died due to multiple organ failure, and 19 patients  developed ESKD with a median of 35 months .Supplementary Table S2.The typical renal pathological TMA lesions are presented in A score sheet was completed by individual pathologists and the reproducibility of the agreement of the scoring by the two pathologists was further assessed. Overall, 15 histopathologic variables were assessed, and reproducibility was assessed statistically using intraclass correlation coefficients (ICCs), which are summarized in Based on the ICC scores, these lesions were divided into 3 groups as follows:Group 1: Indices with values of good or very good reproducibility (ICC > 0.80) included glomerular endothelial cell swelling and proliferation, subendothelial edema on electron microscopy, glomerular mesangiolysis, glomerular necrosis/thrombi, glomerular basement membrane (GBM) double contours, ischemic wrinkle of GBM, global and segmental glomerulosclerosis, vascular endothelial cell swelling and subintimal myxoid edema, arteriolar/arterial fibrinoid necrosis/thrombi, onion skin lesion, intimal fibrosis, arteriolar hyalinosis, tubular atrophy, and interstitial fibrosis.Group 2: Indices with moderate reproducibility (0.40 ≤ ICC ≤ 0.80), only glomerular mesangial proliferation.Group 3: Indices with poor or fair reproducibility (ICC < 0.40), none.Supplementary Table S3.Then, intraobserver reproducibility was further performed, which also showed moderate or good reproducibility of all abovementioned histopathologic variables. More details are listed in The correlation analysis between the 15 enrolled pathological variables above and clinical characteristics at the time of renal biopsy is shown in In briefly, (1) Predominant glomerular lesions were associated with the levels of proteinuria and serum albumin, as well as the deposit of IgA, IgM, IgG, C3, and fibrinogen in glomeruli. (2) Predominant vascular lesions were associated with the levels of serum creatinine and eGFR. (3) Overlap lesions, including glomerular and vascular lesions, were associated with the levels of hemoglobin and platelet count, and the deposit of C1q in glomeruli.Our patients were further grouped by dialysis at baseline into a dialysis group  and a nondialysis group .Their clinical and pathological parameters are compared in p = 0.021) and chronic tubulointerstitial lesions , p = 0.018) were related to a trend of higher risk of continuous dialysis, details were shown in Supplementary Table S4, also presented by the Kaplan–Meier curve , er curve . The muler curve .p = 0.027), GBM double contours , p = 0.020) and glomerular mesangial proliferation , p = 0.002) were risk factors for worse compound kidney prognosis, also presented by the Kaplan–Meier curve , er curve . The muler curve .More importantly, as diagnostic tests and supportive measures etc. might differ between periods, our patients were divided into two groups, as group 1 (2000–2009) and group 2 (2010–2017), based on the period for further prognosis analysis.In the dialysis subgroup and nondialysis subgroup of the ‘2000–2009’ cohort, the univariate Cox regression analysis did not reveal any risk pathological change for prognosis.p = 0.040) was related to a trend of a higher risk of continuous dialysis. The multivariable Cox hazard analysis further identified that severe chronic tubulointerstitial lesion , p = 0.040) was related to a trend of a higher risk of continuous dialysis after adjustment for sex, age, eGFR with or without proteinuria and hematuria.In the dialysis subgroup of the ‘2010–2017’ cohort, the univariate Cox regression analysis showed that severe chronic tubulointerstitial lesion , p = 0.018) was a risk factor for worse prognosis. The multivariable Cox hazard analysis further identified that GBM double contours , p = 0.018) was a risk factor for worse prognosis after adjustment for sex, age, eGFR with or without proteinuria and hematuria.In the nondialysis subgroup of the ‘2010–2017’ cohort, the univariate Cox regression analysis showed that GBM double contours , C-TMA usually results from defective regulation of the alternative complement pathway, including atypical HUS, pregnancy- and postpartum-associated HUS, and malignant hypertension of unknown cause, which were enrolled in our cohort ,5.Recently, Kim summarized the histopathologic changes of TMA and emphasized the importance of a renal biopsy for TMA patients . Habib eThe following information was found by our prognostic analysis. First, the initial dialysis patients with extensive interstitial fibrosis had a poor outcome by Cox hazard analysis, consistent with a previous study ,31. SecoThere are some limitations in our study. First, this was a single-center study. Second, as eculizumab was not approved by the China Food and Drug Administration (CFDA) before 2017, and no patient in our cohort received it. Further validation study with a ‘eculizumab’ cohort is needed.In summary, our renal C-TMA pathological semiquantitative scoring system was reliable with good reproducibility and suggested to disease severity and clinical outcomes, which should be further validated with a larger dataset.Click here for additional data file.


The process of aging population will inevitably increase age-related comorbidities including chronic kidney disease (CKD). In light of this demographic transition, the lack of an age-adjusted CKD classification may enormously increase the number of new diagnoses of CKD in old subjects with an indolent decline in kidney function. Overdiagnosis of CKD will inevitably lead to important clinical consequences and pronounced negative effects on the health-related quality of life of these patients. Based on these data, an appropriate workup for the diagnosis of CKD is critical in reducing the burden of CKD worldwide. Optimal management of CKD should be based on prevention and reduction of risk factors associated with kidney injury. Once the diagnosis of CKD has been made, an appropriate staging of kidney disease and timely prescriptions of promising nephroprotective drugs  appear crucial to slow down the progression toward end-stage kidney disease (ESKD). The management of elderly, comorbid and frail patients also opens new questions on the appropriate renal replacement therapy for this subset of the population. The non-dialytic management of CKD in old subjects with short life expectancy features as a valid option in patient-centered care programs. Considering the multiple implications of CKD for global public health, this review examines the prevalence, diagnosis and principles of treatment of kidney disease in the aging population.  Since 2013, the World Health Organization (WHO) has endorsed a project called “The Global Action Plan” aimed to promote health and psychophysical well-being of subjects worldwide. The goal of this program is to reduce mortality due to non-communicable diseases by 25% in 2025 through a wide action of prevention and control of risk factors . In. In25]. 2, in the absence of urinary anomalies, tends rarely to progress towards ESKD (<1% at 5 years) [A meta-analysis conducted by the “CKD Prognosis Consortium” showed that the risk of ESKD and mortality is generally increased when GFR is substantially lower than 60 mL/min, but surprisingly, this threshold is lower in elderly patients . Indeed,5 years) .2, confirmed that patients with stage IIIa of CKD have a mortality risk lower than CKD stage IIIb and IV and more importantly, these patients had a similar survival rate than the general population [Epidemiological studies have also reported that patients aged more than 65 years have a considerably higher risk of CKD progression only when the GFR is less than 45 mL/min. In support of the thesis, the “Renal Risk in Derby” study, conducted on 1741 people with a mean age of 72.9 ± 9 years and with an average GFR of 54 ± 12 mL/min/1.73 mpulation . Based opulation  proposedIn other words, nephrological evaluation of the elderly patient with a reduction of GFR can no longer depend on a laboratory reporting system that defines GFR > 60 mL/min as normal. The use of a fixed threshold at 60 mL/min may induce misinterpretation of renal function. For instance, GFR slightly greater than 60 mL/min is a strong negative predictor of renal and patient survival in young patients. On the contrary, GFR slightly below 60 mL/min without urinary alterations in a patient aged >65 years represents a physiological condition not subject to further diagnostic investigations.The evaluation of kidney function is also key in the setting of living kidney transplantation as post-donation GFR should remain within normal range without affecting the donor’s survival and the recipient should receive a healthy graft not affected by CKD. The correct interpretation of the donor’s kidney function is complex and must take into account the physiologic reduction of GFR with aging as well as potential comorbidities and lifetime risk of developing ESKD after donation . In para2 or urinary ACR ≥30 mg/g, in the adult US population is 14.4%. Most of the CKD population (93.7%) is affected by stages I and II, namely, early stages of kidney disease characterized by a mild decrease in their GFR (>60 mL/min). The distribution of patients based on KDIGO risk categories indicates that 1.3% of the CKD population is at high risk to progress toward kidney failure and receive RRT. As aforementioned, CKD is common in elderly patients [According to current estimates, about 700 million people are affected by CKD worldwide. The worldwide prevalence of CKD stage I–V is estimated between 3% and 18%, with a higher prevalence in women than males in patients older than 40 years . Recent Demographic characteristics, quality of healthcare, socio-cultural level of the population and methods used for the evaluation of renal function are the main factors influencing the rate of CKD . The difRisk factors most closely related to the development of CKD in the general population are age , hypertension , cardiovascular disease , smoking , diabetes  and obesity  . Other fRisk factors for CKD rarely act alone in the older people because aging increases the prevalence of multiple morbidities having synergistic effects on the development of CKD. Age is the main risk factor for CKD. About 11% of individuals aged more than 65 years without main comorbidities have CKD stage 3 or higher . BesidesA large community-based retrospective cohort study of Japanese adults confirmed that older age was related to faster loss of kidney function. The main risk factors for worsening of kidney function in subjects aged ≥80 years were higher systolic blood pressure, proteinuria and current smoking .A study based on the registry of “Prevention of Progressive Renal Insufficiency Project of Emilia-Romagna region ” conducted in a large cohort of patients with a mean age of (71.2 ± 12.9 years) and a mean GFR of 28.8 mL/min, regularly followed by nephrologists, documented that proteinuria, young age, diabetes and hyperphosphatemia are the leading risk factors for progression of CKD toward ESKD. It is interesting to note that late-stage CKD and advanced age are not strictly associated with a rapid progression of chronic kidney disease. Old patients, especially women, tend to have a slower progression compared to the young ones, who have a severe prognosis of the underlying kidney disease .The KDIGO guidelines classify the probability of progression of CKD into 4 risk categories: low, moderately high, high and very high . In the Reduction of the nephron mass and therefore of the glomerular filtrate determines a rearrangement of the main homeostatic mechanisms regulated by the kidney. The first metabolic complications (hyperparathyroidism and anemia) develop for GFR values usually lower than 50 mL/min and other complications  are observed for progressively lower values of the glomerular filtrate . NonmetaCardiovascular disease is the most severe and frequent complication in patients with CKD. Mortality from cardiovascular disease is high for all stages of CKD, even though it is dramatically high in dialysis patients  ,63,64. OIn a population of older outpatients, CKD contributes significantly to multimorbidity patterns and it was rarely observed without any co-occurring disease. The most significant co-occurring pairs involving CKD included hypertension, anemia, cardiovascular disease, hip fracture and, to a lesser extent, hearing impairment, diabetes and cancer . GeneralCKD poses substantial expenses to the healthcare system . In the An economic cost analysis in Alberta, Canada, reported that expenditure for CKD was higher for patients with lower GFR, more comorbidity, lower education and socioeconomic position. Hospitalization, drugs, physician and ambulatory care accounted for 38%, 35%, 14% and 13% of the annual total costs, respectively .Total costs (direct and indirect) are highly variable among countries. For the Italian healthcare system, it is $530 per year in stages I and II, $1050 in stage III, $4010 in stage IV and $10,612 in stage V. The costs of renal replacement therapy (RRT) are $62,500 per patient-year for hemodialysis and about $45,900 per patient-year for peritoneal dialysis. Kidney transplantation was estimated to cost $61,520 per patient-year the first year and $17,700 from the second year . A more The economic management of CKD also includes direct medical costs , direct non-medical costs  and indirect costs (loss of productivity of the affected patient and/or his caregivers). An additional expense, usually not considered in the management of CKD, is the employment of an external caregiver to help the frails subjects at home and to perform home dialysis in non-self-sufficient patients with ESKD. CKD gradually manifests with a decline in cognitive functions, sleep disturbances, pain, as well as suboptimal control of underlying comorbidities. Furthermore, the chronic and debilitating nature of the disease can invalidate frail patients, resulting in extreme cases of loss of patient autonomy.The incidence of ESRD has reached the plateau both in the US  and EuroIn Europe, incidence of patients on hemodialysis, peritoneal and pre-emptive transplantation is 85%, 11% and 4%, respectively. The rate of kidney transplantation is well-represented among prevalent patients, as 37% of ESKD received kidney transplantation .In the US there is a higher incidence of ESKD than in Europe. The main modalities of renal replacement therapy for incident patients are hemodialysis (85.1%), peritoneal dialysis (11.5%) and pre-emptive renal transplantation 3%). Once dialysis started, kidney transplantation became a valid option as the rate of this RRT modality rise to approximately 30% within 1 year in patients being placed on the waitlist. Also, home hemodialysis, endorsed by national policy, has a greater prevalence than in Europe (1.9% vs. 0.2%) %. Once d.Similar to CKD stages I–V, ESKD requiring dialysis prevalence has a different global distribution. A key issue is the “access” to RRT. Different regulatory policies and social inequities may explain disparities in the rate of ESKD. In Europe, the countries with the highest prevalence of ESKD  have “liberal” access to dialysis care compared to other countries with comparable welfare . In thesKidney transplantation is considered the preferred treatment option for ESKD as it offers a survival advantage over dialysis for the majority of patients including older patients ,78. OverThe critical shortage of organ supply has also stretched the limits of organ donation in terms of age and comorbidities. The use of extremely elderly donors raises questions about the real potential benefit obtained from these organs. A study conducted in Spain showed that recipients receiving a kidney from donors aged >80 years had lower mortality rates than those remaining on dialysis. As expected, graft survival was significantly lower than deceased donor kidneys aged between 60 and 79 years .In parallel, recipients of living donor kidneys aged ≥70 years had a significantly higher rate of graft loss compared with recipients of younger living donor kidneys aged 50 to 59 . NeverthDisease registries offer the advantage of understanding the trend of CKD in a given setting, verifying the effect of the implemented actions and organizing plans for CKD prevention. A useful tool to assess the quality of nephrology care and verify the effectiveness of preventive measures against kidney disease is to monitor the trend of diabetic nephropathy. This estimate, in part biased by different genetic and dietetic backgrounds of the populations, reflects the availability and efficiency of outpatient care services in terms of prevention, education, socioeconomic status as well as the interconnection between different providers such as nephrologists, diabetologists and primary care physicians.Given the high prevalence of CKD in the elderly, KDIGO in 2006 suggested that CKD screening should be offered to patients with risk factors and those over the age of 60 years . Taking Care of CKD stage IIIa without proteinuria and tendency toward progression can be effectively perpetuated by the primary care physician. The best therapeutic management of these patients is based primarily on the reduction of metabolic and cardiovascular risk factors including blood pressure control, lifestyle and balanced diet as depicted in A nephrology intervention should also focus on patients with a high risk of progression. A dedicated outpatient service for patients with advanced CKD (>20 mL/min) is advisable to monitor closely kidney function and establish an educational program on RRT including pre-emptive kidney transplantation . AccordiIndividualization of the appropriate treatment is, therefore, crucial to improving patient’s quality of life. Nevertheless, there is a limited understanding of existing prognostic tools because they lack external validation . The absIn the setting of the current demographic change, the prevalence of CKD and advanced stage of CKD will inevitably tend to increase over time, with significant consequences on the national healthcare systems. Prevention and appropriate management of risk factors for CKD in the young and middle-aged population is key to limiting a further increase in CKD prevalence among the elderly. Kidney dysfunction is common in the elderly population as renal senescence is associated with a progressive and relentless GFR decrease. The diagnosis of CKD based on a fixed threshold is necessarily associated with overdiagnosing of CKD in older people. A context of age-adapted definition is therefore useful to establish effective reduction of kidney function. Once the diagnosis of CKD has been confirmed, coordination with other specialists and with primary care physicians is fundamental to delivering the appropriate care. Primary care physicians may provide the bulk of care for patients with “indolent” CKD and furnish the nephrologist with the key elements to understand the etiology and risk factors for the progression of CKD. A high level of awareness of kidney disease should be pursued among healthcare workers since late diagnosis and consequently “late referral”, is closely associated with lower survival, worse quality of life and high use of economic resources.


Introduction: Asthma is one of the major public health problems that imposes a great burden on societal, financial, and healthcare around the world. Asthma poorly affects the health-related quality of life and daily activities of patients. Treatment of asthma, including inhaled corticosteroids (ICS) and long-acting beta-agonists (LABAs), mainly aims to improve the lung function and reduce symptoms and exacerbations. Current treatment regimens are symptom-based strategies, and the status of airway inflammation after treatment is yet unknown. We conducted this study to understand the comprehensive inflammation or airway remodeling status of patients after ICS-LABA treatment through RNA transcriptome analysis.Materials and methods: Eight newly diagnosed asthmatic patients and two healthy subjects were recruited in this study. Asthmatic patients underwent blood tests, lung function test, and RNA transcriptome analysis before and after ICS-LABA treatment.Results: In comparison with healthy subjects, pretreatment asthmatic patients had higher expression of protein tyrosine kinase and related signaling pathways. After ICS-LABA treatment, the expression of nuclear receptor transcription coactivator, N-acetyltransferase, protein tyrosine kinase, nuclear receptor, and RNA polymerase II-activating transcription factor were downregulated. However, the post-treatment asthmatic patients still had higher expression of cysteine-type endopeptidase, endodeoxyribonuclease, apolipoprotein, and unfolded protein was still upregulated than healthy subjects.Conclusions: The combination of ICS/LABAs decreased airway inflammatory and remodeling pathways. However, allergen stimulation-related pathways were still upregulated in patients after ICS/LABA treatment. The combination of medication and allergen removal is a complete strategy for asthma. Asthma, a major public health concern worldwide, affected an estimated 334 million people Considering the airway inflammation and obstruction, asthma often leads to symptoms of wheezing, breathlessness, chest tightness, and cough Asthma treatment is guided by Global Initiative for Asthma (GINA) strategies. In brief, the GINA guidelines recommend the initiation therapy with anti-inflammatory or bronchodilation, including inhaled corticosteroids (ICS) and long-acting beta₂-agonists (LABAs) for symptom-driven use or as a regular daily medication A central feature of asthma is the symptoms due to underlying airway inflammation. ICS-containing therapies are the mainstay treatment option for asthma Eight newly diagnosed asthmatic subjects and two healthy subjects were recruited for this study. All these patients were adults that over 18 years of age. The diagnosed of asthma was confirmed by the provocation test. These newly diagnosed asthmatic patients were without oral steroid, ICS and LABAs before inclusion. All these patients were at GINA steps 3 and received ICS+LABAs after diagnosis The criteria of healthy subjects was quite strict; there was no personal history of asthma, allergic rhinitis, gastroesophageal reflux disease, diabetes mellitus, hypertension, etc. These healthy subjects did not consume any drugs. This study was conducted after obtaining informed consent from all the participants and was approved by the ethics committee of Taipei Tzu-Chi Hospital.Before asthma treatment, patients underwent blood tests, including RNA transcriptome analysis, Specific Allergen Test Panel , immunoglobulin E (IgE), whole blood cell counts , hemoglobin (Hb), aspartate aminotransferase (AST), aminotransferase (ALT), total bilirubin, creatinine (Cr), blood urea nitrogen (BUN), C-reactive protein (CRP), potassium (K), sodium (Na), and chest radiographs. Demographic information was collected at baseline. After 2 months of treatment, all patients underwent blood tests. Healthy subjects also underwent blood tests, as mentioned above.1) was measured 5 min after each provocation step. Provocative doses that caused a 20% decrease in FEV1 were recorded as PD20Well-trained technicians performed MCT and PFT. PFT was performed between 8 AM and 4 PM using a spirometer , as per the recommendations of the American Thoracic Society, and the European Respiratory Society. MCT was performed using a nebulizer with methacholine doses, and forced expiratory volume (FEVThe Chinese version of the Asthma Control Test (ACT) questionnaire was used to assess symptoms of dyspnea, wheezing, coughing, and rescue medications Purified RNA was used to prepare sequencing libraries using the TruSeq Stranded mRNA Library Prep Kit .We purified mRNA from total RNA (1 µg) using oligo(dT)-coupled magnetic beads and fragmented them into small pieces at high temperature. First-strand cDNA was synthesized using reverse transcriptase and random primers. After double-stranded cDNA was generated and adenylated at the 3′-ends of the DNA fragments, adapters were ligated and purified with the AMPure XP system . Agilent Bioanalyzer 2100 system and real-time PCR system were used to assess the quality of libraries. Eligible libraries were then sequenced on the Illumina NovaSeq 6000 platform with 150 bp paired-end reads generated by Genomics .We removed the sequences from adapters and low-quality bases in the raw data using the Trimmomatic (version 0.39) program The FASTQ files of RNA sequencing data are available at National library of Medicine (NCBI SRA: SUB120238883).t-test was used to compare parameters between asthmatic and healthy subjects. Wilcoxon signed rank test was used to compare parameters of asthmatic patients before and after treatment. Statistical significance was set at p < 0.05. All statistical analyses were performed using SPSS  and R software (version 4.2.0). A value < 0.10 was considered statistically significant for GO and KEGG data.Continuous data were expressed as mean and standard deviation, and categorical data were expressed as frequencies and percentages. A Welch's The characteristics and PFTs of these patients are shown in Table p = 0.0209). IgE level was trend towards be higher in pre-treated asthma patients than that in healthy subjects, but no significant difference was observed . ACT scores of pre-treated asthma patients were lower than those of healthy subjects . We compared post-treatment asthma patients with healthy subjects and found that the eosinophil percentage was 3.9% ± 2.8%, which was trend towards to be higher than that reported in healthy subjects (p = 0.0802) but trend towards a decrease than the value observed in pretreatment asthma patients but without significant difference (p = 0.1641). IgE levels also had trend towards a decrease after treatment, but without analytical significance (p = 0.5703). The ACT score of post-treatment asthma patients was 20.1 ± 2.5, which was lower than that of the healthy subjects  but higher than that of pretreatment asthma patients .The comparison results of laboratory data between asthma patients and healthy subjects are shown in Table There were total 26507 genes identified. A total of 147 differentially expressed genes (DEGs) were found. The criteria of significant difference was PPEE  <0.05. There was an overlap in DEG between asthma baseline/control and asthma baseline/asthma treated, SLA2.SLA2) gene, in the patient group. GO terms, regulated genes, and description of functions are shown in Table The comparison of the RNA transcriptomes between healthy subjects and pre-treatment asthmatic subjects revealed the upregulated protein tyrosine kinase activity, signaling adaptor activity, SRC homology 3/SRC homology 2 (SH3/SH2), which is regulated by the Src-like adaptor 2 (TADA3), SLA2, and interferon alpha-inducible protein 27 (IFI27) genes. The GO terms, regulated genes, and descriptions of functions are shown in Table We compared the RNA transcriptomes of asthma patients before and after treatment with ICS/LABAs, and found downregulation in the ligand-dependent nuclear receptor transcription coactivator activity, N-acyltransferase (NAT) activity, protein tyrosine kinase activity, ligand-dependent nuclear receptor, RNA polymerase II-activating transcription factor, and SH3/SH2, which are regulated by transcriptional adaptor 3 (CASP7), TatD DNase domain-containing 2 (TATDN2), nucleophosmin 1 (NPM1), heat shock protein family D member 1 (HSPD1), and RNA polymerase I transcription factor 3 (RRN3), were highly expressed in asthma patients after ICS/LABA treatment and normal subjects. The heatmap is shown in Fig. The results of the comparison of the RNA transcriptomes of asthma patients after treatment with ICS/LABAs and normal subjects are shown in Table The current study demonstrates some important findings regarding changes in RNA transcription, which are summarized in Fig. Protein tyrosine kinases play essential roles in the proliferation and activation of inflammatory and airway cells. Protein tyrosine kinase signaling is critical in allergic inflammation A transcription coactivator activates the transcription of specific gene sets by binding to a DNA-bound nuclear receptor. RNA polymerase II is a multiprotein complex that functions to transcribe the DNA into precursors of messenger RNA. Transcription factors are required to mediate its binding to upstream gene promoters of RNA polymerase II to initiate transcription. Corticosteroids work by binding to the intracellular glucocorticoid receptor (GR), followed by translocation to the nucleus and binding to glucocorticoid response elements to regulate the transcription of downstream genes NATs are reported to play an important role in atopic diseases, including asthma Cunningham et al. studied the importance of the enzymatic activity of cysteine proteases in asthma We compared post-treatment asthmatic patients with healthy subjects, and found that the expression of apolipoprotein was higher after treatment with ICS/LABA. Apolipoprotein plays a major role in lipid metabolism and exerts both pro- and anti-inflammatory effects Endoplasmic reticulum (ER) stress and unfolded protein response (UPR) are also important in asthma In adults, asthma tends to be more severe in women than in men in terms of prevalence, severity, and duration According to our study, asthma patients under standard control and a well-controlled status still had higher cysteine-type endopeptidase activity involved in the apoptotic process, endodeoxyribonuclease activity, Tat protein, apolipoprotein, unfolded protein, ribosomal small subunit, core promoter binding, and DNA replication origin binding than healthy subjects. This result indicates that symptom control does not mean that inflammation has been completely controlled. Therefore, the development of an inflammatory marker strategy may be helpful. Heaney et al. performed a biomarker strategy  to adjust the corticosteroid dose and compared it with a symptom-based algorithm This study has several limitations. First, the sample size was too small, which may have caused statistical bias. The descriptive statistics had showed difference between groups but had no statistical significance. We attribute these phenomena due to the variance between the groups may quite different. To obtain accurate RNA transcriptome results, we had strict patient inclusion and exclusion criteria. In addition, given the high cost of RNA transcriptome analysis, it is difficult to perform large-scale testing on patients. Second, RNA transcriptome analysis generates a lot of data, but its clinical significance still needs to be further explored. Through this research, we identified several important mediators of airway inflammation and remodeling. Studies on these mediators are limited. We have paved a way for future relevant animal or clinical studies. Third, most of the enrolled patients were women. There may be differences in mRNA expression between genders. Further studies should be performed to compare mRNA expression between genders.The activity of protein tyrosine kinase was higher in asthmatic patients and downregulated by ICS-LABAs. Treatment with ICS-LABAs also decreased nuclear receptor transcription coactivator and NAT activities. Although the symptoms of these asthmatic patients were under control, they still had higher cysteine-type endopeptidase activity and unfolded protein. Thus, these patients were still under stimulation by environmental allergens. The combination of non-pharmacological management and allergen removal is, therefore, a complete strategy.


We aimed to evaluate soluble Klotho and circulating fibroblast growth factor 23 (FGF23) ratio as a risk factor for renal progression, cardiovascular (CV) events, and mortality in chronic kidney disease (CKD).We analyzed 2,099 subjects from a CKD cohort whose soluble Klotho and C-terminal FGF23 levels were measured at enrollment. The Klotho to FGF23 ratio was calculated as Klotho values divided by FGF23 values + 1 . Participants were categorized into quartiles according to Klotho/FGF23 ratio. The primary outcome was renal events, defined as the doubling of serum creatinine, 50% reduction of estimated glomerular filtration rate from the baseline values, or development of end-stage kidney disease. The secondary outcomes consisted of CV events and death. Changes in CV parameters at the time of enrollment and during follow-up according to the Klotho/FGF23 ratio were also examined.P = 0.010) and second  quartiles with regard to the Klotho/FGF23 ratio showed elevated risk of renal events as compared to the fourth quartile group. There was no significant association between Klotho/FGF23 ratio and the composite outcome of CV events and death. The prevalence of left ventricular hypertrophy and vascular calcification was higher in the low Klotho/FGF23 ratio quartiles at baseline and at the fourth-year follow-up.During the follow-up period of 64.0 ± 28.2 months, 735 (35.1%) and 273 (13.0%) subjects developed renal events and composite outcomes of CV events and death, respectively. After adjustment, the first (HR: 1.36; 95% CI: 1.08–1.72, Low Klotho/FGF23 ratio was significantly associated with increased renal events in the cohort of Korean predialysis CKD patients. Klotho and fibroblast growth factor 23 (FGF23) are early laboratory parameters of chronic kidney disease (CKD)-mineral bone disorder (MBD), and the Klotho/FGF23 axis plays an important role in this disorder , 2. KlotFGF23 binds to Klotho and FGF receptors to exert its physiological effects on traditional, on-target organs, such as the kidney and parathyroid glands, thereby regulating phosphate homeostasis and mineral metabolism. Recently, it has been shown that FGF23 could also target cell types that lack Klotho. In CKD patients, excess FGF23 also exerts Klotho-independent effects on non-traditional, off-target organs, such as the heart, cells of the immune system, and the liver . The offThe KoreaN Cohort Study for Outcomes in Patients With Chronic Kidney Disease (KNOW-CKD) was a multicenter prospective cohort study in Korea that enrolled subjects with CKD stages 1 to 5  from nine university-affiliated hospitals. The detailed study methods and design of the KNOW-CKD have been described previously . Among thttp://www.phactax.org) with assistance from the Division of Data Management at the Seoul National University Medical Research Collaborating Center. Patients with a history of diabetes mellitus (DM), a fasting serum glucose ≥126 mg/dL, or those on anti-diabetic medication were considered to have DM. Patients with a history of hypertension (HTN), a systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg, or those on antihypertensive drugs were considered to have HTN. Patients considered to have CV disease were those with a history of coronary artery disease, cerebrovascular disease, congestive heart failure, arrhythmia, or peripheral vascular disease. The following laboratory variables were measured using a ≥8-h fasting blood sample at each participating center: hemoglobin, uric acid, albumin, total cholesterol, C-reactive protein, phosphorus, calcium, and intact parathyroid hormone (PTH). Serum creatinine was measured at a central laboratory  using an isotope dilution mass spectrometry-traceable method , comorbidities, cause of CKD, and laboratory parameters at enrollment were extracted from an electronic data management system  kit  according to the manufacturer's protocol. The intra-assay and inter-assay coefficients of variation were 2.7–3.5%  and 2.9–11.4% , respectively. Serum C-terminal FGF23 was measured using a commercial ELISA kit  according to the manufacturer's protocol. The intra-assay and inter-assay coefficients of variation as reported by the manufacturer were 1.4–2.4% (FGF23 levels: 33.7–302 RU/mL) and 2.4–4.7% (FGF23 levels: 33.6–293 RU/mL), respectively.3 in men and >95 g/m3 in women, according to the American Society of Echocardiography guidelines  mass index was calculated by dividing the LV mass by the body surface area. Left ventricular hypertrophy (LVH) was defined as an LV mass index >115 g/midelines . LV geomidelines  and coroidelines , 30 wereidelines . The ankidelines .The primary outcome was renal events, defined as a composite of a 50% decrease in eGFR from baseline, doubling of serum creatinine level, or development of ESKD. ESKD was defined as the initiation of renal replacement therapy, including dialysis or renal transplantation. The secondary composite outcome consisted of CV events and all-cause mortality. Patients were followed until March 2020. The eGFR decline during the follow-up period was also analyzed. In subgroup analyses, changes in echocardiography parameters, CACS, and AAC scores at 4 years of follow-up were investigated.2-test or Fisher's exact test and were presented as frequencies and percentages. The Klotho to FGF23 ratio was calculated as Klotho values divided by FGF23 values + 1 . A log transformation was used to normalize the Klotho/FGF23 ratio. Participants were categorized into quartiles according to Klotho/FGF23 ratio. Cox proportional hazards models with adjustments, including variables that were significant in a univariable analysis or other clinically relevant variables, were used to analyze the association between the Klotho/FGF23 ratios and study outcomes. The results were expressed as hazard ratios (HRs) and 95% confidence intervals (CIs). Subjects who were lost to follow-up were censored at the date of their last examination. The rates of renal function decline per year were determined using the slope of eGFR analyzed using a generalized linear mixed model. Only 1,851 (88.1%) patients whose eGFR values were measured three or more times during the follow-up period were included in the eGFR decline analysis. The rapid decline of eGFR was defined as eGFR <-3 ml/min/1.73 m2/year. Binary logistic regression analysis was used to identify the risk factors for the rapid decline of kidney function. Multivariable linear regression model analysis was also used to investigate the association between eGFR slope and Klotho/FGF23 ratio. In addition, Harrell's C-index and receiver operating characteristic (ROC) curve analysis were conducted to evaluate the prognostic value of Klotho and FGF23 levels and the Klotho/FGF23 ratio for renal events. P-values < 0.05 were considered statistically significant. The SPSS statistical software  was used for all analyses.Continuous variables were analyzed using analysis of variance or Kruskal–Wallis test. The Kolmogorov–Smirnov test was used to analyze the normality of the distributions of parameters. The results were presented as mean ± standard deviation for variables with normal distributions and as median (interquartile range) for variables with skewed distributions. Categorical variables were evaluated using the χ2. The mean age was younger in the high Klotho/FGF23 ratio quartiles (P = 0.020). The prevalence of DM (P < 0.001), HTN (P < 0.001), and CV disease (P = 0.008) was lower in the high Klotho/FGF23 ratio quartiles. Estimated GFR (P < 0.001) and hemoglobin (P < 0.001) were higher in the high Klotho/FGF23 ratio quartiles. Serum phosphorus (P < 0.001) and PTH (P < 0.001) were lower in the high Klotho/FGF23 ratio quartiles. Binge drinkers were more in the 4th Klotho/FGF23 ratio group (P = 0.033). Health-enhancing physical activity was lower in the 1st and 4th Klotho/FGF23 ratio groups (P = 0.022).The clinical characteristic of the study subjects by Klotho/FGF23 ratio quartiles are shown in P < 0.001). The Kaplan–Meier curves showed that the low Klotho/FGF23 ratio group had a significantly higher cumulative incidence of renal events  and second  quartiles of the Klotho/FGF23 ratio group showed increased renal events as compared to the fourth quartile group (P = 0.008). Similarly, when physical activity, smoking status, and alcohol consumption variables were added in model 4, the low Klotho/FGF23 ratio was significantly associated with developing renal events. To confirm whether the Klotho/FGF23 ratio is a valuable predictor of renal events, we compared Harrell's C-index between Klotho and FGF23 levels and the Klotho/FGF23 ratio described in the statistical analysis section. The Harrell's C-index for Klotho/FGF23 ratio was 0.644. The Harrell's C-indices for Klotho and FGF23 were 0.535 and 0.642, respectively. Furthermore, Harrell's C-index for Klotho/FGF23 ratio added to an adjusted model (model 4) was 0.841. When Klotho and FGF23 levels were added instead of Klotho/FGF23 ratio in the adjusted model (model 4), Harrell's C-index was 0.840. These findings suggest that Klotho/FGF23 ratio can have predictive value for renal events development.During the follow-up period of 64.0 ± 28.2 months, 735 (35.1%) subjects developed renal events. le group . As a coP = 0.153; P < 0.001; During the follow-up period, 273 subjects developed a composite of CV events and death. Composites of death and CV events were not significantly different among the Klotho/FGF23 ratio groups , and third  quartiles of Klotho/FGF23 ratio groups showed a significantly rapid decline in eGFR compared to the fourth quartile group. eGFR slope was significantly associated with log transformed Klotho/FGF23 ratio  and E/E′ (P < 0.001) were higher in the lower Klotho/FGF23 ratio groups. The LV geometry pattern according to Klotho/FGF23 ratio is shown in P < 0.001). CACS > 100 was 27.5% in the first Klotho/FGF23 ratio group and was also higher in the lower quartiles (P = 0.005). Ankle-brachial index was similar according to Klotho/FGF23 ratio quartiles.We further examined the relationship between the Klotho/FGF2 ratio and CV parameters. Baseline echocardiography and vascular calcification parameters are shown in P = 0.012) and E/E′ (P = 0.001) at 4 years were higher in the low Klotho/FGF23 ratio quartiles. The prevalence of LVH was higher in the first Klotho/FGF23 ratio quartile at 4 years . The presence of abdominal aortal calcification (P = 0.001) and coronary artery calcification (P = 0.038) were also higher in the low Klotho/FGF23 ratio quartiles.At 4 years of follow-up, echocardiography and vascular calcification parameters were evaluated in approximately 59% of subjects. Fourth-year echocardiography and vascular calcification parameters are presented in  4 years . Of the de novo LVH were higher in the low Klotho/FGF23 ratio quartile group. The presence of vascular calcification was also higher in the low Klotho/FGF23 ratio quartiles.In the present study, the incidence of renal events during the follow-up period was higher in low Klotho/FGF23 ratio quartile. Subjects in the first quartile Klotho/FGF23 ratio group showed a significantly rapid decline in eGFR. In our study, there was no significant association between the Klotho/FGF23 ratio and the composite outcome of CV events and death. The presence of LVH and vascular calcification were higher in the low Klotho/FGF23 ratio quartile group at enrollment. In subgroup analysis, during the follow-up period, LV mass index and development of 2)  . Klotho 2) , 37. In 2) –40.in vitro study showed that FGF23 was released by proinflammatory M1 macrophages and acted locally to increase tumor necrosis factor-α (TNF-α) production in M0 macrophages in the absence of Klotho  subjects developed de novo LVH, and it developed more frequently in the low Klotho/FGF23 ratio group. In an experimental study, Klotho-deficient CKD mice had accelerated cardiac hypertrophy and cardiac fibrosis compared to wild-type CKD mice , Seoul National University Bundang Hospital (B-1106/129-008), Yonsei University Severance Hospital (4-2011-0163), Kangbuk Samsung Medical Center (2011-01-076), Seoul St. Mary's Hospital (KC11OIMI0441), Gil Hospital (GIRBA2553), Eulji General Hospital (201105-01), Chonnam National University Hospital (CNUH-2011-092), and Pusan Paik Hospital (11-091). The patients/participants provided their written informed consent to participate in this study.HJK and K-HO were involved with the conception and design of the study. HJK, YK, MK, SK, SKP, SS, YYH, JYJ, CA, and K-HO were involved with patient data collection and acquisition. HJK, MK, SKP, and K-HO performed the analysis and interpretation of data. Article draft and revision were carried out by HJK and K-HO. All authors approved the final manuscript.This study was supported by the Research Program funded by the Korea Center for Disease Control and Prevention , the Bio and Medical Technology Development Program of the National Research Foundation (NRF), and funded by the Korean Government (MSIT) (2017M3A9E4044649). The funders had no role in the study design, data collection or analysis, decision to publish, or preparation of the 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Non-invasive detection of unstable angina (UA) patients with different severity of coronary lesions remains challenging. This study aimed to identify plasma lipoproteins (LPs) that can be used as potential biomarkers for assessing the severity of coronary lesions, determined by the Gensini score (GS), in UA patients. We collected blood plasma from 67 inpatients with angiographically normal coronary arteries (NCA) and 230 UA patients, 155 of them with lowGS (GS ≤ 25.4) and 75 with highGS (GS > 25.4), and analyzed it using proton nuclear magnetic resonance spectroscopy to quantify 112 lipoprotein variables. In a logistic regression model adjusted for four well-known risk factors , we tested the association between each lipoprotein and the risk of UA. Combined with the result of LASSO and PLS-DA models, ten of them were identified as important LPs. The discrimination with the addition of selected LPs was evaluated. Compared with the basic logistic model that includes four risk factors, the addition of these ten LPs concentrations did not significantly improve UA versus NCA discrimination. However, thirty-two selected LPs showed notable discrimination power in logistic regression modeling distinguishing highGS UA patients from NCA with a 14.9% increase of the area under the receiver operating characteristics curve. Among these LPs, plasma from highGS patients was enriched with LDL and VLDL subfractions, but lacked HDL subfractions. In summary, we conclude that blood plasma lipoproteins can be used as biomarkers to distinguish UA patients with severe coronary lesions from NCA patients. Unstable angina (UA), a high-risk clinical manifestation of acute coronary syndromes (ACS), is a main cause of emergency medical services and hospital care. Unstable angina is characterized by severe, prolonged angina pain at rest or with minimal exertion, without detectable myocardial necrosis. Although UA patients have lower early mortality and one-year incidence rates of myocardial infarction (MI) than non-ST elevation myocardial infarction (NSTEMI) or ST-elevation (STEMI) patients, half of them develop recurrent coronary ischemia requiring revascularization, leading to the development of severe morbidity and a higher health burden . The ideObservational studies show a robust association between lipoprotein cholesterol levels, such as high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C), and the risk factors of cardiovascular disease (CVD) in the healthy population and in secondary prevention ,4. These1H NMR) spectroscopy. Among them, 1H NMR spectroscopy provides sufficient physicochemical information to identify LPs, and enables faster, inexpensive and reproducible quantification [There are several methods for the measurement of different LP fractions, such as ultracentrifugation, high-performance liquid chromatography (HPLC) and one-dimensional proton nuclear magnetic resonance , which is a comprehensive indicator for describing the plaque burden and the severity of coronary lesions [In this study, we used  lesions ,23, baseThe population of the present study was a subset of patients in an ongoing hospital-based cohort, the Guangdong Cardiovascular Disease Cohort. Briefly, the inpatients in the Department of Cardiology of Sun Yat-sen Memorial Hospital  were recruited from 2017 to 2019 . AnthropThe present study included 487 patients. Of those, 190 patients were subsequently excluded due to non-coronary angiography results, above-mentioned comorbidities, missing covariate data and lack of enough plasma sample for NMR measurement, leaving 297 patients with UA n = 230) and NCA (n = 67) eligible for the final analysis. The selection of patients for this analysis is detailed in 0 and NCAThe serum concentration of ALT, aspartate aminotransferase (AST), fasting glucose, fibrinogen, creatinine, high-sensitivity C-reactive protein (hs-CRP), lipid and apolipoprotein levels, including total cholesterol (TC), total triglyceride (TG), HDL-C, LDL-C, apolipoprotein A1 (Apo-A1), apolipoprotein B (Apo-B) and apolipoprotein E (Apo-E), were measured by an autoanalyzer . Glycated hemoglobin (HbA1c) was determined using high-performance liquid chromatography . High-sensitivity Troponin T (hs-TnT) was measured using standard clinical chemistry assays by an automated system .1H NMR spectra of plasma samples were measured by Bruker Avance III 600 MHz NMR spectrometer  [tg), cholesterol (chol), free cholesterol (fchol) and phospholipids (phol), apolipoprotein A1, A2, B and particle numbers for different LPs.Plasma was centrifuged  after collection and stored at −80 °C until analysis. A 0.5 mL aliquot of each plasma sample was transferred on dry ice to the NMR laboratory . Of the 297 individuals, an extra quality control pooled plasma sample was prepared from 40 randomly selected individuals. As described previously, Germany) . NMR speLipoprotein particles include four main fractions and their corresponding subfractions, which are intermediate density lipoprotein (IDL), very low-density lipoprotein (VLDL) and the five subfractions (VLDL-1 to VLDL-5), low-density lipoprotein (LDL) and six subfractions (LDL-1 to LDL-6), and high-density lipoprotein (HDL) and four subfractions (HDL-1 to HDL-4) . All sam1H NMR and clinical chemistry.Continuous variables are summarized with the means and standard deviation (SD) or medians with interquartile range (IQR). Independent Student’s t-test or Wilcoxon rank sum test was applied for the comparisons of continuous variables, and the chi-square test for categorical variables. Pearson’s correlation coefficients were applied for the agreement of lipoprotein variables measured by both p < 0.05) on LP data based on the ASCA result  of <0.1 was considered as significant. For each lipoprotein variable, the adjusted odds ratios (OR) with 95% confidence intervals (CI) were expressed per SD increment.ANOVA-simultaneous component analysis (ASCA)  was perfA result  were conTo allow for the potential confounding brought by correlated lipoprotein variables, two methods were conducted for variable selection. First, we applied multiple logistic regression with least absolute shrinkage and selection operator (LASSO) for variable selection  to firstSecondly, partial least squares discriminant analysis (PLS-DA)  was condTo identify the key LP variables for differentiating the UA patients  from the NCA group, the distinguishing LP variables were selected under the following conditions: (1) had significant OR in logistic regression and VIP > 1 in PLS-DA, or (2) had significant OR in logistic regression and selected by LASSO model, or (3) had VIP > 1 in PLS-DA and selected by LASSO model. The selected LP variables were combined as a panel for the discrimination of two groups .Further, the selected LP variables were used in multivariate logistic regression analysis to test their impact on differentiating UA or UA subgroups from NCA . For each comparison, three logistic regression models were built. Firstly, sex, age, BMI and the use of lipid-lowering drugs were investigated in model 1. Then the combined LP variables, selected from combinations of logistics regression, LASSO, and PLS-DA analyses performed in two groups , were tested in model 2. Model 3 was adjusted for the combined selected LP variables and the four risk factors used in model 1. The area under the receiver operator characteristic curve (AUCROC) was calculated for assessing the accuracy of the added value of the selected lipoprotein variables for UA progression. Receiver operating characteristic (ROC) curves of different models were built and their corresponding AUCROC were tested using the Delong test.Sensitivity analysis was applied to the patients without lipid-lowering treatment at baseline (n = 223) using logistic regression analysis adjusted by sex, age and BMI.Partial Pearson’s correlation coefficient analyses were conducted to assess the relationship of each LP with the Gensini score and CVD risk biomarkers, including glucose, HbA1c, creatinine, hs-CRP, fibrinogen and hs-TnT, using the same adjustments as mentioned previously.TM  based on MATLAB R2016b. The LASSO regression [PLS-DA analyses were performed in the PLS Toolboxgression  and Delop < 0.05) in lowGS to highGS groups.The value of six LPs, including total triglycerides (TG), total cholesterol (TC), HDL-C, LDL-C, Apo-A1 and Apo-B, measured by clinical assays and 1H NMR showed good agreement  and higher levels of another 14 LP variables were more likely to develop UA (Our results showed that 19 of 112 lipoprotein variables had significant associations with the risk of UA (FDR-p < 0.1) in logistic regression analysis, indicating that patients with lower levels of 5 LP variables  . Model 1 was adjusted by sex, age, body mass index (BMI) and lipid-lowering drugs and depicted an AUCROC of 0.77 (95% CI: 0.70–0.83), while model 2 included the 10 selected lipoprotein variables depicted an AUCROC of 0.68 (95% CI: 0.61–0.76). However, by adjusting the model with the ten lipoprotein variables together with sex, age and BMI, model 3 slightly improved the discrimination with an AUCROC value of 0.78  A.chol as a potential variable that can distinguish lowGS patients from NCA patients. Three LP variables were identified by Lasso regression analysis to distinguish highGS patients from NCA patients, including HDL-C, HDL phol and VLDL-4 tg. A total of 32 lipoprotein variables, 29 of them selected by PLS-DA and LASSO, and 3 LPs selected by logistic regression, PLS-DA and LASSO, were identified as distinguishing lipoprotein variables from highGS patients to NCA patients   C.During sensitivity analysis, a total of 223 patients  who did not receive lipid-lowering drugs at baseline were included. The analysis was applied to control the effect of using lipid-lowering drugs. The associations of lipoprotein variables with UA, lowGS and highGS compared to NCA patients were tested by logistic regression analysis. The number of significant LP variables in the comparison of highGS and NCA patients was reduced but there were still 33 variables that remained significant. Most of them were VLDL variables and triglycerides from different LP particles . HoweverTo investigate the distribution of LPs in blood and the potential biological pathways involved in coronary atherosclerosis, 112 LP variables were further analyzed to investigate their correlations with six CVD biomarkers  and the Gensini score.p < 0.1). After adjusting for sex, age, BMI and the use of lipid-lowering drugs, the number of LP variables that were significantly associated with HbA1c, creatinine, hs-CRP and fibrinogen and the Gensini scores were 83, 28, 4, 12 and 21, respectively ; conversely, 30 variables, which mainly were Apo-A1, Apo-A2, LDL-2 and 3, HDL main fraction and subfractions, had negative correlations with it . Creatinine had weak but significant positive correlations with Apo-B, the ratio of Apo-B/Apo-A1 and total particle number . Moreover, creatinine level was positively associated with the LPs containing Apo-B, including IDL, VLDL (VLDL-3 and VLDL-4) and LDL (LDL-6) particles . Fibrinogen and hs-CRP showed positive correlations with fewer lipoprotein variables, most of which were LDL-6 variables. The Gensini score had positive associations with IDL, VLDL subfractions  and small LDL subfractions (LDL-5 and 6) , and negative associations with HDL-C and HDL phol .ectively . As for tg, VLDL-4 tg and LDL-6 tg showed positive correlations with more CVD biomarkers and the Gensini score than other variables, indicating that these lipoprotein variables may be important factors reflecting the degree of coronary stenosis in UA patients.Notably, Apo-B/Apo-A1 ratio, VLDL-3 1H NMR could be used to distinguish UA patients with high Gensini score (>25.4) from the NCA group with a satisfactory discrimination accuracy. This may offer a strategy to classify patients with different severities of coronary lesions according to their lipoprotein profile.The study proves that coronary lesions are associated with a change in concentrations of human blood plasma lipoproteins in unstable angina patients. We demonstrated that a plasma lipoprotein particle profile measured by Previous studies showed that LDL subfractions with different sizes play dissimilar roles in CVD, and their associations with CVD are inconsistent. Small dense LDL particles (sdLDL) are more atherogenic and associated with higher mortality in patients with MI . Large LOur results also prove that more serious coronary lesions (high-GS) is associated with plasma concentrations of VLDL, LDL, and HDL main and subfractions, including molecular classes such as triglycerides and Apo-B/Apo-A1 ratio. Among these LP variables, VLDL particles are lipoproteins containing Apo-B, and HDL particles are rich in Apo-A1, so Apo-B/Apo-A1 is a response variable reflecting the changes in VLDL and HDL particles and can be a potential biomarker for highGS. The results of the sensitivity analysis showed after removing the patients with lipid-lowering treatment, 42.8% of LP variables (33 out of 70 variables) remained significant in the comparison of highGS and NCA groups, suggesting that the LP profiles between these two groups are a result of the severity of coronary lesions.The LP profiles between lowGS and highGS patients were different, indicating that these two groups of UA patients have different underlying pathophysiology and respond differently to medical therapies. In this study, the severity of coronary lesions of lowGS and highGS differed greatly. The average Gensini score of the former group was four times lower than that of the latter, and no patient in the lowGS group had obstruction lesions. Some studies have shown that coronary heart disease patients with a Gensini score below 25 have a low occurrence of cardiovascular events . TherefoIn the correlation analysis between LP and CVD-related biomarkers, no LP variables were found to be significantly correlated with glucose, hs-TnT and Gensini score. However, before multiple comparison corrections, Apo-B/Apo-A1, LDL-5 and 6, VLDL-3 and 4 were positively correlated with the Gensini score. Results from previous studies investigating the correlations between LPs and Gensini score have been conflicting. One study reveals that large size and small size HDL-C had opposite correlation with the Gensini score in patients with angina , while stg and VLDL-4 tg, suggesting that LPs play a prominent role in the thrombosis or inflammation process of unstable angina.Regarding HbA1c, the positive correlations between 26 VLDL variables and HbA1c may be related to insulin resistance, which is usually accompanied by high levels of blood glucose and HbA1c in diabetes patients. In addition, long-term hyperglycemia contributes to the glycosylation of LDL particles. This glycosylation process mainly influences Apo-B and phospholipids of LDL, which decreases the LDL clearance and increases the LDL oxidation susceptibility . The preTwenty-one LPs showed significant correlations with the Gensini score, mainly including VLDL and LDL-5 and 6 particles. VLDL particles play an important role in the development of atherosclerosis via the mechanism of endothelial dysfunction and the increase of systemic inflammation . In addiIn clinical practice, coronary angiography is a reliable tool for detecting the severity of coronary lesions in UA patients . HoweverAlthough we identified differing lipoprotein profiles between lowGS and highGS patients, it does not prove a causal role of a change of lipoprotein profiles in as a result of the progression of coronary lesions. External validation and longer follow-ups are needed to confirm and extend our findings by providing more conclusive evidence regarding the causal associations between LPs and UA. To reflect the disease progression and prognosis in patients with unstable angina more comprehensively, further study is needed to investigate the correlation of lipoprotein profile and other characteristics of atherosclerotic plaque in unstable angina patients, such as the vulnerability and activity evaluated by Optical Coherence Tomography (OCT) or Intravascular ultrasound (IVUS).tg and decreased LDL-1 chol, HDL phol, HDL-2 chol and HDL-3 Apo-A1 concentrations as well as LDL-2 particle numbers  were found to be key LP variables distinguishing UA from NCA patients. Increased Apo-B/Apo-A1, VLDL particles and decreased Apo-A1, plasma LDL particles , HDL particles  are characteristics of UA patients with a high Gensini score that distinguishes them from NCA patients. Thus, the findings from our study prove that blood plasma lipoproteins can be used as biomarkers to distinguish UA patients with severe coronary lesions from NCA patients.This is the first study investigating the relationships between lipoprotein main/subfractions and coronary stenosis in unstable angina patients. Increased VLDL-4


To observe the effects of different positive end-expiratory pressure (PEEP) ventilation strategies on pulmonary compliance and complications in patients undergoing robotic-assisted laparoscopic prostate surgery.A total of 120 patients with the American Society of Anesthesiologists Physical Status Class I or II who underwent elective robotic-assisted laparoscopic prostatectomy were enrolled. We randomized the patients divided into divided into three groups of 40 patients each: PEEP0, PEEP5, or PEEP10. Master Anesthetist used volume control ventilation intraoperatively with an intraoperative deep muscle relaxation strategy. Respiratory mechanics indexes were recorded at six time-points: 10 mimuts after anaesthesia induction, immediately after pneumoperitoneum establishment, 30 min, 60 min, 90 min, and at the end of pneumoperitoneum. Arterial blood gas analysis and oxygenation index calculation were performed 10 mimuts after anaesthesia induction, 60 mimuts after pneumoperitoneum, and after tracheal extubation. Postoperative pulmonary complications were also recorded.2OPEEP group was higher than in the 5cmH2OPEEP (P < 0.05) and 0cmH2OPEEP groups(P < 0.05). The driving pressure (ΔP) immediately after pneumoperitoneum establishment, at 30 min, 60 min, and 90 min in the 10cmH2OPEEP group was lower than in the 5cmH2OPEEP (P < 0.05) and 0cmH2OPEEP groups (P < 0.05). Sixty min after pneumoperitoneum and tracheal extubation, the PaCO2 did not differ significantly among the three groups (P > 0.05). The oxygenation index (PaO2/FiO2) was higher in the PEEP5 group than in the PEEP0 and PEEP10 groups 60 min after pneumoperitoneum and after tracheal extubation, with a statistically significant difference (P < 0.05). In postoperative pulmonary complications, the incidence of atelectasis was higher in the PEEP0 group than in the PEEP5 and PEEP10 groups, with a statistically significant difference (p < 0.05).After pneumoperitoneum, peak inspiratory pressure (Ppeak), plateau pressure (Pplat), mean pressure (Pmean), driving pressure (ΔP), and airway resistance (Raw) increased significantly, and pulmonary compliance (Crs) decreased, persisting during pneumoperitoneum in all groups. Between immediately after pneumoperitoneum establishment, 30 min, 60 min, and 90 min, pulmonary compliance in the 10cmH2O during RARP increases lung compliance, improves intraoperative oxygenation index and reduces postoperative atelectasis.The use of PEEP at 5cmHThis study was registered in the China Clinical Trials Registry on May 30, 2020 (Registration No. ChiCTR2000033380).The online version contains supplementary material available at 10.1186/s12871-022-01869-1. For laptilation , 9.Most anaesthetized patients treated with RARP surgery have a healthy level of pulmonary function with good lung compliance. There is a lack of systematic studies on whether intraoperative PEEP is required to improve oxygenation and reduce postoperative pulmonary complications in this group. It is essential to guide clinical anesthesiologists in managing the respiratory function of patients undergoing RARP surgery with safer and more effective mechanical ventilation parameters by identifying the appropriate PEEP values. In this study, we investigated the feasibility of a PEEP ventilation strategy for patients undergoing RARP surgery and its effects on ventilation, oxygenation, and Postoperative oxygenation function.This prospective randomized, controlled trial was reviewed and approved by the IIT Ethics Review Panel of the Clinical Research Ethics Committee of the First Hospital of Zhejiang University School of Medicine on 06/05/2020 (Session No. 48). The study was registered in the China Clinical Trials Registry (Registration No. ChiCTR2000033380).Our research follows the ethical standards of the WHO Declaration of Helsinki (1964) and its successive amendments. Studies that are adequately controlled, blinded, randomized, and of sufficient statistical power to confidentially and accurately interpret the effect reported.We recruited a total of 120 patients who underwent robotic-assisted laparoscopic radical prostatectomy at the First Hospital of Zhejiang University School of Medicine from July 2020 to June 2021. Written informed consent was obtained from all participants. The inclusion criteria were Patients undergoing RARP, ASA classification I-III. Exclusion criteria were age > 80 years, history of severe cardiopulmonary, hepatic, and renal disease, history of neuromuscular disease, excessive obesity or malnutrition , and history of drug allergy. Hemodynamic instability due to positive end-expiratory pressure during the study period and difficulty in maintaining mean arterial pressure above 65 mmHg with intravenous norepinephrine (0.03ug/kg/h) will be terminated. Using SPSS 23 , patients were randomly allocated to three groups (40 patients per group): PEEP0, PEEP5, and PEEP10 groups. Randomization was performed by a researcher not involved in the anesthesia or statistical analysis. The attending anesthetist was given an envelope containing the allocation results. The patient, the surgeon, and the resident anesthetist responsible for the records were blinded to the PEEP level. Nine patients did not meet the inclusion criteria, and six declined to participate. Eight patients were excluded due to issues with recruitment, loss of data records, and loss of follow-up, four patients were excluded due to a change of surgical approach, two patients were terminated due to failure to maintain circulation, and 2 cases were excluded due to failure of pneumoperitoneum time. A flowchart of the study is shown in Fig. 2O, respectively, according to randomized groups. The Anaesthetist adjusted the respiratory frequency before pneumoperitoneum (Pnp) to keep the partial pressure of end-expiratory carbon dioxide (ETCO2) at 30–35 mmHg. IfETCO2 ≤ 60 mmHg, Anaesthetist did not adjust the respiratory parameters, but if ETCO2 > 60 mmHg, the increase in respiratory frequency was first adjusted. If ETCO2 continued to rise, the tidal volume was increased appropriately. According to the pretest, Ppeak was generally less than 30cmH2O water column. In addition, we set 40cmH2O as the upper limit to prevent unacceptable levels of high driving or plateau pressure. Anaesthetists set no recruitment manoeuvres for any ventilation modes.Patients were routinely monitored after admission to the operating room, arterial pressure was measured continuously by proper radial artery puncture placement, and we performed blood gas analysis. Anaesthesia was induced intravenously with etomidate 0.3 mg/kg, fentanyl 4 μg/kg, and rocuronium 0.6 mg/kg, followed by tracheal intubation. All patients were mechanically ventilated using a DrägerFabius GS anaesthesia workstation  with ventilation set to volume-controlled breathing , tidal volume set to an initial value of 7 ml/kg based on ideal body weight, frequency 12 times/min, and PEEP set to 0, 5, and 10 cmHAt the beginning of surgery, the Anaesthetist adjusted the position to a 30-degree head-down position according to the surgical needs, and the pneumoperitoneum pressure was adjusted to maintain 13 cmH20.Anaesthesia maintenance: propofol 4–10 mg/kg/h and remifentanil 8–18 μg/kg/h pumped to keep the BIS value at 40–60. We administered intraoperative rocuronium bromide at 0.6 mg/kg/h to maintain a deep neuromuscular block (NMB). Deep NMB is defined as no responses to train-of-four (TOF) stimulation and 1–2 replies to post-tetanic count (PTC) during neuromuscular monitoring. After pneumoperitoneum, the surgery did not require profound neuromuscular blockade, and we no longer recorded pulmonary compliance indicators as we did in the state of profound neuromuscular blockade. Rocuronium was discontinued at the end of the pneumoperitoneum.2.3.Monitoring items and time points.At the end of the surgery, neostigmine (0.05 mg/kg) and atropine (0.1 mg/kg) was intravenously administered under the guidance of the NMB monitor. The patient was extubated in the anaesthesia recovery room (PACU), and Travelling Nurse performed a blood gas analysis before Recovery Room Nurse sent the patient to the general ward. The criteria for discharge from the PACU was an Aldrete score of > 9, as assessed by the anesthesiologist in charge of the PACU before leaving the PACU and returning to the ward. Patients performed a low-dose chest computed tomography (CT) scan the day after the operation. TCO2, and ventilation pressure–volume loop using a CARESCAPE Monitor B650  monitor. Blood gas analysis was performed using an ABL-90FLEX analyzer , and neuromuscular blockade was monitored by accelerated EMG of the thumb adductors using TOF Watch SX .We monitored patients with ECG, pulse oximetry, temperature, BIS, invasive arterial pressure, E2OPEEP on pulmonary compliance (Crs) and driving pressure (ΔP) during pneumoperitoneum in patients undergoing RARP. The secondary outcomes of the study were oxygenation index and pulmonary complications.The primary outcome indicators were comparing the effects of applying 0, 5, and 10 cmHTeam personnel recorded data at the following six time-points for PEEP0, PEEP5, and PEEP10 groups: after induction, pneumoperitoneum establishment, 30 min after pneumoperitoneum, 60 min after pneumoperitoneum, 90 min after pneumoperitoneum, and at the end of pneumoperitoneum: tidal volume, respiratory rate, end-expiratory carbon dioxide partial pressure, peak airway pressure, plateau pressure, lung compliance, airway resistance, finger oxygen saturation, blood pressure, heart rate, and duration of surgery. Anaesthetist performed blood gas analysis after induction of anaesthesia, 1 h after pneumoperitoneum, and after tracheal extubation. Tracheal extubation time, PACU time, and agitation during the awakening period were recorded in the PACU. Tracheal extubation time was the time from the end of surgery to the tracheal tube removal. PACU time was the time from admission to departure from the PACU. PACU anaesthesia nurses recorded the patient's Riker score; if the Riker score was ≥ 5, we called it awakening agitation.Follow-up visits were performed on postoperative days 1 and 3 and 1 month postoperatively to record postoperative pain scores, finger pulse oxygen saturation, and postoperative complications.The Kolmogorov–Smirnov test was used to test the normality of the distribution of all variables. Values for peak inspiratory pressure (Peak), mean pressure (Pmean), lung compliance (Crs), airway resistance (Raw), partial pressure of carbon dioxide in the arteries (PaCO2) and the ratio of partial pressure of O2 in the arterial blood to the fraction of oxygen absorbed (PaO2/FiO2) at different time points are expressed as mean and standard deviation. Patient characteristics, time to pneumoperitoneum, time to surgery and time to extubation are expressed as means and standard deviations. One-way ANOVA was used to analyse differences between groups for normally distributed measures, and LSD tests were used for post hoc two-way comparisons. Differences between multiple time points for non-normally distributed actions were analysed using Kruskal–Wallis and one-way analysis of variance (ANOVA) post hoc tests, and Mann–Whitney U tests were used to analyse differences between the two-time points and groups. χ2 tests were used to compare the number of patients with agitation on awakening and the number of patients with postoperative pulmonary complications in all groups.2O were 27 mL/cmH2O, 32 mL/cmH2O and 34 mL/cmH2O with standard deviations of 7, 9 and 10 respectively. considering a P value = 0.05 and a degree of certainty of 0.90, a minimum of 28 patients per group was required to differentiate the Crs in each group.A pre-test was performed to determine the sample size. The mean Crs at PEEP for pneumoperitoneum (Pnp) 0, 5 and 10 cmHPatient characteristics such as age, BMI, time to pneumoperitoneum and time to surgery Table  did not p < 0.05) (Table p > 0.05) , there was no statistically significant difference between the three groups at each time point; compared between the three groups, MAP values in the T2.T3.T4.T5 PEEP10 group were lower than those in the PEEP0 and PEEP5 groups, with statistically significant differences (P < 0.05)   in peak, mean and raw values for the 0 and 5 cmH2O PEEP groups immediately after pneumoperitoneum establishment, 30 min, 60 min, and 90 min  . At 60 min after pneumoperitoneum and after tracheal extubation, the oxygenation index (PaO/FiO2) was higher in the PEEP5 group than in the PEEP0 and PEEP10 groups, with a statistically significant difference (P < 0.05) (Table 2O PEEP group (P < 0.05)   increased, while Crs decreased  Fig. . After e05) Fig. . There w5) Table , but theLaparoscopic patients under general anaesthesia are prone to pulmonary atelectasis and postoperative pulmonary complications after mechanical ventilation , 12. In 2O or 10 cmH2O PEEP in this study showed an increase in lung compliance, presumably because a certain PEEP level counteracts the effects of manual pneumoperitoneum and the Trendelenburg position on lung compliance in RARP patients. These results are consistent with previous clinical findings [2O PEEP groups 10 min after anaesthesia induction, 60 min after pneumoperitoneum, or after tracheal extubation. We feel that the sample size may not have been large enough to detect statistically significant differences between the 0 cmH2O PEEP and 5cmH2O PEEP.We recorded these respiratory kinetic parameters  at six different time points throughout the pneumoperitoneum. Therefore, our study found that the establishment of pneumoperitoneum and the change in surgical position decreased respiratory system compliance in patients, consistent with previous results . This mafindings . Most stfindings . The chofindings . In a stfindings . There w2O [2O in the 0 cmH2O PEEP group. Comparing the three groups, the 10cmH2O group was the smallest Δp value(Δp section of Fig. 2O allows for maintaining more tolerable values of driving pressure during pneumoperitoneum.In patients with respiratory distress, a decrease inΔp induced by a change in ventilator settings is strongly associated with increased survival . Previou2O . The tit2O . Our res2O did not significantly improve key intraoperative oxygenation indices or considerably reduce the incidence of postoperative pulmonary complications but may reduce mean arterial pressure, demonstrating a limited protective effect on the lungs. Similarly, Van Hecke et al. reported that optimizing lung compliance by PEEP during laparoscopic bariatric surgery did not reduce the incidence of postoperative hypoxaemia [Furthermore, the results of this study demonstrate that PEEP at 10 cm Hpoxaemia . In contpoxaemia . We hypopoxaemia . Excessipoxaemia , which ipoxaemia 29. Futur2O did not reach the intended number of 28 patients. Finally, we did not individualize the PEEP settings [There are limitations to this study. Firstly, postoperative lung function and lung CT monitoring, which would have helped to accurately assess the incidence of pulmonary complications, were not performed. Secondly, intraoperative cardiac output values were not recorded, which would have allowed us to understand the haemodynamic impact of different PEEP values. The lack of transpulmonary pressure monitoring is also a shortcoming. Thirdly, the PEEP group of 0 cmHsettings . Using i2O level not only increases lung compliance, reduces driving pressure, improves intraoperative oxygenation index and reduces pulmonary atelectasis but also has less impact on blood pressure compared to PEEP at 0 cm H2O and 10 cm H2O levels. An individualized lung-protective ventilation strategy is required in the future.In robotic-assisted laparoscopic prostatectomy under deep muscle relaxation, the application of PEEP at 5 cm HAdditional file 1:SupplementaryTable 1. Intra-group situation of the 0 cmH2O PEEP group at different time points. SupplementaryTable 2 Intra-group situation of the 5 cmH2O PEEP group at different time poins. SupplementaryTable3 Intra-group situation of the 10cmH2O PEEP group at different time poins.