SII was significantly and positively correlated with BMI, weight, blood glucose, HbA1c, CRP, and creatinine, and negatively correlated with the glomerular filtration rate (GFR) value. SII values higher than 336 have 75% sensitivity and 70% specificity in detecting DKI. Conclusion: The SII value can predict diabetic kidney injury in diabetics, and it can be used as an adjunctive diagnostic tool.Background: The systemic inflammatory index (SII) is a new inflammatory marker that has been the subject of various studies in diseases with chronic inflammation. Diabetic nephropathy is a disease associated with chronic inflammation. We aimed to evaluate the relationship between SII and diabetic nephropathy. Methods: Patients with diabetes who applied to our outpatient clinic were included in the study. Diabetic patients were divided into two groups: those with diabetic nephropathy and those without. In addition, healthy individuals who applied to our clinic for general check-ups during these dates were included as the control group. The SII values and other characteristics of the three study groups were compared. Results: The median SII value for those with DKI was 584 (178–4819); for those without DKI, it was 282 (64–618); and for the control group, it was 236 (77.5–617) ( Diabetes mellitus is a complex metabolic disorder marked by hyperglycemia and many complications that impact various organs throughout the body. The condition arises from an insufficient ability to utilize carbohydrates, proteins, and fats due to insulin deficiency or resistance . Over 40Diabetic nephropathy is the most significant cause of end-stage renal disease. There is an increase in the prevalence of diabetic nephropathy globally, especially in developing countries . DiabeteUnfortunately, the pathogenesis of diabetic nephropathy is quite complex and still not fully understood. Therefore, there is still weak therapeutic efficacy in the treatment of diabetic nephropathy. It has been shown that diabetic nephropathy can still progress to end-stage renal disease and increase mortality even with standard treatment, including tight blood sugar and blood pressure control. For all of these reasons, research to understand the mechanisms of the pathogenesis of diabetic nephropathy requires both the understanding of the cause and the development of new treatment strategies. Considering that oxidative stress, angiotensin II, and inflammatory processes—which are thought to play an important role in the pathogenesis of diabetic nephropathy—are important points in the development and progression of diabetic nephropathy, studies and new treatment strategies have focused on these issues.It is known that oxidative stress plays a role in the pathogenesis of nephropathy in patients with hyperglycemia . ActivatDiabetic nephropathy is characterized by proteinuria due to glomerular damage and is accompanied by a decrease in the glomerular filtration rate. End-stage renal disease develops due to increased proteinuria and a decreased glomerular filtration rate. Diabetic nephropathy is the most common cause of both chronic renal failure and end-stage renal disease .In the clinic, we provide diagnoses and follow-up care for diabetic nephropathy by evaluating the amount of albuminuria and proteinuria in urinalysis. Urinalysis is important in diabetic patients. In patients with nephropathy, the spot urine albumin/creatinine ratio, the spot urine protein/creatinine ratio, and 24-h urine albuminuria and proteinuria should be monitored. In patients with nephropathy, renoprotective medications are used in addition to controlling hyperglycemia to halt progression and treat nephropathy.Tervaert et al. categorize diabetic nephropathy into four main glomerular lesions with a separate assessment for the degree of interstitial and vascular involvement . Class IThe most common pathological changes identified in kidney biopsies of clinical diabetic nephropathy patients are glomerular lesions, particularly diffuse and nodular mesangial enlargement and glomerular basement membrane thickening. As the disease progresses, diffuse mesangial enlargement develops into nodular deposits of the mesangial matrix in the late stage of diabetic nephropathy. Also known as Kimmelstiel–Wilson nodules, these nodular lesions can be seen in approximately 25% of patients with advanced diabetic nephropathy ,16,17.Nodular lesions and diffuse lesions are the two stages of diabetic nephropathy. Patients with nodular diabetic glomerulosclerosis show more severe kidney injury, longer diabetic durations, and worse kidney prognosis compared with patients with diffuse mesangial enlargement. Diffuse mesangial enlargement, which develops in the fifth year from the onset of diabetes, is the earliest change that can be observed with light microscopy .It is possible to classify diabetic kidney disease according to urinary albumin excretion and the degree of renal dysfunction. The period of microalbuminuria, in which there is very little albumin excretion, is considered the earliest stage of the disorder. However, the presence of microalbumin in the urine should be considered an early warning sign of serious kidney problems rather than an innocent finding. Indeed, treatments and approaches that reduce microalbuminuria have been reported to slow down and even reverse progressive kidney damage . AccordiBlocking the renin–angiotensin–aldosterone system, which is among the leading treatments to prevent or slow down diabetic renal disease, is based on either inhibiting the angiotensin converting enzyme or blocking the angiotensin receptor type 1. Angiotensin converting enzyme 2, which provides the conversion of angiotensin 1 to angiotensin 1–9 and angiotensin 2 to angiotensin 1–7, is a zinc-dependent enzyme and has been shown to be expressed in the heart and blood vessels, in addition to the kidney . In animOne of the pathophysiological mechanisms in the development of diabetic nephropathy is excessive extracellular protein production in the kidney tissue. One of the agents responsible for the overproduction of extracellular matrix proteins and their accumulation in kidney tissue is transforming growth factor-β; its expression is increased by high plasma glucose, angiotensin 2, and some other fibrotic stimuli. In addition to these direct effects, transforming growth factor-β also indirectly contributes to diabetic nephropathy by increasing the levels of connective tissue growth factor .Glomerular structural disorders are also thought to have an important role in the pathogenesis of diabetic nephropathy. In the early phase of the disease, the hyperfiltration phase and accompanying increased albumin excretion are characteristic features of diabetic nephropathy. The cells surrounding the glomerular capillaries are called podocytes. These cells are of neuroepithelial origin and show quite different characteristics. There are many proteins in the extensions of podocytes that surround the vessels. Nephrin, which is one of them, acts like a zipper and allows the passage of substances such as water and glucose, while the larger protein does not allow the passage of substances in the structure. Research shows that proteinuria and nephrin protein disorders play a role in the course of diabetic nephropathy. In diabetic patients, it has been shown that the foot protrusions of podocytes are retracted and flattened, resulting in thickening of the glomerular basement membrane. In animal experiments, it has been determined that there is a decrease in both the renal nephrin level and the number of protrusions in rats with diabetic nephropathy . Not onlUnderstanding the key features of inflammatory mechanisms involved in the development and progression of diabetic nephropathy also allows for the identification of new potential targets and facilitates the design of innovative anti-inflammatory therapeutic strategies. Structural changes that occur in diabetic nephropathy can affect all renal compartments. Current literature suggests that both systemic and local renal inflammation play critical roles in the progression of diabetic nephropathy . We knowAnother novel inflammatory marker has been developed by using hemogram markers, including neutrophil count, lymphocyte count, and platelet count. This new marker has been called the systemic inflammatory index (SII). The systemic inflammatory index is a novel inflammatory marker that has been studied for its potential to reflect local immune response and systemic inflammation. It was developed based on neutrophil, lymphocyte, and platelet counts; thus, the same inflammatory mechanisms that cause alteration in these cells may also cause an increase in SII levels. Cytokines either increase or decrease during inflammatory processes. For example, highly sensitive CRP increases and neuregulin-4 decreases during inflammation. This marker—which is derived from a test that can be performed anywhere, such as a hemogram, with cheap and rapid results—is valuable as an indicator of inflammation because it is calculated with neutrophils, lymphocytes, and platelets in the hemogram. The systemic inflammatory index is calculated with the following formula: (SII = platelet count × neutrophil count/lymphocyte count). It was first used by Hu et al. to predict the prognosis of patients with hepatocellular carcinoma . The SIIThis study aimed to assess the potential of SII, an inflammatory marker, as a predictive biomarker for identifying kidney damage in diabetic nephropathy, a microvascular complication of diabetes.This study includes patients diagnosed with type 2 diabetes mellitus who applied to the internal medicine clinics of Bolu Abant Izzet Baysal University Medical Faculty Hospital between March 2020 and December 2022. Diabetic patients are divided into two groups: those with diabetic nephropathy and those without. In addition, healthy individuals who applied to our clinic for general check-ups during these dates are included in the control group.Patients diagnosed with type 2 diabetes mellitus who are 18 or older and healthy controls over 18 are included in the study. Excluded from the study are patients under 18; those diagnosed with type 1 diabetes mellitus; those with malignancies, liver failure, and autoimmune and rheumatic diseases; pregnant women; those with acute infections; those with diabetic feet; those who have recently undergone surgery; and those who refused to participate.Patient data—such as age, gender, body mass index, and duration of diabetes—are recorded from the outpatient clinic records. Additionally, laboratory values such as complete blood count; kidney, thyroid, and liver function tests; serum albumin levels; fasting glucose; glycated hemoglobin (HbA1c); C-reactive protein; spot urine protein; spot urine microalbumin; and spot urine creatinine are recorded. The systemic immune-inflammation index (SII), calculated from the complete blood count (SII = platelet count × neutrophil count/lymphocyte count), is also recorded. The SII values and other characteristics of the three study groups are compared.p-value of less than 0.05 will be considered statistically significant.After data collection, the statistical program SPSS  is used to analyze the data. The Kolmogorov–Smirnov test is used to assess normal distribution, while categorical variables are compared using the chi-square test. The Kruskal–Wallis test is used to evaluate whether there is a significant difference in median values between groups. Correlation analysis is performed with Pearson’s correlation test. Logistic regression analysis considering other confounding factors as well as SII is performed. ROC curve analysis is used to determine the sensitivity and specificity of SII in predicting diabetic nephropathy. A p < 0.001).There were 539 participants, of which 126 had type 2 diabetes mellitus with diabetic kidney injury, 227 had type 2 diabetes mellitus without diabetic kidney injury, and 186 were healthy controls. The median ages for each group were 59 (41–86) for those with DKI, 58 (29–76) for those without DKI, and 53 (18–76) for the control group. Age was found to be statistically different between each group (p < 0.001). The participants with DKI consisted of 71 (56%) women and 59 (44%) men, while those without DKI included 134 (59%) women and 93 (41%) men. The healthy control group included 37 (20%) women and 149 (80%) men. Gender was significantly different between the groups (p = 0.87), platelet count (p = 0.34), urea (p = 0.12), creatine (p = 0.24), LDL cholesterol (p = 0.35), and total cholesterol (p = 0.12) among each group. However, the BMI (p < 0.001), weight (p < 0.001), waist circumference (p < 0.001), systolic blood pressure (p = 0.02), white blood cell count (p < 0.001), lymphocyte count (p < 0.001), neutrophil count (p < 0.001), hemoglobin (p < 0.001), hematocrit (p < 0.001), blood glucose (p < 0.001), HbA1c (p < 0.00.), CRP (p < 0.001), serum albumin (p < 0.001), AST (p < 0.001), ALT (p < 0.001), and HDL cholesterol (p < 0.001) were found to be different, statistically. There were no differences in terms of diastolic blood pressure (p < 0.001).The median SII value for those with DKI was 584 (178–4819); for those without DKI, it was 282 (64–618); and for the control group, it was 236 (77.5–617) (p = 0.03). The rates of retinopathy and neuropathy were higher in the DKI group .Smoking rates did not differ between the groups, but alcohol consumption varied significantly (p = 0.045), weight , blood glucose , HbA1c , CRP , and creatinine . However, the glomerular filtration rate (GFR) value was significantly and negatively correlated  with SII.Correlation analyses revealed that SII was significantly and positively correlated with BMI . An SII value higher than 336 showed DKI with 75% sensitivity and 70% specificity .A binary logistic regression analysis considering age, gender, BMI, GFR, triglyceride, and SII revealed that SII was an independent risk factor for DKI  value was significantly and negatively correlated with SII. We also showed that the SII value has 75% sensitivity and 70% specificity in detecting DKI.SII is a novel inflammatory index which is calculated using neutrophils, lymphocytes, and platelets; all of these cells are important in inflammation . Thus, tAs is well established, diabetes and its microvascular complications are considered as inflammatory diseases. Diabetic kidney injury, which is a microvascular complication of diabetes, is associated with chronic and low-grade inflammation. Microvascular injury is a principal factor of both systemic and local kidney inflammation, with the involvement of inflammatory cells such as neutrophils, monocytes, lymphocytes, and platelet, which are related to the development of diabetic kidney injury in patients with diabetes ,41,42,43Neutrophils in peripheral blood are especially connected to the pathogenesis of diabetic kidney injury, as hyperglycemia induces an increase in the number of circulating neutrophils. Neutrophils migrate through chemokines to the glomerular basement membrane injury site. Thus, the inflammatory cascade begins .Leukocytes also play an important role in renal disease progression. Leukocytes affect the kidney, including inflammatory mechanisms independent of infection, causing proteolytic and oxidative damage to the mesangial cells . ActivatA study conducted in Turkey observed serum uric acid levels as a potential predictor of diabetic nephropathy. The study revealed that high serum uric acid levels could be related to deteriorated kidney functions and increased albumin excretion in diabetic nephropathy patients. In addition, serum uric acid was positively correlated with daily albuminuria in that study .Other inflammatory markers derived from a hemogram, such as neutrophil lymphocyte ratio (NLR), and those derived from the C-reactive protein, such as the C-reactive protein/albumin rate (CAR), are also found to be associated with DKI ,52. For C-reactive protein is related to insulin resistance and hyperglycemia, and hyperglycemia and elevated C-reactive protein levels are also associated with the development of diabetic nephropathy. It is also well known that serum albumin levels have been defined as negative markers of inflammation. Thus, the C-reactive protein/albumin rate is elevated in inflammatory conditions like diabetes and its microvascular complications.Poorly controlled type 2 diabetes and obesity are also associated with inflammatory markers like the neutrophil lymphocyte ratio and the C-reactive protein/albumin rate ,27,52. AThe elevated SII value in diabetic kidney injury in the present study is not surprising since the SII value is also an inflammatory marker. Accordingly, in our study, increased SII values, and thus increased inflammation, are positively correlated with CRP, BMI, weight, blood glucose, HbA1c, and creatinine, and negatively correlated with the glomerular filtration rate (GFR), similar to other findings in the literature.Our study had some limitations. The retrospective study design and relatively small study population are two of these limitations. Another limitation is the single-center nature of the work.In conclusion, we suggest that the SII value could be evaluated in diabetic patients suspected of DKI, as an adjunctive diagnostic tool. There is a great need for markers such as the SII value in the evaluation of diabetic nephropathy. The pathogenesis of diabetic nephropathy, which is still unexplained, is becoming a global problem, increasing day by day. There is a need for new research and new treatment strategies.


Kidney biopsies have long been avoided in pregnancy because of concerns of maternal and fetal complications. In this debate, we argue that a kidney biopsy in a patient with suspected glomerular disease can provide essential information that justifies the potential risk, and we advocate that counseling about a kidney biopsy in pregnancy be a shared, patient-centered discussion without distortion of these potential risks.1 However, among those presenting with proteinuric diseases of pregnancy , the rate of undiagnosed CKD is likely higher.2 In addition, pregnancy is often a time of regular health investigations which can reveal impaired kidney function or proteinuria, and pregnancy itself may serve as an unmasking or triggering event bringing glomerular disease to attention. Notably, while pregnancy induces several physiologic changes in the kidney, including vasodilation and hyperfiltration, an increase in proteinuria is modest, typically <300 mg/24 hours.3 Beyond this, particularly when proteinuria develops before 20 of weeks gestation, a glomerular disease should be on the differential.CKD is rare among reproductive aged patients and estimated to affect about 3% of pregnancies.4 Histopathologic evaluation of kidney tissue elucidates or confirms a diagnosis; may reveal unexpected or additional glomerular, tubular, or interstitial pathology; and provides information regarding degree of activity and chronicity. This information can have significant therapeutic implications.Kidney biopsy is the gold standard diagnostic test for glomerular disease and should be undertaken when the results are expected to alter treatment.de novo glomerular disease including lupus nephritis, FSGS, or IgA nephropathy. A biopsy is essential for differentiating among the potential etiologies because the two most common glomerular diseases in pregnancy, FSGS and IgA nephropathy, have no serologic markers. Genetic conditions which may arise in the childbearing age group, including Alport syndrome and Fabry disease, can be quickly diagnosed with a kidney biopsy, wherein genetic testing may take weeks or be more expensive or inaccessible to patients. Furthermore, the appropriate treatment of lupus nephritis is typically guided by pathologic features, including World Health Organization Class and activity and chronicity scores. Therefore, a biopsy is essential for the accurate and timely diagnosis and treatment of patients with suspected glomerular disease.When patients are carefully selected, kidney biopsies performed during pregnancy can be high yield, informing both kidney and pregnancy management. Performing a biopsy for new-onset proteinuria or AKI in a young patient frequently leads to a diagnosis of a 4 In a recent case series of 20 pregnant patients who underwent kidney biopsy between 11 and 30 weeks for significant proteinuria, biopsy-confirmed diagnosis informed treatment: 17 of 20 patients received immunosuppression and had improvement in proteinuria, and three patients avoided immunosuppression because they were found to have unexpected advanced glomerulosclerosis or diabetic nephropathy.5 A case series of biopsies performed in 11 pregnant patients with presumptive lupus flares identified proliferative lupus nephritis in 91% of patients, and the authors thoughtfully describe how five patients weighed this information with their values to determine whether to continue or terminate their pregnancy and how this affected their subsequent medical treatment as well.6Glomerular diseases can be treated with pregnancy-safe medications such as prednisone and calcineurin inhibitors, resulting in improved kidney function and proteinuria and decreasing risk for adverse pregnancy outcomes. A systematic narrative review of kidney biopsies performed in pregnancy demonstrated that 39 of 59 biopsies (66%) resulted in therapeutic change, specifically the addition of immunosuppressive medications or the prolongation of pregnancy.8 A case report of two transplant kidney biopsies in pregnancy, performed at 20 and 23 weeks' gestation, juxtaposed how meaningfully excluding or confirming preeclampsia when it could not otherwise be determined assisted in the prolongation of one pregnancy and the delivery of another.9 Although soluble fms-like tyrosine kinase-1 and placental growth factor (PlGF) testing in pregnancy has showed promising results to help rule in or rule out preeclampsia,11 this test is only very recently approved in the United States and not yet widely available, nor validated in people with kidney disease. With an established diagnosis other than preeclampsia, pregnancy-safe treatments can potentially be pursued, proteinuria and kidney function monitored closely, and gestation prolonged, lessening the likelihood of fetal complications of prematurity.A biopsy can also elucidate the etiology and determine treatment in kidney transplant patients with new-onset graft dysfunction and is recommended when necessary.12 In pregnancy, performing a kidney biopsy becomes more technically challenging with growth of a gravid uterus and is often completed in the lateral decubitus position in later stages of pregnancy. In addition, higher kidney blood flow in pregnancy can increase the likelihood of bleeding. However, in a systematic narrative review of 11 studies including 197 antepartum biopsies and their complications from 1982 to 2012, minor complications such as macrohematuria and hematomas not requiring transfusion occurred in only 5% of cases.5 Four major complications were reported (2%), all of which included major bleeding with perinephric hematomas requiring blood transfusion. Immediate fetal complications associated with biopsy were rare: One twin gestation developed placental abruption and preterm delivery, and one singleton gestation had preterm birth with perinatal death. There were no maternal deaths. These major complications occurred at a median of 25 weeks' gestation (range 23–26 weeks).4 While major complication rates of kidney biopsy in pregnancy are similar to that of all-comers, total complication rates are significantly higher than biopsies performed after pregnancy (7% versus 1%) likely because of this otherwise healthier patient population.4A percutaneous kidney biopsy is typically performed with an automated device under imaging, most commonly ultrasonography, and in the prone position. A recent meta-analysis estimated complication rates from more than 110,000 biopsies and reported macroscopic hematuria in 3.5%, perinephric hematoma in 11%, and bleeding requiring blood transfusion in 1.5%.6 Finally, the case series of 20 patients in Mexico reported 1 of 20 (5%) experienced major bleeding and hematoma requiring blood transfusion; this biopsy was performed at 11 weeks' gestation.5 Of note, in this series, most patients had kidney biopsies performed between 12 and 26 weeks' gestation, with only four patients biopsied after 26 weeks. In all cases described, biopsies were diagnostic with adequate tissue for analysis.6 Transplant patients were excluded from Piccoli's systematic review, and while reports of transplant kidney biopsy in pregnancy are few, it is believed to be better tolerated because of graft location.9Since Piccoli's systematic review, another case series of 11 pregnant people with known lupus biopsied at a median of 16 weeks (9–27 weeks) reported no known complications resulting from biopsy.In summary, while risks of complications of a kidney biopsy are higher in pregnancy than postpartum, they are similar to that of all patients who undergo a kidney biopsy. Therapeutic changes are common after biopsy, and the data obtained can be pivotal in informing decisions that affect both maternal and fetal health. The most severe complications have been described late in the second trimester at 23–26 weeks' gestational age. Although more recent series described that biopsies have safely been performed at up to 30 weeks' gestation, the data are still very limited on biopsies performed after 26 weeks. The benefit of obtaining biopsy is likely greatest earlier in pregnancy, when the risks of major complications are lower, and there is greater advantage in precisely defining the diagnosis and prognostic features to inform management.13 Finally, there may be local factors relevant to decision making, including the ability to manage biopsy complications, access higher levels of needed neonatal care exemplified in a recent case report,14 or access therapeutic termination. All these factors may be considered when weighing a potential kidney biopsy.Ultimately, the decision to undergo a kidney biopsy in pregnancy is one a patient must make fully informed by one's nephrologist and high-risk obstetrician. Individual risk tolerance, comfort with uncertainty, and values and priorities related to treatment attributes will inform patients' decision making. Individual and local resources may also influence decision making. In some settings, serologic and genetic testing may be unavailable, costly, and/or untimely, and a kidney biopsy can be the most parsimonious and effective way to obtain data that informs management both in pregnancy and thereafter. In the United States, pregnant women are eligible for Medicaid coverage which extends 60 days after birth; coverage beyond this has been expanded in some but not all states. Delaying biopsy until postpartum may have different challenges in access to appropriate outpatient care particularly for patients with maternal morbidity at delivery.15 While the risk/benefit ratio needs to be examined carefully in pregnant women, there are many situations where biopsy is withheld because of fear of complications that are not definitively supported by evidence and are similar to the general population pursuing a kidney biopsy. This should be shared with patients, so they can make an informed decision.In addition, we must acknowledge our own cognitive and societal biases when considering risks in pregnancy. A Hastings Center Report thoughtfully pointed out that in pregnancy, medicine is often oriented toward the risks of interventions  with less consideration of the risks of failing to intervene. In society, the ideal of a self-sacrificing good mother can lead to the judgment that any fetal risk can trump considerations important to the woman herself, including examples from diet to antidepressants.postpartum kidney biopsy, it can generally be performed safely with a <10% risk of complications, largely minor. In thoughtfully selected patients, a kidney biopsy will likely provide diagnostic information and guide therapy. This will facilitate the ability for patients to make autonomous, informed decisions and can optimize the health of the pregnant person, as well as the developing fetus.Ultimately, while a kidney biopsy in pregnancy may carry higher risk than a native


A review of the literature was made to find and choose research papers, on drugs (amiodarone and adenosine) used for managing supraventricular tachycardia (SVT) in children and infants (one hour to 17 years of age) with no structural heart disease by PRISMA guideline. Our team conducted an exhaustive systematic literature review (SLR), utilizing an extensive search methodology across recognized databases like PubMed, PubMed Central, Google Scholar, Web of Science, and The Cochrane Library. We included 10 scholarly articles that satisfied our rigorous selection criteria including systematic reviews/meta-analysis, and randomized control trials, shedding light on treatment with amiodarone and adenosine for SVT in pediatric patients.There is no first- or second-line treatment for SVT in pediatrics, and drug effectiveness can vary significantly between patients. Adenosine has a shorter half-life than other drugs, instead, it is safer and more valuable when an electrocardiogram is uncertain, it is recommended as an acute management, and it continues as the first-line option for paroxysmal SVT. Amiodarone management patients with acute STV within, its use showed better results when administered 48 hours after diagnosis. Furthermore, it is recommended to reduce the incidence of junctional ectopic tachycardia (JET), by pre-operative prophylaxis, also for chronic control in this and other types of SVT. In none of the evaluated studies were documented significant adverse effects in pediatric patients. Side effects that did occur were mild and easily managed. The studies also emphasize that although both amiodarone and adenosine can successfully convert SVT to sinus rhythm, better results have been observed when using combined therapies of each recommended medication. Therefore, more randomized clinical trials, meta-analyses, and systematic reviews are needed to solidify and possibly standardize an effective and safe pharmacological treatment for SVT and its types in pediatric patients. Supraventricular tachycardia (SVT) is a condition that affects the normal rhythm of the heart. It can happen to people of all ages. It is distinguished by a heartbeat caused by irregular electrical activity, in the upper section of the heart, specifically in the atria or the atrioventricular node. Understanding this condition is essential for both healthcare providers and patients as SVT can manifest in ways and necessitate various approaches to management -3.Diagnosing and categorizing SVT frequently involves using a 12-lead electrocardiogram (ECG). SVT encompasses types, such, as SVT (PSTV) junctional ectopic tachycardia (JET), and atrial tachycardia, among others. Determining the subtype of SVT is crucial as it guides each individual's treatment approach and long-term management. It allows healthcare professionals to customize interventions based on the patient’s condition -6.SVT can cause symptoms, some of which can be pretty distressing. For example, junctional ectopic tachycardia, a type of SVT, is characterized by heart rhythms that start near the atrioventricular node. Paroxysmal tachycardia can trigger episodes of fast heartbeats while atrial fibrillation leads to chaotic electrical activity, in the atria, resulting in irregular and rapid heart rhythms. These abnormal activity patterns can significantly impact those affected well-being and overall quality of life ,7,8.Pediatric patients, in particular, are at risk for SVT, considered one of the most common cardiac emergencies in this age group. What further complicates the management of SVT in children is that the exact tachycardia mechanism is often unknown, and accelerated rhythms can be distressing to young patients. Additionally, SVT can cause significant morbidity in pediatric cases, making effective treatment strategies imperative ,7,9,10.When it comes to dealing with SVT in children, how we handle it depends on how the patient shows symptoms and their overall condition. It is essential to consider factors, like age, general health, and possible underlying causes of the arrhythmia when coming up with a treatment strategy. In a lot of situations, there is a chance that SVT will resolve spontaneously in infants because of the nature of their arrhythmia patterns. This gives us optimism, for managing it without measures ,11,12.Pharmaceutical drugs play a role in the treatment of SVT, in children and, among the various medications used, amiodarone is considered a key option. Amiodarone is a type of spectrum medicine that works by blocking both sodium and potassium channels in the heart. Additionally, it has some properties. Its mechanism of action involves prolonging periods and inhibiting ion channels, which together help decrease excitability in the heart ,9,13,14.Amiodarone is highly effective, in treating arrhythmias, especially when other treatments are unsuccessful. It has established itself as a component in managing SVTs due to its way of working, and its ability to effectively treat a wide range of arrhythmias ,15,16.Adenosine is another medication frequently employed in the management of SVT. Adenosine is an endogenous nucleoside with a remarkably short half-life of less than a minute. Its unique action involves repressing calcium influx and enhancing potassium conduction, leading to the inhibition of atrioventricular nodal conduction and an increase in the AV nodal refractory period. This makes adenosine particularly useful in cases of paroxysmal SVT, including conditions like Wolff-Parkinson-White syndrome -20.Different types and symptoms of SVT highlight the importance of understanding and using treatment approaches. When it comes to children this becomes more crucial as we need to consider their requirements and the possibility of natural recovery. Amiodarone and adenosine play a role in treating SVT, providing ways to restore normal heart rhythm and enhance the overall prognosis for individuals affected by this condition.MethodologyWe followed the stringent methodological criteria indicated in the PRISMA guidelines while performing our systematic review, ensuring the comprehensiveness and openness of our methodology and conclusions. We searched three credible databases: PubMed, PubMed Central, Google Scholar, Web of Science, and the Cochrane Library. To achieve a strong capture of relevant material, we used sophisticated search strategies such as MeSH keyword searching and Boolean logic. Furthermore, only full-length free publications were included to guarantee thorough data extraction and analysis.We used a rigorous, comprehensive approach to quality evaluation in the methodology portion of our systematic review of the literature to improve the credibility and dependability of our results. We used the Assessment of Multiple Systematic Reviews (AMSTAR) checklist to assess the methodological rigor of the included systematic reviews. We used the Cochrane risk of bias assessment method to analyze the possible bias in the clinical trials included in our study. The Newcastle-Ottawa Quality Assessment Scale was used in non-randomized investigations, such as cross-sectional studies. We also used the Scale for the Assessment of Narrative Review Articles (SANRA) to assess the quality of narrative reviews included in our research.Study timeline and search strategyTo discover papers relevant to this systematic review, a thorough search was undertaken on September 15, 2023, across numerous databases, including PubMed, PubMed Central, Google Scholar, Web of Science, and The Cochrane Library. We used the normal search feature in PubMed. In addition, we updated our search approach, which included the use of Medical Subject Headings (MeSH) keywords as well as the Boolean operators “AND,” “OR,” and “NOT” to increase the precision and sensitivity of our search. Table Inclusion and exclusion criteriaWe considered observational studies, RCTs, systematic reviews, standard reviews, meta-analysis journals, and other English-language literature. We included studies published after 2018 that compared the efficacy of adenosine and amiodarone in the treatment of supraventricular arrhythmias in pediatric patients, but we excluded editorials, perspectives, case reports, peer reviews, gray literature, unpublished studies, and animal studies  over the next 24 hours. This preoperative amiodarone was demonstrated to reduce the incidence of JET and no significant adverse events .For Atrial Tachyarrhythmias, Arvind et al. presented that the use of amiodarone on postoperative JET restored sinus rhythm in 93.5% of the patients with a median time taken of seven hours. Only one patient presented recurrence. Hill et al.'s  study prWadile et al.'s study revealed that from 35 patients who were given prophylactic postoperative amiodarone, only 8.5% presented JET. Instead, amiodarone had a higher incidence of bradycardia and hypotension than the other medications and control groups, however, the side effects were mild. It was associated with significantly lower inotrope requirements, ventilation hours, ICU, and hospital stay ,21,22.Hashim et al.'s study showed that the acute management with adenosine is effective in around 70 to 85% of the patients, the dosage seems to be an important factor higher doses of 300 to 500 μg/kg were effective in suppressing the SVT, but the minimum dose to be effective should be no less than 100 μg/kg in children and 150 to 200 μg/kg in infancy. Also, the study made a comparison with amiodarone (5 μg/kg/min) and concluded that it was effective in suppressing SVT as well as adenosine. Increasing the dose can bring more incidence of adverse effects, toxicity, and heart problems such as bradycardia .Ahmad et al.'s study revealed that paroxysmal SVT management with adenosine as the first line with an initial intravenous dose of 6 mg stat and if there was unsuccessful the further dosing was 12 mg after one to two mins, it was quick in producing results with brief side effects, these were drug-like chest tightness, feelings of electric shock, and flushing with the conversion dose. Only two of 14 patients presented PSTV recurrence ,24.In the prehospital study, 87 patients were given adenosine, and 60 patients converted to sinus rhythm. It concluded that adenosine had a higher conversion rate and quick mechanism of action in converting PSVT into sinus rhythm than other medications; however, it presented a higher recurrence.Sadoh et al.'s study demonstrated that children who were given adenosine 75% achieved success in the treatment, 33% of them responded at the first doses and 67% needed a second dose to revert the SVT. Kotruchin et al.'s study showed a comparison between the double‐syringe (DST) and the single‐syringe (SST) techniques of adenosine administration. DST and SST patients received 6 mg per 2 mL and if it failed there was a second dose of 12 mg per 4 mL, finally if the second dose was unsuccessful, the treatment was considered to have failed; the total administered dose was 8.6 ± 5.1 mg and 7.6 ± 4.5 mg, respectively. The effectiveness of the 6 mg adenosine dose was 73.3% and 80%, respectively. There was no significant success difference between any technique, and the SST was also practical and safe -25.SVT is a common manifestation in pediatrics and should be treated with fewer adverse effects. This review shows efficacy, safety, and associated adverse effects of amiodarone and adenosine in the treatment of SVT in pediatric patients. Adenosine and amiodarone achieved meaningful arrhythmia control in pediatric patients. However, both of them showed a higher recurrence of side effects compared to other medications. Nevertheless, they consistently presented mild and easily treatable adverse effects, with hypotension being the most common. Amiodarone studies concluded that if there is a longer time to treatment initiation, the success rate will decrease, with the best achievement showed at 48 hours; amiodarone has shown promising results in reducing the incidence of JET when used as prophylaxis both pre and postoperatively ways; it also achieved significant results for chronic treatment on SVTs. Adenosine is the recommended first-line drug treatment for SVT types as an acute dosage, it continues as the first-line option for paroxysmal SVT.While both medications have shown to be effective and safe, in treating SVTs studies highlight that better outcomes can be achieved by using them in conjunction with medications, like beta blockers and calcium channel blockers. Due to this would be important to improve the quality of the study that we provide with more randomized clinical, systematic reviews and meta-analyses in this way we can support which of the provided insights were more accurate.


They were assigned to three groups, 30 min/day continuous, or 6 in the time (rmssd) and frequency domain, blood pressure variability, and baroreflex sensitivity (BRS). RR interval corrected rmssd was reduced supine (p = 0.0358) and during HUT (p = 0.0161). Heart rate variability in the high-frequency band  and BRS (p < 0.0001) decreased, whereas blood pressure variability in the low-frequency band  increased following bedrest in all groups. We did not detect significant interactions between bedrest and interventions. We conclude that up to daily 30 min of artificial gravity on a short-arm centrifuge with 1Gz at the center of mass do not suffice to prevent changes in autonomic cardiovascular control following 60-day of 6° head-down tilt bed rest.Impaired cardiovascular autonomic control following space flight or immobilization may limit the ability to cope with additional hemodynamic stimuli. Head-down tilt bedrest is an established terrestrial analog for space flight and offers the opportunity to test potential countermeasures for autonomic cardiovascular deconditioning. Previous studies revealed a possible benefit of daily artificial gravity on cardiovascular autonomic control following head-down tilt bedrest, but there is a need for efficiency in a long-term study before an artificial gravity facility would be brought to space. We hypothesized that artificial gravity through short-arm centrifugation attenuates functional adaptions of autonomic function during head-down tilt bed rest. 24 healthy persons (8 women, 33.4 ± 9.3 years, 24.3 ± 2.1 kg/mClinical Trial Registration: https://drks.de/search/en/trial/DRKS00015677, identifier, DRKS00015677 The autonomic nervous system regulates the cardiovascular system, which enables human beings to maintain blood pressure and organ perfusion in the face of environmental challenges including those experienced during and following spaceflight , 2. IndeNon-invasive measurements of heart rate variability, blood pressure variability, and baroreflex sensitivity are considered to reflect autonomic influences on the sinus node and on vascular tone and can be utilized to track changes in cardiovascular autonomic control –9. Such The study was part of the artificial gravity bed rest ESA study , which tested the efficacy of daily artificial gravity through short-arm centrifugation as a multipurpose countermeasure. Hereby, we focused on adjustments in autonomic function leading to changes in the balance between sympathetic and parasympathetic cardiovascular modulation following head-down tilt bedrest. Therefore, typical changes following space flight and bed rest, namely reductions in baroreflex-mediated parasympathetic heart rate control and enhanced sympathetic modulation of the heart and the vasculature should be attenuated through daily artificial gravity –18. We h2; mean ± standard deviation), All subjects provided written informed consent prior to study entry. The North Rhine Medical Association Ethics Committee approved the study.Our study is part of the NASA/ESA/DLR 60-day −6° head-down-tilt bed rest study AGBRESA, which was conducted at the DLR:envihab research facility. The methodology and study design were discussed and determined by the advisory boards of these international space agencies. Detailed criteria including a consort flow sheet regarding inclusion, exclusion, psychological, and medical screening procedures have been recently published . ParticiStudy design and standardization measures have been described elsewhere . BrieflyDuring the bed rest period, participants were assigned to a control group without countermeasure, or two different artificial gravity interventions. One artificial gravity group underwent 30 min continuous centrifugation. The other group underwent 6 × 5 min daily artificial gravity with 3 min breaks. Centrifugation elicited gravitational forces of 1Gz at the center of mass. For safety reasons, heart rate was measured continuously by 3-lead electrocardiogram and blood pressure was assessed intermittently with an oscillometric brachial cuff during centrifugation .We conducted tilt table testing 5 days before entering bed rest and immediately following 60-day bed rest in the morning hours after a light breakfast. We recorded heart rate through a three-lead electrocardiogram and finger blood pressure  continuously, and oscillometric brachial blood pressure in intervals of two minutes. We adjusted for body position-related hydrostatic pressure influences on finger blood pressure (Finapres corrector). Following instrumentation, which required 10–15 min, participants remained in the supine position for additional 15 min followed by 5 min baseline recordings. Then, we tilted participants up to 80°. For upright heart rate and blood pressure variability as well as baroreflex sensitivity measurements, we analyzed the first five minutes during 80° head-up tilt after excluding the initial dynamic response in the first minute based on the inspection of a trained scientist. In participants unable to stand long enough, a minimum of three minutes stable recording after the initial dynamic phase was required for spectral analysis .Rmssd based on international standard recommendations was used to describe HRV in the time domain, which reflects respiratory sinus arrhythmia and baroreflex mediated parasympathetic heart rate control . MoreoveWe calculated spontaneous baroreflex sensitivity by determining the slope of the linear regression line between systolic blood pressures and subsequent RR intervals, utilizing the sequence technique , 25. We P < 0.05 indicated statistical significance. Respecting the explorative character of the analysis, we did adjust p-values for multiple tests. The data supporting our results are available from the corresponding author upon reasonable request.We report results as mean ± standard deviation. We logarithmically transformed HRV parameters as indicated. Based on the prospective study design and to account for few missing values, we applied linear mixed-effects models to assess changes in autonomic function following head-down tilt bed rest. For each parameter, we fitted a random intercept model with fixed effects for bed rest, body position in tilt table testing, and intervention group. Adjustments for age and sex were included. Representative heart rate and systolic blood pressure variability analyses before and after bedrest are shown in The RR-interval was reduced in all groups following bed rest in supine position and showed an even steeper decrease during head up tilt . Rmssd wMean arterial pressure was elevated following bedrest and in HUT, whereas there was no evidence for a group difference. Supine blood pressure variability in the low frequency range increased following 60-day of head-down tilt bed rest in the supine and in an upright position at 80° HUT , which are established measures of parasympathetic heart rate modulation, were substantially reduced with bedrest particularly when standing . Low freIn our study, changes in autonomic cardiovascular control towards sympathetic predominance may have contributed to an increase in mean arterial blood pressure. In contrast, a recent study employing direct sympathetic nerve recordings through microneurography showed sympathetic activation with stable blood pressure following 30-day head-down tilt bedrest . We dareThe relatively low number of study participants explained by the complexity and costs of head-down tilt bed rest studies is an important limitation given the substantial interindividual variability in short-term autonomic heart rate and blood pressure control. However, our study included more participants than previous investigations . MoreoveIn the absence of sufficient countermeasures, the extreme environmental conditions in space and simulated weightlessness through head-down tilt bed rest decrease the ability of the cardiovascular system to cope with acute hemodynamic challenges. In our study, daily artificial gravity up to 30 min a day elicited through short arm centrifugation did not prevent changes in autonomic cardiovascular control during 60-day of head-down tilt bed rest. Moreover, while artificial gravity attenuated reductions in orthostatic tolerance with head-down tilt bed rest, orthostatic tolerance was not fully maintained . Perhaps


Bioelectrical impedance analysis (BIA) is a method that measures electrical currents conducted through water, which assesses fluid status by measuring extracellular water (ECW), total body water (TBW), and resistance (R). Limited studies are done to evaluate the utility of BIA in patients with congestive heart failure (CHF), and therefore, we performed a systematic review and meta-analysis to evaluate this. A comprehensive literature search was performed at Medline and Embase until March 2022. Our primary outcome was a comparison of TBW and ECW between patients with CHF and controls. Our secondary outcome was to compare R between the groups. All analysis was conducted using RevMan 5.4 software. Six studies with 1,046 patients met our inclusion criteria. Out of 1,046 patients, 526 had CHF and 538 had no CHF. Among patients with CHF, all 526 had decompensated CHF. There was no significant difference in TBW between patients with heart failure and the control group (mean deviation (MD) = 1.42 (-0.44-3.27), percent of variation (I2) = 0%, p = 0.13). ECW was significantly higher with an assessment of BIA in heart failure patients compared to patients in the control group (MD = 1.62 (0.82-2.42), I2 = 0%, p < 0.0001). Resistance of extracellular fluid was significantly lower in the heart failure group (MD = -45.64 (-72.88--18.41), I2 = 83%, p = 0.001). Publication bias was deferred as the number of included studies was less than 10. BIA can be helpful in ambulatory and inpatient setting to identify patients’ fluid status, which can improve outcomes. However, larger prospective studies are needed to further evaluate the usefulness of BIA in the CHF population. Congestive heart failure (CHF) is currently the leading cause of hospitalizations across the United States and Europe, affecting around 26 million patients. The worldwide financial burden is $108 billion per year .Traditional monitoring for heart failure exacerbations including patients’ fluid status is often a clinical finding, such as daily body weight, oxygen demand, lower extremity edema, or pulmonary crackles upon auscultation. However, before patients present with these signs and symptoms, they may have asymptomatic structural or functional cardiac abnormalities that serve as precursors of CHF -6. ThereBioelectrical impedance analysis (BIA) is a fast, safe, and noninvasive method that uses the body’s alteration of electrical current through water and tissue at different frequencies through cell membranes to acquire different impedances to assess fluid retention. BIA has been introduced in the medical fields of nephrology, hepatology, nutrition, and rehabilitation -9. Body The BIA test involves placing two electrodes on the person’s right hand and foot, and a low-level electrical current is sent through the body. These electrical currents are usually conducted through water due to their low resistivity . ImpedanIn this manuscript, we sought to systemically review the literature and study the impact of BIA in regard to a patient’s fluid status in the acute heart failure setting.This abstract was previously presented at the Florida Chapter of the American College of Cardiology (FACC) Annual Meeting Abstract and Case Presentation in Orlando, FL, USA, on August 21, 2022.ResultsThe initial search strategy revealed a total of 827 studies. After the removal of duplicates, 730 underwent title review, excluding 314 records. Of the remaining 416 studies, 397 were excluded due to a lack of reporting outcomes of interests and insufficient data. The remaining 13 studies underwent full-text review and yielded a final article count of six. Figure Figure DiscussionStrategic monitoring and novel markers to guide CHF management remain to be an area of interest and of great importance ,20. TherThe main composite of the human body is water, measured as TBW, which is comprised of ICW (55%-65%) and ECW (35%-45%) . The manThere has been another meta-analysis that did assess impedance monitoring in patients with heart failure, specifically with implanted devices such as CardioMEMS, OptiVol, and CorVue . These dTo the best of our literature search, this is the first medical review and meta-analysis that comprehensively assesses the use of external BIA as a marker of acute heart failure exacerbations in the inpatient or outpatient setting. Some studies revealed that patients who present to the hospital in an acute heart failure exacerbation have a higher TBW and ECW with an associated higher resistance. Génot et al.  did not Overall, there was no significant difference in TBW when comparing CHF patients to the control. However, when looking at ECW, there was a substantial difference between the two groups. We found that CHF patients had a higher ECW content when compared to the control group. Theoretically, we would expect to see TBW also higher in the CHF group. It is theorized that patients with CHF have an impaired ability to compensate due to electrolyte abnormalities, specifically potassium and sodium . NormallInterestingly enough, there were two other markers that previous papers used to assess volume status in acute heart failure patients. Due to the lack of reporting data in the included studies, we were unable to meta-analytically evaluate the utility of these markers. Both hydration index and phase angle were used as markers in heart failure patients ,16,29. TLinking BIA with molecular digital makers could help give physicians important information regarding volume and fluid status to help with medical decision-making for patients with CHF. With a difference of ECW and R in heart failure patients compared to the control, external BIA could possibly be used in the future in the emergency room, inpatient, or clinical environment to assess for appropriate diuresis and possibly catch patients before they start exhibiting symptoms of heart failure and requiring hospitalization. Future larger prospective studies are needed to further evaluate the significance of BIA in patients with CHF.


Aim: The study aimed to investigate the association between the use of serotonergic antidepressants and blood transfusion requirements in orthopedic surgical patients.Methodology: A retrospective follow-up study was conducted at Kota Trauma Hospital, Kota, Rajasthan focusing on patients who underwent orthopedic surgeries between November 2021 through December 2022. Patients were categorized into two groups: users of serotonergic antidepressants and users of other antidepressants (non-selective serotonergic antidepressants). The requirement for blood transfusion for both groups was assessed. Covariate factors, such as medication use and comorbidities , were examined to control potential confounding variables.Result: A total of 170 subjects with complete medical records were included in the study. The results presented a significant association between the usage of serotonergic antidepressants and blood transfusion requirements (p=0.001). While no significant differences between the two groups were observed in perioperative hemoglobin levels and fluid infusion, there was a significant difference in blood loss and postoperative drainage.Conclusion: Serotonergic antidepressant usage was correlated with increased blood transfusion requirements in orthopedic surgery patients on antidepressants. The study underscores the importance of considering medication factors in perioperative management and highlights potential implications for patient care strategies. Selective serotonin reuptake inhibitors (SSRIs) are extensively used pharmaceuticals for the treatment of depression, owing to their notable effectiveness and favorable safety characteristics ,2. Over A number of case reports and observational studies have shown a potential association between SSRIs and an increased risk of bleeding ,9. The pA number of observational studies have been conducted to investigate the association between the risk of bleeding and the use of SSRIs. However, it is worth noting that only two studies ,14 have The study conducted by Movig et al.  investigStudy participantsThe research was carried out at Kota Trauma Hospital, Kota, Rajasthan. Patients who had elbow, knee, or shoulder implant surgeries between January 1, 2021, and December 31, 2022, were included in the research. Patients' data were gathered from hospital records. The Medical Ethics Committee approved the study plan, and patients were requested to provide informed permission.Study designA retrospective study design was used for the current study. Patients were excluded if they did not provide informed consent, their medical records were missing or incomplete or had incomplete drug prescription data. The primary outcome variable was the necessity for blood transfusions during surgery. Secondary outcomes included bleeding during the procedure, the need for infusions, and the loss of drainage fluid. Prescription data were received from neighborhood pharmacies, and additional pre and postoperative information was retrieved from hospital records.Covariate factorsThe study examined potential factors that could influence the results, including the use of medications like corticosteroids, calcium-channel blockers, Fe supplements, aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), and vitamin K (antagonists). Additionally, concomitant diseases such as diabetes mellitus, renal diseases, bleeding ulcers, and cardiovascular diseases were taken into account as potential factors that could confound the association being studied.Statistical analysisStatistical Package for Social Sciences (SPSS) version 25  was used to perform the statistical tests. The mean and standard deviation were used to describe all continuous values, whereas numbers and percentages were used to represent categorical data. Descriptive statistics were used to determine the frequencies and proportions. Inferential statistics were used to determine the association between variables and to compare the data. The χ2 test was used to determine the varied proportions of categorical variables.A total of 170 patients were included in the study. Table The usage of various medications was recorded, and it was noted that certain antidepressants  were more commonly used in the blood transfusion group compared to the no-blood-transfusion group. NSAIDs were more prevalent among patients who did not require a blood transfusion.Morbidity and comorbidity percentages were also assessed. While diabetes mellitus, cardiovascular diseases, and renal diseases were relatively evenly distributed between the two groups, bleeding ulcers were notably higher in the no-blood-transfusion group (10%).Table Regarding hematologic parameters, the perioperative hemoglobin levels showed no substantial difference between the two groups, with mean levels of 10.56±1.16 g/dl for serotonergic users and 10.62±1.24 g/dl for non-serotonergic users, resulting in a p-value of 0.07. However, the perioperative blood loss was notably higher in the serotonergic antidepressant group (0-7500 ml) compared to the non-serotonergic group (0-6500 ml), with a significant p-value of 0.001.Perioperative fluid infusion ranged from 300 ml to 5000 ml for serotonergic users and 200 ml to 9500 ml for non-serotonergic users, with no significant difference (p=0.24). Postoperative drainage ranged from 60 ml to 1750 ml for serotonergic users and 0 ml to 3000 ml for non-serotonergic users, resulting in a p-value of 0.05, indicating a moderate difference.Table This retrospective research examined the correlation between the perioperative administration of serotonergic antidepressants and the likelihood of receiving a blood transfusion of two or more units in patients who had orthopaedic surgery. The findings revealed a threefold elevation in the risk of such blood transfusions among those who were exposed to serotonergic antidepressants during the perioperative period. The results of the current research indicated that those who were prescribed serotonergic antidepressants had a statistically significant increase in blood loss during orthopaedic surgical procedures compared to those who were not taking any antidepressant medication. The available case reports have provided evidence suggesting a potential association between serotonergic antidepressants and complications linked to bleeding. Previous research has shown that the use of serotonergic antidepressants is significantly linked to an increased likelihood of experiencing serious gastrointestinal bleeding, especially in those who are concurrently using NSAIDs. In a recent study conducted by Yang et al. (2023) , it was Orthopaedic and rheumatology patients who suffer from excruciating osteoarthritis often take NSAIDs before undergoing joint replacement surgery. According to Friedman et al. 2013) [13 [20], Patients on calcium-channel blockers did not have a higher risk of perioperative blood transfusion in the current trial, but they did need more post-operative blood transfusions. Rheumatoid arthritis is often treated in ambulatory people who receive intramuscular methotrexate. The requirement for perioperative blood transfusions in orthopaedic patients with rheumatoid arthritis is supported by our data even though methotrexate itself is not known to be linked to a higher risk of bleeding ,21.A reduction in intraplatelet serotonin concentrations that impact platelet aggregation may be the underlying cause of the SSRIs' increased risk of bleeding . The surOur investigation may have some limitations regarding the influences of variables (other than the exposure of interest) on the risk of the outcome, similar to previous observational studies. But, we think it is unlikely that any possible biases have had a big impact on our findings. First, information bias seems to be very improbable given that serotonergic antidepressants are not often related to bleeding issues during orthopaedic surgeries in routine clinical practice. Second, we think that selection bias was not a significant problem in this research since a well-defined population was used to sample all of the patients. Recall bias is minimal since all data were gathered in the past according to the study's retrospective design. The hematological laboratory, which has highly secure procedures for managing and recording blood transfusion needs in the clinic, provided the data required for end-point definition electronically.The study has some limitations including sample size and study area. As the research only included one hospital of a city, the results of a larger sample size may vary.The current research revealed a significant association between the usage of serotonergic antidepressants and blood transfusion requirements. Due to the common and rising use of antidepressants, the link between serotonergic antidepressants and perioperative blood transfusion in orthopaedic surgery may represent a risk to the health of older patients. There is a chance that a lot of patients will be exposed to this danger. The study underscores the importance of considering medication factors in perioperative management and highlights potential implications for patient care strategies.


Plasmatic levels of LOS and EXP3174, obtained by liquid chromatography coupled with mass-mass spectroscopy, were correlated with blood pressure control, biochemical markers and the metabolomic fingerprint of the groups. Some biomarkers have been correlated with key aspects of hypertension and CKD progression. For instance, higher levels of trigonelline, urea and fumaric acid were found as characteristic markers of kidney failure. In the hypertensive group, the urea levels found could indicate the onset of kidney damage when associated with uncontrolled blood pressure. In this sense, the results point to a new approach to identify CKD in early stages and may contribute to improving pharmacotherapy and reducing morbidity and mortality associated with hypertension and CKD.Systemic arterial hypertension (SAH) is one of the most prevalent chronic diseases worldwide and, when dysregulated, may cause serious complications. Losartan (LOS) blocks relevant physiological aspects of hypertension, acting mainly on the reduction of peripheral vascular resistance. Complications of hypertension include nephropathy, in which diagnosis is based on the observation of functional or structural renal dysfunction. Therefore, blood pressure control is essential to attenuate the progression of chronic kidney disease (CKD). In this study,  SAH is one of the most prevalent chronic diseases worldwide, reaching about 30% of the population. During the early stages, it presents itself silently, while the progression may cause serious complications. Elevated and sustained levels of blood pressure (BP) are indicative for diagnosis, and follow up and continuous treatment are used to control and reduce its complications ,2.The antihypertensive drug LOS, an angiotensin-2 receptor antagonist, blocks all relevant physiological mechanisms of hypertension, acting mainly on the reduction of peripheral vascular resistance . Its halLOS can be administered in daily doses of 25–100 mg with good tolerance and few side effects, confirmed by different studies since the1980s , between 0.8 and 8.5 ppm using Mestre Nova® software version 12.0. The spectral region comprised between 4.7 and 5.2 ppm was removed due to variability in the suppression of the water signal. A representative spectrum of the classification was loaded in ChenoMX NMR Suite software v8.5  and confirmed by the human metabolome database (HMDB) if found in human plasma and with a concentration ≥ 20µM, and categorized in the metabolomine if common or uncommon in the MRI bank plasma metabolism (BMRB) and related literature. A receptor operating characteristic (ROC) analysis was performed to assess the diagnostic accuracy of each candidate biomarker and a panel of predictive biomarkers that showed the highest accuracy was presented based on the combinational ROC analysis. A heat map methodology was also used to correlate the metabolites to the analytical and relevant clinical aspects.The https://www.metaboanalyst.ca/, accessed on 1 December 2022) and the Metabolic Biological Role (MBRole) . These are online platforms for metabolite annotation enrichment analysis that calculate the p-values with the cumulative hypergeometric distribution by comparing the number of compounds in the set and in the background with a given annotation [p < 0.05 were considered significant. The Human Metabolome Database, Biological Magnetic Resonance and Bruker Biofluid Reference Compound Database Library and the Metaboanalyst 4.0 software were used to confirm the identity, the metabolomic pattern and its correlation with the pharmaco-toxicological parameters of LOS and its EXP3174.To assess the biological roles of the identified metabolites and identify overrepresented pathways in the metabolite list, we used the web-based Metaboanalyst 3.0  [The data obtained from the questionnaires were tabulated using Microsoftue (OSC)  and alsoue (OSC) ,51. The 2 and Q2. R2 = 1 indicates perfect description of the data by the model and Q2 = 1 indicates perfect predictability. In general, Q2 > 0.5 and the difference between R2 and Q2 < 0.3 demonstrate good predictability [Two types of multivariate methods were used for the NMR bucket data. The first method is the unsupervised principal component analysis (PCA) which was used for the detection of anomalous or outlier samples that have to be discarded because they do not satisfy the quality criteria, possibly due to errors during sample collection, preparation, storage and/or NMR measurement. The NMR data of the samples not discarded by PCA were subsequently analyzed by the MSA method of the Orthogonal-Partial Least Squares-Discriminant Analysis (OPLS-DA). Based on their pattern of intensities, those spectral buckets that best discriminate between groups provided the highest values of VIP scores and loading factors in OPLS-DA. A random test with 2000 permutations was performed with the derived OPLS-DA model to confirm the robustness of the method for a model based on the two main components describing the variability of the samples, resulting in the reported values of Rtability . Cross-vp value of the distribution was calculated with the unpaired t-test. The normality of the data was tested by the Kolmogorov–Smirnov normality test. If data underwent the Gaussian distribution performed with Welch’s correction, it was assumed that the standard deviation was not equal, or otherwise, the Mann–Whitney test was used.A univariate analysis was carried out to study the signal intensity of selected NMR buckets with the highest VIP scores and loading factors found in the MSA calculation by OPLS-DA. They are the buckets with the maximum relevance for the group classification achieved by the MSA method. The selected buckets were those with a loading factor comprised of a range from the maximum down to 50% of this value. The distribution of NMR intensities of each of the selected buckets were represented as Boxplots and the 1H patterns of the 750 MHz metabolite ChenoMX® NMR Suite software v8.5 database. A metabolite candidate is obtained when the bucket chemical shift, intensity and signal profile  can be matched to a given signal of a metabolite in the spectral database, and simultaneously, other additional 1H peaks of the metabolite match are compatible with the experimental spectrum. Only those metabolites with favorable matching, and that could be assigned unambiguously, were reported.Metabolite assignment was carried out for each NMR bucket that satisfied the same criterion of selection of the univariate analysis, to identify plausible candidates as biomarkers of the disease. The experimental signal profile and intensity of the chemical shift of the bucket were then matched to the The NMR metabolomics study of plasma samples from hypertensive and hypertensive chronic kidney disease volunteers identified several biomarkers that distinguished the groups of patients. Remarkably, higher levels of trigonelline, urea and fumaric acid compared to the other groups were considered characteristic markers of renal impairment. For patients with systemic arterial hypertension, urea levels were also likely to mark the onset of kidney injury when associated with the high values of blood pressure found.Although the number of subjects was limited within the groups, the statistical model predicted with adequate robustness. 50 of LOS was achieved by solely 50% of hypertensive patients and limited to 21.05% among renal patients, while the therapeutic range was reached by a very limited number of patients in both groups, except for the renal outpatients.Hypertensive and renal patients presented high blood pressure levels before LOS administration, and were classified as high and very high, respectively. Additionally, the ECRegarding the biochemical tests, creatinine and urea were found critically above the normal range among the renal patients, while the hypertensive patients also presented urea values well above the reference range.The differences found by the NMR metabolomic analysis among the groups were in agreement with the blood pressure values and provided relevant and consistent data on the pharmacometabolomic profile and the distinction between the hypertensive and chronic kidney disease groups. The latter was also differentiated according to the different progression levels of the disease. Clinical protocols for the therapeutic monitoring of LOS can be created from the proposed methodology, efficiently assisting in pharmacological treatment, especially for high-risk patients, such as hypertensive and diabetic patients, to avoid or limit the renal impairment in early stages. Moreover, renal patients can improve the treatment outcomes, avoiding the progressive dysfunction caused by the disease, especially in outpatients, while increasing the quality of life and reducing the expenses related to this clinical condition.Personalized medicine to improve the therapeutic strategies and individual follow-up is a modern and necessary approach. In view of the various possibilities that this type of study represents and the results found, there is a need for further investigation, including populational-based studies covering this topic and complementing the findings to understand the mechanisms involved in hypertension, kidney disease, their relationship and to also validate the results found using a new cohort. This improvement would make this methodology useful for clinical practice to assess the response based on molecular biomarkers.


The objectives of this study were to assess the correlation between ORi and PaO2, as well as to determine its ability in detecting mild hyperoxemia in dogs.The oxygen reserve index (ORi) is a real-time, continuous index measured with multi-wavelength pulse CO-oximetry technology. It estimates mild hyperoxemia in humans, which is defined as a partial pressure of oxygen  between simultaneous measurements of ORi and PaO2. The trending ability of ORi to identify dependable and proportional changes of PaO2 was determined. The diagnostic performances of ORi to detect PaO2 ≥ 150 mmHg and ≥ 190 mmHg were estimated using the area under the receiver operating characteristic curve (AUROC). The effects of perfusion index (PI), haemoglobin (Hb), arterial blood pH and partial pressure of carbon dioxide (PaCO2) on AUROC for PaO2 ≥ 150 mmHg were evaluated.This prospective observational study enrolled 37 anaesthetised and mechanically ventilated dogs undergoing elective procedures. Simultaneous measurements of ORi and PaO2 were collected. PaO2 values ranged from 74 to 258 mmHg. A strong positive correlation  was found between ORi and PaO2. The trending ability ORi was 90.7%, with 92% sensitivity and 89% specificity in detecting decreasing PaO2. An ORi value ≥ 0.53 and ≥ 0.76 indicated a PaO2 ≥ 150 and ≥ 190 mmHg, respectively, with ≥ 82% sensitivity, ≥ 77% specificity and AUROC ≥ 0.75. The AUROC of ORi was not affected by PI, Hb, pH and PaCO2.A total of 101 paired measurements of ORi and PaOIn anaesthetised dogs, ORi may detect mild hyperoxaemia, although it does not replace blood gas analysis for measuring the arterial partial pressure of oxygen. ORi monitoring could be used to non-invasively assess oxygenation in dogs receiving supplemental oxygen, limiting excessive hyperoxia. However, SpO2 provides limited information in hyperoxaemic patients, remaining > 98% for arterial partial oxygen pressure (PaO2) > 100mmHg , EtCO2, and FiO2. Other procedures included additionally an electrocardiogram and an oesophageal temperature as basic monitoring. A multiparameter monitor  continuously displayed those parameters. A multi-wave pulse CO-oximeter  constantly showed the pulse wave and the SpO2. Lactate Ringer’s solution  3–5 ml/kg/h was infused IV during the procedure. The arterial catheter 22G  was aseptically inserted into the dorsal pedal or palmar artery after anaesthesia induction for blood pressure measurement and blood collection. A mean blood pressure below 65 mmHg was treated by decreasing the volatile agent; if pressure did not improve after 15 min, a 5 ml/kg crystalloid bolus was infused over 10 min. Inotropes or vasopressors were administered if the previous treatments did not increase the pressure. If a dog received one of those treatments, no further data were collected from that subject until 30 min had elapsed from the end of the treatment.Food, but not water, was withheld 8 h before anaesthesia. Dogs undergoing diagnostic procedures received butorphanol  0.1–0.2 mg/kg alone or mixed with dexmedetomidine 2–4 µg/kg  intramuscularly as premedication before intravenous catheter placement. An animal also received midazolam 0.1 mg/kg . In patients undergoing surgical procedures, methadone  was administered instead of butorphanol for pre-emptive analgesia. General anaesthesia was induced with propofol  2–5 mg/kg intravenously. Following orotracheal intubation, anaesthesia was maintained with sevoflurane  or isoflurane  carried in a mixture of oxygen and air to obtain a FiO–3 cmH2O  The resp2, displayed also ORi and PI. The adhesive sensor  was wrapped circumferentially around the folded tongue and then connected to the CO-oximetry.The multi-wavelength pulse CO-oximeter used to measure the SpO2) was measured by a blood gas analyser  using a multi-parameter cartridge . The blood sample, collected through the arterial catheter into a pre-heparinized syringe  over two to three breaths, was analysed immediately after collection. Two ml of blood were drawn and discarded to avoid sample contamination or dilution, and after sampling the artery was flushed with 1 ml of heparinized solution (10 UI/ml).The arterial partial pressure of oxygen , PI, oesophageal temperature (Temp), FiO2, EtCO2, were recorded. Blood variables measured were: temperature-corrected blood pH, temperature-corrected PaO2, temperature-corrected arterial blood carbon dioxide (PaCO2), haematocrit (Hct), lactatemia (lac), bicarbonate (HCO3−), and calculated total haemoglobin (Hb).All measurements were recorded during the anaesthesia maintenance. There were no fixed time points for data collection, and consecutive measurements were separated by at least a FiOThe pulse CO-oximeter probe was not repositioned between consecutive paired measurements in the same dog.2, with a power of 95% and an alpha of 0.01 and a 25% drop-out rate. All statistical analysis was performed using RStudio  as interface for R . The Shapiro-Wilk test was used to evaluate the normal distribution of continuous parameters. Normally distributed data were expressed as mean ± standard deviation, while non-normally distributed values as median (minimum-maximum).Based on the results of a study conducted on donkeys , an esti2 was analysed using a linear mixed-effects regression model for repeated measurements. The fixed effect in the model were PaO2, as primary variable of interest, and included PI, Hct, and PaCO2 as confounding factors. To account for within-subject correlation across the repeatedly measured data, we introduced dogs as random effects [2, was evaluated with the 4-quadrant plot. The analysis was also used to calculate the sensitivity and specificity of ORi in predicting PaO2 changes, as reported previously [2 between consecutive blood samples was plotted against the delta of the corresponding measurements of ORi. The percentage of data points in the upper right and lower left quadrants over the data points in all quadrants represent the concordance rate. A concordance rate over 90% was judged indicative of good trending ability [The correlation between ORi and PaO effects . “Trendieviously . Briefly ability .2 ≥ 150 mmHg and PaO2 ≥ 190 mmHg was determined using Youden’s index, which aims to maximize the sum of sensitivity and specificity while assigning equal weight to false-positive and false-negative results [2 on the diagnostic performance of ORi in predicting PaO2 ≥ 150 mmHg were estimated using the semiparametric approach described by Farragi [The optimal cut-off point to predict a PaO results . The tes Farragi .


Background and Objective: Infectious diseases continue to be a global burden and their impact is even worse if the patients already have other comorbidities. Because chronic kidney disease is very frequent, affecting 10% of the population, our study aims to explore the impact that infectious events have on its progression. Material and Methods: This is a retrospective, observational study based on a cohort of 238 dialyzed patients from the Nephrology Clinic of “Dr. Carol Davila” Clinical Hospital of Nephrology, Bucharest, who were followed from their first visit for five years, between 1 January 2007 and 1 January 2022. For each of them, the presence of an infectious event and the moment of the initiation of dialysis were recorded. Results: Statistical analysis showed that the patients who had at least one infectious episode were older (p = 0.004), their hemoglobin and lymphocytes were significantly lower  and the time until the initiation of dialysis was lower (p = 0.007). Also, the preservation of kidney function was influenced by the number and the severity of infectious episodes. In the univariate Cox model, the following variables were associated with increased risk of dialysis: advanced age , low hemoglobin , previous diagnosis of chronic obstructive pulmonary disease , presence of hematuria  and increased values of proteinuria  and of serum creatinine measured both at the time of the first visit and at the time of each infectious event . Also, the presence of an infectious episode was associated with a 1.7-fold increase in the risk of dialysis initiation. The independent predictors of survival identified by the multivariate Cox model were age , serum creatinine  and proteinuria  at the time of enrollment, but also the presence of an infectious episode during the patient’s evolution . Conclusions: In the evolution of patients with chronic kidney disease, an active search for individual factors favoring the occurrence of infectious episodes should be taken into consideration to prevent a faster progression toward end-stage kidney disease. One such study was conducted by Ishigami in 2019 and claimed that the risk of hospitalization due to infectious causes increases by 50% in stage G3 of CKD and by two to three times in stages G4 and G5 compared to stage G2 . In addiBecause of these aspects, it becomes necessary to evaluate if only CKD favors the infections, or if the infectious events are also independent risk factors for the progression of the deterioration of kidney function.This is a retrospective, observational study in which we analyzed a cohort of 238 patients from the Nephrology Clinic of “Dr. Carol Davila” Clinical Hospital of Nephrology, Bucharest. We looked for patients who were on dialysis on 1 January 2022 and we followed them from the moment of their first visit to the clinic to the moment of the initiation of the kidney replacement therapy (KRT). However, because each of them had a different time until they reached the end point, defined as the initiation of the KRT, and thus the follow-up period would not have been homogenous, we chose to focus on their first five years of periodic controls to assess who needed KRT and, especially, what infectious events occurred during this time frame.We chose this study design for a few reasons: the most important is that we had easy access to all the information needed for our study, with our aim being just to test what occurs to a patient with an infectious event in the past regarding the progression toward KRT, a fact that does not necessarily need special parameters or advanced laboratory tests that could have been missed in the last 15 years. In addition, in this way, we were able to create a large enough cohort in a relatively short time, which allowed us to carefully analyze the follow-up parameters, including what we were particularly interested in, namely the occurrence of infectious episodes.Initially, we included all the patients that were dialyzed on 1 January 2022, and the cohort comprised 404 persons. However, after careful analysis, we excluded 150 of them either because they did not come periodically for the control, or the time intervals between the check-ups were over six months, which was considered to be too much to obtain relevant information about an infectious event. In addition, those under the age of 18 at the time of first presentation to the clinic and those with a kidney transplant, which meant another 16 patients, were also excluded, and, therefore, the final cohort was represented by 238 patients. The first visit of the patients in the clinic ranged from 1 April 2007 to 31 December 2016, which allowed for each of them to have five years of follow-up until 1 January 2022, considered the end of this study. Also, the end point was considered either the initiation of KRT, if this occurred before completing five years of follow-up, or the end of this time frame, so that the follow-up period was homogenous.The following parameters were recorded: age, sex and comorbidities, also evaluated using the Charlson score; complete blood count and values of the inflammation parameters at the first visit to the hospital; the presence of infectious episodes, classified according to severity into mild, moderate and severe; the microorganisms involved; the prescribed antibiotic treatment; episodes of septic acute kidney injury; and the need to initiate kidney replacement therapy (KRT). The information about the infectious events was obtained in multiple ways: the most frequent one is that the patients presented directly in our clinic for investigations and treatment when such an event occurred and we used our own clinical and laboratory results; another one is by using the information provided to the patients when he/she was discharged from other hospitals, information that has been recorded in our documents at each visit.The main hypothesis of this study is that an infectious episode occurring in a patient with CKD leads to a faster progression toward end-stage kidney disease and the need for KRT initiation, with all the consequences involved. To test this hypothesis, we evaluated the statistically significant differences between those with and without infections using the Mann–Whitney U test and Fisher’s exact test, we built Kaplan–Meier survival curves, we performed univariate Cox regression to identify the risk factors for KRT initiation, and last, but not least, we included the significant variables obtained from the univariate analysis in a multivariate Cox model to identify the independent predictors of KRT initiation in the cohort.p-value measures the differences between groups and was obtained using the statistical tests detailed below. The end point is defined as the moment at which KRT is initiated during the follow-up period , all the other variables had an abnormal distribution and are reported as the median and inter-quartile range (IQR). The first 11 variables presented in the table below have the values recorded at the time of the first visit. Also, in the last column, the p period .The first step was to analyze the differences between those with and without infections using the Mann–Whitney U test, to compare the values of continuous variables, and Fisher’s exact test, to compare the values of categorical data. We used the Mann–Whitney U test because the data in our cohort had an abnormal distribution.p = 0.004; hemoglobin and lymphocytes were significantly lower: p = 0.03 and p = 0.02, respectively; females were more likely to have an infectious event: p = 0.01; hematuria and leukocyturia at the time of the first visit were also more frequent: p = 0.01 and p = <0.001, respectively; the time until the end point was lower: p = 0.007; the initiation of KRT was more frequent: p = 0.004; and, as expected, the final glomerular filtration rate was lower in the group with infections: p = 0.017. A crucial aspect that should be emphasized is that there were no differences between groups regarding the initial stage of CKD, the etiology of CKD and the risk group calculated based on serum creatinine and proteinuria, as a heterogeneous distribution of these variables could have led to erroneous conclusions, because it is expected for a person in a more advanced stage, in a higher risk group or with a specific etiology of CKD to reach the end point faster. Also, except for COPD, which was more frequent in those who underwent an infectious episode, p = 0.008, the other comorbidities evaluated  were equally distributed in the groups too.The following variables were significantly different in the group of the patients that experienced at least one infectious event: age was significantly higher: Mild infections: did not require hospitalization for treatment, were self-limited or required a short course of antibiotic therapy (less than 5 days). The inflammatory syndrome was minimal or absent. Among these, the following were identified in our patients: asymptomatic bacteriuria, cystitis, dental infections, uncomplicated upper-respiratory-tract infections and gastritis.Moderate infections: inflammatory syndrome present , required hospitalization or occurred during hospitalization and had the potential for progression in the absence of antibiotic treatment. Among them, the following were identified in our group: orchiepididymitis, prostatitis and post-operative infections of soft tissue.Clostridioides difficile, pyelonephritis and acute lower-respiratory-tract infections. In our study, we excluded viral infections such as those caused by hepatitis B or C or HIV due to the multitude of different possible patterns of glomerular injury associated with them, each with a different evolution toward end-stage kidney disease. On the other hand, viral infections causing upper- or lower-respiratory-tract infections were not excluded, but we could not properly identify which virus was involved specifically.Severe infections: had significant inflammatory syndrome , required hospitalization and prolonged antibiotic therapy, and patients often presented with altered general condition. Severe infections are also considered life-threatening. Among them, the following were identified in our patients: sepsis, endocarditis, cholecystitis, enterocolitis due to In our cohort, 117 patients had at least one infectious episode. To be able to assess the impact on kidney function as precisely as possible, the infections were classified according to severity, using the following criteria :Mild infIn the evolution of each patient, the occurrence of a maximum of three infectious episodes was followed, documented by the type of infection, the microorganism involved, when it was possible, and the impact on kidney function estimated based on serum creatinine. For those patients in whom more than three infectious episodes were identified (24 patients), a separate column was filled in, without further details.Kaplan–Meier survival analysis reported that there is a significant difference in 5-year survival without the need for KRT between those with and without infections, p(Log-Rank)—0.005, much lower in the group that experienced at least one infectious episode .Also, the severity of infectious events is associated with a lower survival time of kidney function. The differences appear between the absence of any type of infection and the occurrence of a mild (p Log Rank 0.007) or severe one (p Log Rank 0.043). Interestingly, in this cohort, there was no significant difference regarding moderate infectious events, most probably because the number of these was not large enough .On the other hand, the survival of kidney function does not appear to decrease with the number of infectious events, with the only significant difference being between no infection during follow-up and only one such event—p Log Rank 0.010 .Last, but not least, in our cohort, the presence of a septic acute kidney injury was not associated with a lower kidney function survival during follow-up, most probably due to the small number of such events in our group—p Log Rank 0.072.To determine the risk of each variable being associated with reaching the end point faster, the univariate Cox model was used, with the following results: from the values recorded at the moment of the first visit in the clinic, advanced age, low hemoglobin level, the diagnosis of chronic obstructive pulmonary disease, the presence of hematuria, as well as increased values of proteinuria/day and serum creatinine were associated with increased risk of KRT initiation during the 5-year follow-up period. Also, the presence of an infectious episode during follow-up was associated with a 1.7-fold increase in the risk of initiating KRT. Among the types of infections registered in the cohort, only the first episode showed significant associations, as follows: lower-urinary-tract infections increase the risk by 1.9 times and acute lower-respiratory-tract infections increase the risk by 3.6 times. Also, increased values of serum creatinine at the time of the onset of infections are associated with an increased risk of KRT .Lastly, these variables were included in a multivariate Cox model to be able to determine the independent predictors of the survival of kidney function. After analysis, it was found that they are represented by serum creatinine and proteinuria measured at the time of enrollment, which are also validated, well-known predictors of CKD progression, but also the age and the presence of an infectious episode during the patient’s evolution, without, however, the ability to specify, based on the data of this cohort, which type of infection predisposes the patient to reaching end-stage kidney disease quicker. The precise statistical values are presented in This study has confirmed that an infectious event that appears in the evolution of a patient with chronic kidney disease has the independent capacity to induce a more rapid progression toward end-stage kidney disease and, consequently, the necessity of KRT. Another important aspect of this study is that there are no differences between the stages of the CKD, the risk group or the etiology of CKD at the time of the first visit between those who experienced an infectious event and those who did not, a fact that allows us to draw correct conclusions.On the other hand, this article has a few limitations.First of all, the cohort is not very large, which does not allow a better exploration of the impact on the survival of the kidney function of each type of infection and, therefore, of the microorganisms involved. However, it allowed a good follow-up of the patients, as well as of the treatments performed and biological parameters. Also, because this study is unicentric, carried out in a tertiary center focused on the study of kidney diseases and includes a reasonable number of patients, it provides results that can be extrapolated for the kidney and infectious pathology in this area of the country.Secondly, being a retrospective study, we can assume that the patients experienced more infectious events that could not have been captured, in both of the groups, which, again, can have a significant impact. In addition, the treatment, even though we recorded it for each infectious event, could not be statistically evaluated, because the compliance of the patients could not be controlled at an acceptable level of trust. Because of this aspect, in many cases, it is possible that the progression of CKD to be due to the persistent inflammatory state induced by chronic infection.Last, but not least, the nephrotoxicity of antibiotics can play a key role in patients with infectious events, because studies argue that they are prescribed in up to 64% of cases in much higher doses and they can affect the kidney through multiple routes: interstitial nephritis, direct tubular toxicity, immune dysfunction and decreased renal perfusion ,10.The mechanisms that lie behind the fact that an infectious event can lead to a faster progression toward ESKD are yet to be fully understood, but it is supposed that the main causes are related to persistent infection, genetic alterations of the complement pathways, tubulointerstitial changes and pre-existent kidney damage . Also, aAlso, this study confirmed the importance of the classical predictor factors for the progression of chronic kidney disease—serum creatinine and proteinuria at the baseline. Of these two predictors, proteinuria is linked to the activation of inflammatory and fibrotic pathways that lead to glomerulosclerosis and advanced CKD, but also to an increased risk of infection . In addiOther useful markers that evaluate the progression of CKD have been proposed, like cystatin C; neutrophil-gelatinase-associated lipocalin (NGAL); kidney injury molecule 1 (KIM-1), also considered one of the links between acute kidney injury and CKD; or liver-type fatty acid binding protein (L-FABP), which is correlated with the tubulointerstitial damage, but also claimed to be even more sensitive than proteinuria in predicting the progression of CKD, although with a lower specificity ,20,21,22The results of this study demonstrate that the presence of an infectious episode in the evolution of a patient with CKD is an independent predictor of the survival of kidney function, along with the well-known, classical predictor factors—serum creatinine and proteinuria at the time of enrolment. Also, the severity and the number of infectious events influence the preservation of kidney function, with mild and severe infections having the greatest impact. On the other hand, the occurrence of septic acute kidney injury does not seem to have an impact on the evolution of kidney function degradation, a fact that can be explained by the small number of these events in our cohort.Correlating these aspects with the one presented in the literature, according to which the risk of death from an infectious cause increases as kidney function deteriorates, all patients have to be instructed not to treat infectious episodes superficially, and, from the moment they occur, be followed more closely and at shorter intervals. Patients should also be advised to stop any nephrotoxic medication/supplement to minimize the negative impact of cumulative offending factors, and clinicians should be advised to carefully adjust the doses of antibiotics to the kidney function. In addition, supplementary tests should be taken into consideration after the initial infectious episode to ensure that the infection was really cured.Further research is needed to confirm the findings of our study and, in the future, to provide better insight into the mechanisms that lead to the progression of CKD and into the most useful biomarkers that can be used to evaluate the patients.