Autonomic and vascular failures are common phenotypes of sepsis, typically characterized by tachycardia despite corrected hypotension/hypovolemia, vasopressor resistance, increased arterial stiffness and decreased peripheral vascular resistance. In a 5-day swine experiment of polymicrobial sepsis we aimed at characterizing arterial properties and autonomic mechanisms responsible for cardiovascular homeostasis regulation, with the final goal to verify whether the resuscitation therapy in agreement with standard guidelines was successful in restoring a physiological condition of hemodynamic profile, cardiovascular interactions and autonomic control. Twenty pigs were randomized to polymicrobial sepsis and protocol-based resuscitation or to prolonged mechanical ventilation and sedation without sepsis. The animals were studied at baseline, after sepsis development, and every 24 h during the 3-days resuscitation period. Beat-to-beat carotid blood pressure (BP), carotid blood flow, and central venous pressure were continuously recorded. The two-element Windkessel model was adopted to study carotid arterial compliance, systemic vascular resistance and characteristic time constant τ. Effective arterial elastance was calculated as a simple estimate of total arterial load. Cardiac baroreflex sensitivity (BRS) and low frequency (LF) spectral power of diastolic BP were computed to assess autonomic activity. Sepsis induced significant vascular and autonomic alterations, manifested as increased arterial stiffness, decreased vascular resistance and τ constant, reduced BRS and LF power, higher arterial afterload and elevated heart rate in septic pigs compared to sham animals. This compromised condition was persistent until the end of the experiment, despite achievement of recommended resuscitation goals by administered vasopressors and fluids. Vascular and autonomic alterations persist 3 days after goal-directed resuscitation in a clinically relevant sepsis model. We hypothesize that the addition of these variables to standard clinical markers may better profile patients’ response to treatment and this could drive a more tailored therapy which could have a potential impact on long-term outcomes. The initial compensatory increase of sympathetic outflow to the heart and peripheral vessels has been shown to become detrimental to the successful correction of hypovolemia and hypotension if prolonged8. A sustained sympathetic overstimulation is a common phenotype in septic patients, proved also by the high concentration of circulating catecholamines, and it has been found significantly associated to a higher risk of mortality and morbidity12. This condition of adrenergic stress is not routinely targeted during sepsis resuscitation, although it may be a crucial determinant of many complications secondary from sepsis, such as septic cardiomyopathy, vasopressor resistance, immunomodulation and generally organ dysfunctions15. In particular, the vascular endothelium regulates the vascular tone, haemostasis and/or vascular permeability, and arterial vascular functions have been reported to be severely impaired during sepsis16; recent direct and indirect evidence suggests that sympathetic overactivity and vascular dysfunction may be closely and causally related to each other in a very complex fashion17. For example, sympatho-excitatory manoeuvres have been shown to induce endothelial dysfunction and they typically lead to increased stiffness of large arteries19; on the other side, stiffer arteries may alter the baroreflex function, thus interfering with the sympathetic control of smooth muscle vascular tone20. Furthermore, the α1-adrenergic receptors, mainly located in the peripheral vessels, may undergo the desensitization process, a feedback mechanism to protect the receptor against overstimulation, and this further contributes to the failure of autonomic modulation of vascular tone and a less effectiveness of vasopressor therapy21. Finally, experimental evidence indicates that the sympathetic ANS is critically influenced, both at central and peripheral level, by the most relevant factors regulating vascular functions, such as nitric oxide (NO), reactive oxygen species (ROS), and endothelin, that are all known to be involved in the dysregulated inflammatory response to sepsis and septic shock16.The autonomic nervous system (ANS) plays a central role in maintaining cardiovascular homeostasis both in physiological and pathological conditions; there is, indeed, a large body of research works reporting a failure of the cardiovascular autonomic control mechanisms during sepsis and septic shock23. However, the limited period of observation after the full resuscitation has not permitted to obtain conclusive results, but only an indication about the short-term effects of resuscitation, i.e. about 5/6 h after the resuscitation procedure.Previous studies of our group have proposed several indices able to highlight the cardiovascular autonomic dysfunction in different experimental populations during septic shock resuscitation, and we hypothesize that the introduction of these indices to standard therapy targets, such as mean arterial pressure, lactate, and oxygen saturation as suggested by the international SSC guidelines, could be helpful to better evaluate the therapy effectiveness in restoring circulatory characteristics and cardiovascular regulatory mechanisms and to implement an improved resuscitation strategyThe aim of this work is to characterize the arterial properties and the autonomic cardiovascular response in a long-term swine experiment of polymicrobial sepsis, in order to investigate whether the standard resuscitation therapy was successful in restoring a physiological condition of hemodynamic profile, cardiovascular interactions and autonomic control. Moreover, the analyses exploited the long-time window after resuscitation (72 h) to disentangle and explore possible differences in the early and late response to the therapy.The animal experiment was carried out in collaboration with the Inselspital University Hospital of Bern, Switzerland, and was performed in accordance with the EU Directive 2010/63/EU for animal experiments and the ARRIVE guidelines for animal research, and with the approval of the Animal Care Committee of the Canton of Bern (BE103/16).O2 at 30%, PEEP at 5 cmH2O, tidal volume at 8 mL/kg, and respiratory rate at 20 breaths/min and later adjusted with the goal to keep pH between 7.35 and 7.45 and PaCO2 between 35 and 45 mmHg. Gastric output was measured by a gastric probe inserted into the stomach and used also for the later enteral nutrition infusion. During surgical preparation, ringer lactate (RL) solution was infused at 3 mL/kg/h, and measurable blood loss was 1:1 replaced with RL. Rocuronium was administrated (30–50 mg as bolus) only during instrumentation if necessary for better exposure . After surgeries, 10 mL/kg RL was infused as bolus to all animals to prevent hypovolemia.Twenty mechanically ventilated and sedated domestic pigs  were used for the experiment. Ketamine (20 mg/kg) and xylazine (2 mg/kg) were intramuscularly administered for animal sedation. General anaesthesia was induced by intravenous infusion of midazolam (0.5–1.0 mg/kg) and atropine (0.02 mg/kg) and maintained with propofol (4–10 mg/kg/h) and fentanyl (3–20 g/kg/h), standard drugs for sedation and analgesia also in critically ill patients. Additional bolus of propofol (20–40 mg) and fentanyl (50–200 g) were administered if necessary, according to sedation depth evaluated hourly by noise pinching and presence of spontaneous movements. After tracheal intubation, the pigs underwent mechanical ventilation in volume-controlled mode, initially with FIThe animal was placed in a supine position for instrumentation, a midline neck incision was performed to allow placement of an arterial catheter  in the left carotid artery, a pulmonary artery catheter  via left external jugular vein, a venous catheter in the left internal jugular vein  for volume infusion, a triple-lumen catheter  in the right internal jugular vein, and a flow probe  around the right carotid artery. Thereafter, a midline laparotomy was performed for placement of a catheter into the urinary bladder for drainage and measurement of urine output. Also, a large-bore drainage tube was placed intraperitoneally for induction of fecal peritonitis.2 saturations were measured continuously with a Vigilance monitor or intermittently with a blood gas analyzer . Blood flows were measured with ultrasonic transit time perivascular flowmeters using double-channel TS 140 420 flowmeters . The signals of all the pressures and blood flows were recorded at 100 Hz by a data acquisition system . More details can be found in24.All pressures were measured and displayed on a multi-modular monitor . Continuous cardiac output  was measured with a Vigilance monitor , and Op > 0.05, not published). Sepsis was induced by peritoneal instillation of 2 g/kg of autologous feces dissolved in 250 mL warmed glucose 5% solution. After 8 h of observation without resuscitation, another set of blood samples was collected (T2). During stabilization and observation periods, RL infusion rate was reduced to 1.5 mL/kg/h. Before peritonitis induction, to avoid hypovolemia, a bolus of 150 mL of RL was infused to all animals and repeated until there was no fluid response (i.e. increase in cardiac output or stroke volume ≥ 10% after 10 min of fluid bolus). Then, the protocol-based resuscitation was started and continued for approximately 76 h , including fluid infusion, vasopressor support, electrolyte maintenance, antibiotic therapy, and reduction of body temperature. During the resuscitation period, a basal infusion with RL solution, glucose solution (G50%) and enteral nutrition (36 h after RP) was maintained at 3.0 ml/kg/h. Additional fluid boluses were given to treat hypovolemia. In particular, after 150 ml bolus of RL was given, if cardiac output or stroke volume increased by more than 10%, the fluid response was considered positive, and a repeated fluid bolus was given. This was repeated until the bolus resulted in a negative fluid response. If correction of hypovolemia was not sufficient to keep the mean arterial pressure above 65 mmHg, a continuous infusion of noradrenaline was started to keep the blood pressure at this level, as suggest in the 2013 sepsis guidelines25, which were the only available at the time this experimental protocol was designed.Instrumentation was followed by a one hour stabilization phase, during which no manipulation on the animal was allowed, thereafter baseline blood samples were taken (time point T1). Subsequently pigs were randomized to fecal peritonitis (SS n = 10)/sham (SH n = 10) and to groups with/without abdominal negative pressure therapy, which was the objective of a separate study with no influence on systemic and splanchnic hemodynamics nor abdominal organ function  was ≤ 50%, dobutamine administration was started at a dose of 5 mg/h. This dose was increased by the same amount every 30 min until the SvO2 was 50% or higher or until a maximal dose of 20 mg/h was reached. The sepsis guidelines from 2013 suggested dobutamine infusion in the presence of myocardial dysfunction or ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure25. As a surrogate of low cardiac output, we used mixed venous oxygen saturation which represents the body’s oxygen reserve by taking into account not only cardiac output, but rather systemic oxygen delivery in relation to oxygen consumption.If the mixed venous oxygen saturation  was used as an antibiotic. Liquemin 10000 IU/24 h was infused IV to prevent deep vein thrombosis. If core temperature exceeded 39.5 °C, the animal was cooled by fan, lowering of room temperature, alcohol spray and ice bags. Further blood samples were taken just before RP + 24 h (T3), RP + 48 h (T4) and two of hours after RP + 72 h (T5). At the end of the experiment animals were euthanized by bolus infusion of 40 mmol of potassium chloride. Further details can be found in28. The following beat-to-beat time series were derived from ABP signals: systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), pulse pressure (PP), and heart period (HP), defined as the time difference between consecutive onsets . Beat-to-beat mean CBF was also computed. Continuous cardiac output (CCO) and central venous pressure (CVP) were averaged on each HP time interval to get beat-to-beat series. Beat-to-beat values of carotid stroke volume (carotid SV) was assessed from CBF by integrating it over each heart cycle by means of the trapezoid method; beat-to-beat values of global stroke volume  were computed as All signals were continuously recorded for the entire duration of the experiment. The time points used for blood analyses were considered as reference to identify and select stationary portion of signals (5–10 min) for successive analyses. The carotid arterial blood pressure (ABP) and blood flow (CBF) were analysed and the onsets of each heart pulse were identified using available algorithmsANS cardiovascular control was evaluated by estimating the power spectral density of DAP component and the cardiac baroreflex sensitivity (BRS). The time series of DAP values were resampled at 2 Hz to obtain evenly spaced signals, successively were detrended using a 10th order polynomial function, and then normalized by dividing the detrended signal by its standard deviation in order to have zero-mean oscillations and unitary SD. The stationarity of the resulting time series was assessed by the Kwiatkowski-Phillips-Schmidt-Shin (KPSS) test. Power spectra were estimated via autoregressive spectral analysis. Spectral indices were computed as low-frequency power , total power (TP), which is the total area under the spectrum, and the normalized LF power, i.e. LF/(TP-VLF)%, where VLF is the very low frequency power [0–0.04 Hz].29 was adopted to estimate the cardiac BRS on the time series of SAP and HP which were resampled at 2 Hz. We decided to restrict the analysis of BRS only to the LF component of the feedback gain, since this component gives indications on the sympathetic activity30. The autonomic cardiovascular indices were computed over 2-min windows with 50% overlap and then averaged.The bivariate closed-loop model method31. The method proposed by Mukkamala and colleagues32 estimates the exponential decay over pretty large windows (6 min) so to avoid cumulative effects of the wave reflections, which are attenuated in the central ABP waveforms only. More specifically, the ABP response to a single, solitary cardiac contraction is estimated from the ABP waveform. Then, the Windkessel time constant is measured by fitting an exponential to the tail end of this estimated response once the faster wave reflections have vanished. We adopted this method for a robust estimate of The arterial tree was modelled as a two-element Windkessel model, and several indices were derived to characterize its properties. The Windkessel time constant 33; we thus computed the beat-to-beat carotid arterial compliance (cAC) as Arterial compliance is defined as the change in arterial blood volume due to a given change in arterial blood pressure31. We named systemic vascular resistance (SVR) the estimate obtained with the global CCO, and carotid vascular resistance (carotid VR) the estimate obtained with the CO computed from the carotid SV (CO = SV*HP). Both vascular resistance indices were then normalized by the animal weight:We calculated the vascular resistance, previously named TPR, with two different approaches based on the Windkessel modelThe indices of vascular resistance and cAC were computed on a beat-to-beat basis and then averaged at each time point. The index 34 proposed an estimate of Ea from a blood pressure measurement recorded in a peripheral vascular district; they proved that, given a reliable SV measurement, the ratio MAP/SV provides a robust Ea surrogate over a wide range of hemodynamic conditions and is interchangeably in any peripheral artery. In this case MAP is proposed as a surrogate for the left ventricular end-systolic pressure (LV ESP). We similarly estimated Ea by using carotid artery pressure and carotid stroke volume according to Eq.  is considered a simple estimate of total arterial load. Monge Garcia et al.Ea was computed on a beat-to-beat basis and then averaged at each time point.9/L), leukocytes , creatinine , prothrombin time , bilirubin (µmol/L), ammonia (µmol/L), and band neutrophils . Finally, high sensitive cardiac troponin I  was measured from plasma samples using a specific ELISA kit  to have an indirect measure of cardiac stress.The overall dosages of fluids and vasopressors (VP) were calculated by summing up the dosage from the start of the experiment to each time point. The only vasopressor administered was noradrenaline (100 μg/mL and 200 μg/mL), and the fluids used were NaCl 0.9%, ringer lactate and glucose solution (G50%). Urine output UO (mL) was retrieved as the cumulative amount from the start of the experiment until each time point. Fluid balance (mL) was computed as the difference between the amount of intravenous fluids given and UO at each time point. The amount of sedative drugs (propofol and fentanyl) was computed as cumulative dosage at each time point. VP, fluids, UO, fluid balance and sedation amount were normalized to the animal’s weight. We also considered the following parameters: mixed venous oxygen saturation , hematocrit , hemoglobin , platelets  at T2 were excluded from the statistical analyses.35 despite developing all the criteria for a septic shock and tissular hypoperfusion36. According to the surviving sepsis campaign guidelines from 201325, which were the only available at the time this protocol was designed, severe sepsis was defined as sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion; our porcine sepsis phenotype is therefore compatible with this definition. Moreover, the hypotensive state together with the systemic inflammation triggered a tachycardic condition in SS pigs, that was characterized by a significantly higher HR compared to SH at T2 38.In this study we evaluated the effect of sepsis development and protocolled resuscitation on autonomic mechanisms for cardiovascular control and arterial vascular properties during a 5-day swine experiment. Our results generally confirmed previous studies39. Indeed, the raised cardiac troponin I observed in septic pigs . All together these results point out that the vascular alterations occurring in the early phase of sepsis development characterize not only the first hours of therapy administration, when recovery from hypotension is of primary importance and massive fluids and vasopressors infusion are crucial for survival, but they persist also after days, when hemodynamic stabilization of the patient has been achieved. Long-term post-ICU disabilities are known to occur commonly in sepsis survivors, leading to a higher risk for future cardiovascular adverse events or hospital readmission46. Our results support the hypothesis that the persisting arterial stiffening plays a major role in this process, and a timely intervention to limit this phenomenon could positively impact the long-term outcome of septic patients. For example, in a previous experimental study23 we observed an improvement in compliance and τ values when septic shock pigs were treated with the adjunction of esmolol in comparison to septic pigs treated with fluids and noradrenaline only. The potential anti-inflammatory effect of esmolol together with its adrenergic antagonist effect could explain the improvement of vascular properties, as the proposed indices showed.Acute inflammation and sepsis are known to impair endothelial functions and to induce a stiffening of large compliant vessels, such as the aorta47, Ea was proposed as a steady-state arterial parameter that expresses all the extracardiac forces opposing to ventricular ejection, and incorporating peripheral resistance, characteristic impedance, total lumped arterial compliance and also systolic and diastolic time intervals; therefore, it is a net measure of ventricular afterload or arterial load. The gold-standard method to estimate Ea consists in the left ventricular pressure–volume analysis and Ea is estimated as the ratio of left ventricular end-systolic pressure (LV ESP) and stroke volume. However, given the increasing interest in using this index in critical care medicine, surrogates for LV ESP have been proposed and validated, in particular, from commonly available measures such as arterial peripheral pressure, in this study LV ESP was approximated with the mean arterial pressure34.The increase in arterial stiffness may also help to explain the higher cardiac afterload in SS pigs compared to SH, measured from the effective elastance Ea index. In the original publication of Sunagawa et al.48. Several studies have reported that septic patients may often exhibit VA uncoupling50. Generally, uncoupling reflects a reduction in LV ejection efficiency, which can promote LV energetic failure and a condition of overall cardiovascular inefficiency. In the present study the LV elastance was not available, so we could not compute VA coupling. We can only speculate about possible mechanisms explaining the reduction in SV observed in SS pigs: it could be the result of a cardiac inability to cope with the elevated afterload (e.g. due to inotropic dysfunction), and tachycardia could thus reflect a compensatory mechanism in order to increase CO to meet the metabolic needs. On the contrary, reduced SV could be secondary to the elevated HR, the latter caused by autonomic chronotropic dysfunction. However, our data clearly indicates that 3 days of therapy administration were not able to restore the hemodynamic baseline condition in SS pigs, hinting that the overall cardiovascular system has been altered.Higher values of Ea indicates higher “load” against which the heart must eject blood. This may lead to ventriculo-arterial (VA) uncoupling, depending on the cardiac reserve (cardiac preload and ventricular contractility)52. In our study, SVR was low in SS pigs, despite substantial amounts of vasopressor infused during the experiment, as shown in Fig. 53, and suggests that the overall hemodynamic response to sepsis therapy is highly dependent on the complex interaction between triggered inflammatory processes and drug therapy. In particular, the elevated burden of adrenergic stress derived from massive administration of noradrenaline may contribute to increased vascular stiffness, arterial afterload and HR. This prolonged adrenergic stress condition has been associated with increased overall mortality risk54. Moreover, large scientific evidence has reported a decreased arterial compliance in response to a sympathetic stimulation57, and in a recent clinical observational study58, elevated doses of noradrenaline were found to increase arterial characteristic impedance, pulse wave velocity , and reflection phenomena, while reducing aortic compliance. Conversely, reduced arterial compliance may interfere with the autonomic baroreflex mechanism by mechanically reducing baroreceptors sensitivity. We reported a decrease in carotid compliance, so we can reasonably suppose that the carotid baroreceptors may have been significantly affected. The loss of baroreceptors sensitivity is a potential mechanism explaining the reduced BRS observed in SS pigs compared to SH  to induce vasoconstriction of arterial blood vessels, which usually causes a rise in blood pressure and vascular resistance; (ii) to induce an increase in preload due to venoconstriction and a redistribution of blood from unstressed to stressed volume; this leads to an increase in stroke volume and, consequently, in cardiac output; (ii) to increase cardiac contractility but to only minimally affect heart rate, i.e. initial transient increase through β1-receptors stimulation followed by a decrease due to activation of baroreceptors and vagal-mediated slowing of heart rate in response to the elevation in arterial pressure38. However, our experiment reflects the common clinical practice which is still today to increase blood pressure above 60–65 mmHg in critically ill patients; a survey from 2010 showed that > 87% of all responding critical care physicians would have used norepinephrine to increase blood pressure “almost always” or “mostly” in a patient with severe sepsis, even without knowing lactate concentration59. It could be argued that extrapolating a target blood pressure used clinically without a solid scientific foundation to an animal model exposed to vasodilatory drugs, i.e., dobutamine, as needed based on our research protocol, makes our findings less translationally relevant. However, none of the septic animals received dobutamine, since their mixed venous oxygen saturations were always above the threshold for the use of this drug. The achievement of blood pressure targets does not necessarily guarantee a sufficient organ perfusion, which is the main goal for sepsis resuscitation. For this reason, we think that blood pressure targets could be redefined, depending on negative autonomic and vascular effects evolving with vasopressor use.The use of noradrenaline for hypotension guided by the SSC guidelines and dobutamine for low mixed venous oxygen saturation without documentation of hypoperfusion, i.e., hyperlactatemia, in this model could be challenged. Despite the SSC recommendation, the evidence that supports a specific mean arterial pressure target is weak. In fact, the most recent guidelines recommend a specific blood pressure target if the patient is on a vasopressor agent, with no specific recommendation on the timing for vasopressor therapy60. The proposed study analyzed the experimental data retrospectively, without the possibility to do any active interventions.An opportunity could have been to test alternative approaches to guide hemodynamic management in this experimental setting, for example, by using measurements based on organ perfusion. However, the original protocol has been designed to particularly evaluate the contribution of specific nursing manoeuvres on organ dysfunction during sepsis resuscitation61.The septic animals were treated only with antibiotics for the peritonitis, and this may not reflect clinical practice in which surgical interventions are considered to eradicate the source of infection. However, in our setting, there was no bowel leak which would have allow sustained leakage of feces into the peritoneal cavity. We chose our experimental setting because we demonstrated earlier that this model mimics sepsis-induced organ failure and allows to study the pathophysiology and effects of treatment over several daysThis work confirmed evidence from previous studies showing that sepsis induces severe vascular and autonomic alterations, as demonstrated by reduced carotid compliance, systemic vascular resistance and arterial time constant τ, increased arterial load, and depressed arterial baroreflex sensitivity. Despite hemodynamic stabilization, reduced inflammation, and achievement of the recommended hemodynamic targets, such as, e.g., MAP > 65 mmHg, the observed alterations persisted even after 3 days of successful therapy, potentially explaining the next development of sepsis-related cardiovascular disease. In particular, increased concentrations of circulating cardiac troponin I, enduring even after days of successful therapy, may be a useful marker for stratification of patients at higher risk to develop long-term cardiac complications.62, and these indices may be additional markers to help clinical decision making in this setting. The proposed indices are based on routinely recorded waveforms so they can be computed without additional setup, this makes them ideal candidates for a real-time bedside monitoring of cardiovascular alterations.Although the proposed indices cannot explain the source of the observed cardiovascular derangements, they are able to capture the macroscopic phenotype of vascular and autonomic dysfunctions, therefore, they may be used as markers of the global cardiovascular response to sepsis and the administered/recommended treatment. In the future, they may be used to guide the vasopressor dosage in order to balance the beneficial and harmful effects of such treatment. For example, they may be exploited in the setting of adrenergic stress monitoring: if increasing dosage of adrenergic vasopressor does not result in adequate improvements of blood pressure but exacerbates autonomic and vascular dysfunction, it may be read as a signal of harm for the patient and dosing tapering or a multimodal vasopressor strategy could be considered. There is a urgent need for a new tailor, multimodal vasopressor therapy strategy in septic shock patientsMoreover, the proposed indices can better detail the patient’s response to treatment, and they could be useful to evaluate the effectiveness of different therapeutic options at the cardiovascular level, overcoming the limitations of using global hemodynamic end-points. The evaluation of different treatments for septic shock resuscitation , could take advantage of these indices which may contribute in identifying possible cluster of patients who will benefit from these therapies and in clarifying possible mechanisms at the origin of a hopefully better outcome.Supplementary Information.


Studies of the impact of fetal intervention through vesicoamniotic shunting are marred by a device malfunction rate of up to 60%. In this study, we delineate the postnatal course and infant kidney function following definitive urinary diversion This is a retrospective, single-center cohort study of 16 male infants who survived the fetal intervention to birth, from 2010 to 2014 at a single center. All had patent shunts in place at birth. Perinatal and biochemical characteristics were collected with patients followed for one year, or until demise, with serial measures of serum creatinine (SCr) and serum cystatin C (CysC).3 . All neonates were born preterm [median 34 weeks ] and the majority with low birth weight [median 2340 grams ]. 63% required positive pressure ventilation. Advanced chronic kidney disease stage 4–5 at 1 year of age was predicted by neonatal characteristics: peak SCr ≥2 mg/dl, time to peak SCr > 6 days, discharge SCr ≥1.0 mg/dl, CysC ≥2.5 mg/l, urine protein:creatinine ≥4.8 mg/mg, urine microalbumin:creatinine ≥2.2 mg/mg. In infancy, a nadir SCr ≥0.5 mg/dl occurring before 160 days (5.3 months) of age was also predictive of advanced chronic kidney disease stage 4–5 at 1 year. Three patients died in the neonatal period, with 1 receiving kidney replacement therapy (KRT). Three additional patients required KRT before 12 months of age.Of the 16 males, 81% were non-white . Shunts were placed at a median of 20 weeks  gestation, with median fetal bladder volume of 39 cmEven with definitive vesicoamniotic shunting for cLUTO, postnatal morbidity and mortality remain high, emphasizing the role of renal dysplasia, in spite of urinary diversion, in postnatal kidney dysfunction. Neonatal and infant biochemical parameters exhibit distinct trends that offer families and physicians a better understanding of the prognosis of childhood kidney function. The antenatal diagnosis of fetal cLUTO is based on the identification of megacystis, with a fetal bladder diameter greater than 7 mm by screening anatomical ultrasound  includes the three most common diagnoses of posterior urethral valves (PUV), urethral atresia and Eagle-Barrett syndrome, with respective prevalence rates of 64%, 32% and 4% . The inctrasound . Even thtrasound . This detrasound . Furthertrasound . HoweverIn spite of advancements in prenatal diagnosis and novel fetal interventions such as VAS and cystoscopy, kidney functional outcomes have not shown to be significantly impacted in cLUTO . This suThis study aims to delineate the impact of VAS on a cohort of infants with severe cLUTO, who were all born with mechanically functional shunts. The trends in biochemical characteristics are compared between those children with CKD stage 1–3 vs. 4–5 at one year of life, to guide future medical practice and the approach to KRT in this vulnerable population.With institutional review board approval, a retrospective cohort analysis of all infants born live following fetal vesicoamniotic shunting from January 2010 through December 2014 was performed at a single center. All infants were diagnosed with cLUTO antenatally, based on ultrasonographic evidence of megacystis with or without bilateral hydronephrosis. The “keyhole” sign of the dilated proximal urethra was visualized in 12 of 16 fetuses. Fifteen of 16 mothers consented to vesicocentesis for fetal urine electrolyte analysis prior to VAS placement. All VAS were placed percutaneously by ultrasound-guidance, by a single operator with expertise in maternal-fetal medicine. Consent for fetal VAS placement was obtained independently by the perinatologist, following a shared-decision making approach with the mother. The VAS used in all subjects was the combination of a standard double pig-tail catheter and an atrial septal occluder/double-disk device ]/SCr (mg/dl). It was also calculated from CysC as recommended in infants and subjects with low muscle mass (cys = 70.69(CysC)−0.931. While absolute values of eGFR may have differed, the CKD stage was consistent between the two measurement techniques in all patients.Patients were categorized into two subgroups according to their stage of CKD at 1 year of life. The first group, CKD 1–3, had an estimated glomerular filtration rate (eGFR) ≥30 ml/min/1.73 mD report : eGFRcr cle mass : eGFRcysAll postnatal biochemical parameters were collected based on provider recommendation, in accordance with center practice pattern. This includes the use of Cystatin C routinely, given the authors' previously published study of this biomarker in the neonatal population .p value < 0.05 was considered significant, and all analyses were two-tailed.Data sets were tested for normality with the D'Agostino and Pearson omnibus normality test. Due to the small cohort size, continuous variable data are expressed as the median with interquartile range (IQR)  as appropriate. Intergroup comparisons were tested with Mann-Whitney U for nonparametric data. Proportional differences between the 2 groups were tested with the Fisher exact test with odds ratios and 95% confidence intervals. The odds ratios were then graphed in a Forest plot. Receiver operating characteristic (ROC) and area under the curve (AUC) analyses were used to assess the sensitivity and specificity of perinatal and biochemical markers to predict the early progression to advanced CKD by 1 year of age. The threshold was taken as the value of the marker with the highest sensitivity at a specificity ≥80% with a significant likelihood ratio. Simple linear regression was used to determine the correlation between SCr or CysC over time, in each subgroup. Statistical analyses were performed using GraphPad Prism . A The university-based institutional review board waved consent for this retrospective analysis of infants born live at our center.in situ at birth. N = 10, 62%) developed advanced CKD stage 4–5 in the first year of life. Three infants died during the neonatal period, either within the first month of life or during the neonatal intensive care hospitalization. Two had comorbid, extrarenal anomalies and succumbed to complications of sepsis: one at 3 days of age and the other at 54 days of age on KRT. The third infant died of urosepsis, following discharge from the neonatal hospitalization with optimistic renal function .Of the 16 infants born live during the study period, all had a functioning VAS 3 (range 3.6 to 90.7 cm3). Based on the cLUTO staging system proposed by Fontanella et al  of 5.3 for CKD 4–5 in the first year of life when neonatal SCr continued to rise for more than 6 days after birth. In addition, when the neonatal SCr rose above 2.0 mg/dl, there was an LR of 6 for CKD 4–5. In concordance with the natural history of a downturn in SCr as peripheral vascular resistance decreases and systemic blood pressure increases postnatally , the SCrThe serial measurement of SCr along the course of infancy identified significant differences in the nadir SCr between the two groups. In the CKD 4–5 group, the nadir SCr was significantly higher at 1.3 mg/dl, compared to 0.4 mg/dl in the CKD 1–3 group. Furthermore, it was achieved much sooner in the CKD 4–5 group at a median of 50 days of life . Alternatively explained, patients with better long-term kidney function at 12 months of age exhibited a greater decline in SCr over a longer period of time, specifically over a median of 257 days or more than 8 months. ROC-AUC analyses reveal a LR of 5 for developing CKD 4–5 at 1 year when nadir SCr is ≥0.5 mg/dl at <160 days (5.3 months) of life. These data are summarized in p values and r correlation coefficients.Throughout the first year, patients in both groups required multiple re-hospitalizations, a median of 4 . In the CKD 4–5 group, KRT was initiated in 3 of those 10 patients, or 19% of the entire cLUTO cohort. 2 were started on peritoneal dialysis, and 1 was started on continuous kidney replacement therapy (CKRT) prior to demise during the neonatal intensive care stay. Neither of the 2 patients requiring maintenance peritoneal dialysis were initiated in the neonatal period. Lastly, of the 14 patients who survived to neonatal hospital discharge, all were able to void spontaneously without need for urethral/bladder catheterization or vesicostomy, at that time.2, at 12 months of age.This single center cohort study of infants born with a functional VAS inserted for severe cLUTO evaluated the perinatal and biochemical risk factors associated with advanced CKD stage 4–5, or eGFR <30 ml/min/1.73 mIn order to assess the potential benefit of any intervention, it is key that said intervention is operational. Since the inception of vesicoamniotic shunting more than four decades ago , multiplIn addition to VAS functionality, the estimation of kidney function has not been standardized across publications, which can be misleading towards understanding outcomes. Some studies declare “normal renal function” without providing any definition , 26. SomAs a biomarker independent of muscle mass and that does not cross the placenta, CysC is poised to be a more accurate measure of neonatal kidney function than SCr . In one Natural trends in biomarkers are important for KRT planning, particularly in patient groups with high rates of end-stage kidney disease. A conservative approach with our cohort resulted in the neonatal discharge of the 14 survivors without a dialysis catheter, nor a dependence on KRT. In a retrospective analysis of PUV patients in the Pediatric Health Information System (PHIS) database, 56% of patients who had received a dialysis catheter did not go on to require kidney transplantation. Nearly three quarters of those had the catheter placed as a neonate , further3 (ml)  , 20. Whig system , which mg system . When img system , perhapsLimitations of this study include its retrospective design and small sample size. Regarding the fetal urine analytes, analysis for this study was limited to measurement from a single, initial vesicocentesis based on the center protocol of the time, rather than from sequential sampling. While limited data suggests improved predictive capacity from serial measurements of fetal urine , the proFuture investigations should aim to expand the sample size by both number of subjects and centers. Given the vulnerability of cLUTO patients, a more specific understanding of non-invasive biomarkers would also improve care. The prospective trending of the urine protein profile and/or the peptidomic-metabolomic signature can be done with little to no discomfort to the infant. Ultrasonographic parameters, including renal parenchymal area previously studied by our group in this specific population , are als


Medication adherence plays an essential role in controlling blood pressure to reduce morbidity and mortality of hypertension disease. Thus, this study aimed to determine the association of medication adherence measured by self-reported pill count with blood pressure levels among patients at several community health centers in Surabaya.Adherence was assessed using the pill count method by comparing the total number of antihypertension drugs taken with the prescribed drugs. The inclusion criteria involved hypertensive patients who received antihypertension drugs, specifically adults and elderly, except the pregnant woman. The patient blood pressure was measured by healthcare workers in the targeted community health centers. Descriptive and multivariable logistic regression analyses were performed to assess factors associated with medication adherence with blood pressure levels.P = 0.000) more likely to have non-adherent medication than patients with controlled blood pressure. Reciprocally, non-adherent participants (pill count < 80%) were about six times  more likely to have uncontrolled blood pressure compared to adherent patients (pill count ≥ 80%). Age less than 40 years old  and having middle school educational level  were found to be independent factors associated with uncontrolled blood pressure.A total of 264 hypertensive outpatients participating in this study, 77.65% of participants were adherent to antihypertensive drugs based on the pill count method, and 40.91% of participants had controlled blood pressure. Patients with uncontrolled blood pressure were about six times (adjusted odds ratio [AOR]: 6.15; 95% confidence interval [CI]: 2.694–14.039; The result showed that non-adherence to antihypertension drugs is associated with uncontrolled blood pressure. Then, age could be associated with uncontrolled blood pressure. Thus, pharmacists and other healthcare providers should pay attention to improving medication adherence and maintaining the controlled blood pressure.The online version contains supplementary material available at 10.1186/s40885-022-00195-5. Hypertension is a non-communicable disease that is currently increasing in prevalence. Based on a national population survey in 2018, the prevalence of hypertension in Indonesia was 34.1% (age ≥18 years old) [Hypertension is defined as clinical blood pressure at or above 140/90 mmHg , 6. AlthThe importance of monitoring the adherence to antihypertensive drugs can help healthcare staff examine and control patients’ blood pressure. Thus, this study aimed to determine the association of medication adherence with the blood pressure of hypertensive patients. There are two methods of measuring adherence, direct and indirect methods , 12. DirPuskesmas), including Benowo, Jeruk, Ketabang, Tambak Rejo, and Gayungan. The community health center is the primary health care center covering a sub-district in Surabaya, East Java, Indonesia. Prospective data collection was done in 2 months (April and May 2020). Adherence was assessed by comparing the total number of prescribed antihypertension drugs and the remaining drugs when visiting the community health centers. A direct interview was performed to ask the patients about the number of remaining drugs and the sociodemographic characteristics . Type of therapy and comorbidities were recorded from the patient’s medical record at community health centers. Blood pressure was measured by healthcare workers.This research was conducted in five community health centers  for the statistical analysis. A chi-square test was used to determine the association between demographic characteristics with medication adherence and blood pressure. Multivariable logistic regression models were fitted to identify the association of explanatory variables with the outcomes. Variables with a P-value less than 0.20 were considered for inclusion in a multivariable logistic regression analysis in which confounders could be controlled. The necessary assumptions of logistic regression were made by checking Hosmer and Lemeshow’s goodness of fittest statistics. Variables with a P-value less than 0.05 in the multivariable logistic regression analysis were considered as statistically significant determinants. Adjusted odds ratio (AOR) with 95% confidence interval (CI) was calculated to measure the strength of the association between the explanatory variable and the outcome variable.A total of 264 patients on antihypertension treatment who participated in this study came from Benowo (40 patients), Jeruk (40 patients), Tambak Rejo (74 patients), Ketabang (40 patients), and Gayungan (70 patients). The majority of the study population was female (73.48%), aged 40–61 years old (51.13%), and educated up to high school (35.98%). Most subjects were prescribed a single antihypertensive agent (91.67%), and the remaining received a combination (8.33%). Regarding comorbidities, more than half of patients had diabetes and dyslipidemia (57.95%). The proportion of adherent and non-adherent patients were 77.65% and 22.35%, respectively. Then, according to the JNC 8 standard, patients were classified as having controlled  and uncontrolled blood pressure  (Table P = 0.000). Meanwhile, age and patient adherence could influence the blood pressure . Then, sex, type of therapy, education level, and the presence of comorbid disease did not associate with adherence nor blood pressure.Tables P = 0.000). Moreover, uncontrolled blood pressure was associated with those aged <60 years and educated up to middle school. Then, sex, type of therapy, and the presence of the comorbid disease did not associate with poor adherence or uncontrolled blood pressure  in both statistical analyses. In contrast, ample studies proved many independent predictors related to medication adherence. For instance, Khayyat et al.  reportedThen, the comorbidities accompanying hypertension were not associated with poor medication adherence and uncontrolled blood pressure Tables  and 5. OP = 0.010)  Table . It may The level of education in this study is known not to affect medication adherence or blood pressure control based on the chi-square test. However, multivariable logistic regression found that patients educated up to middle school had higher blood pressure control than college graduates. Other studies also showed inconsistent results. Ayodapo et al.  reportedPuskesmas did not represent the whole city. So, it is necessary to add the number of respondents from many more Puskesmas for future study.The success of hypertension therapy is influenced by adherence and other factors, such as lifestyle, physical activity, diet, sleep patterns, body mass index, smoking status, and stress . Those fWe found a significant association between medication adherence and blood pressure control. In addition, age was found to be an independent predictor that affects blood pressure. Thus, pharmacists and other healthcare providers should pay attention to improving medication adherence and maintaining controlled blood pressure, particularly for patients below 40 years old.Additional file 1.Additional file 2.


Asthma is significantly related to chronic rhinosinusitis (CRS) both in prevalence and severity. However, the clinical patterns of uncontrolled asthma with and without comorbid CRS are still unclear. This study aimed to explore the clinical characteristics and cytokine patterns of patients with uncontrolled asthma, with and without comorbid CRS.22 parameters associated with demographic characteristics, CRS comorbidity, severity of airflow obstruction and airway inflammation, and inflammation type of asthma were collected and assessed in 143 patients with uncontrolled asthma. Different clusters were explored using two-step cluster analysis. Sputum samples were collected for assessment of Th1/Th2/Th17 and epithelium-derived cytokines.2), and highest levels of eosinophils, fraction of exhaled nitric oxide (FeNO) and IgE. Sputum samples from Cluster 3 showed significantly higher levels of Interleukin (IL)-5, IL-13, IL-33, and tumor necrosis factor (TNF)-α than the other two clusters; and remarkably elevated IL-4, IL-17 and interferon (IFN)-γ compared with cluster 2. The levels of IL-10 and IL-25 were not significantly different among the three clusters.Comorbid CRS was identified as the most important variable for prediction of different clusters, followed by pulmonary function parameters and blood eosinophil level. Three clusters of patients were determined: Cluster 1 (n = 46) characterized by non-atopic patients with non-eosinophilic asthma without CRS, demonstrating moderate airflow limitation; Cluster 2 (n = 54) characterized by asthma patients with mild airflow limitation and CRS, demonstrating higher levels of blood eosinophils and immunoglobulin E (IgE) than cluster 1; Cluster 3 (n = 43) characterized by eosinophilic asthma patients with severe airflow limitation and CRS , demonstrating worst lung function, lowest partial pressure of oxygen (PaOUncontrolled asthma may be endotyped into three clusters characterized by CRS comorbidity and inflammatory cytokine patterns. Furthermore, a united-airways approach may be especially necessary for management of asthma patients with Type 2 features.The online version contains supplementary material available at 10.1186/s12931-022-02028-3. Asthma is a heterogeneous disease, with different underlying processes. Recognizable clusters of demographic, clinical and/or pathophysiological characteristics are often referred to as “asthma phenotypes”. However, no strong association has been found between specific pathological features and particular clinical patterns or treatment responses . Thus, eAn increasing number of studies have provided consistent evidence that asthma is closely related to chronic rhinosinusitis (CRS), thus strongly supporting the united airway concept , 5. IndeInvestigation of airway inflammatory characteristics, especially the expression of proinflammatory cytokines in patients with uncontrolled asthma is meaningful, as the feature of airway inflammation may be more prominent in the uncontrolled stage, and biologics targeting the related cytokines can be adopted more precisely for treatment of uncontrolled asthma. Since both Th2 and non-Th2 mechanisms are involved in asthma pathogenesis, simultaneous evaluations of traditional Th1/Th2/Th17 and related epithelium-derived cytokines in the airway are necessary. Seys and colleagues  evaluateIdeal criteria for defining heterogeneity of asthma are recommended to be based on both phenotype and putative pathophysiology (endotype) , 5. In tThis was a single center cross-sectional study, involving patients with uncontrolled asthma. Patients referred to Beijing Tongren Hospital for complaints of recurrent and intermittent wheeze, shortness of breath, chest tightness, and cough were consecutively enrolled into the study from Sept 2017 to Sept 2019.Asthma and uncontrolled asthma were defined according to the criteria of Global Initiative for Asthma (GINA) . BrieflyOn enrollment, demographic and clinical data were collected for each patient using standard questionnaires, medical histories, and other records; including general demographics, age at first symptoms of asthma, nasal disease and other underlying disease, and medication use for asthma. Blood and sputum were collected for further analyses, and the patients were examined for various clinical parameters as detailed below. 22 parameters associated with demographic characteristics , comorbid CRS , severity of airflow obstruction and airway inflammation , and inflammation type of asthma , were collected and clustered using two-step cluster analysis. Sputum samples from a number of patients in each cluster were subsequently analyzed for several cytokines to investigate the possible mechanism/s of airway inflammation. The study flow chart is shown as Fig. The study was approved by the local ethics committee of Beijing Tongren Hospital, Capital Medical University, and written informed consent was obtained from all patients prior to entry into the study.An automatic immunoassay system  was used to assess serum T-IgE and s-IgE, according to the manufacturer′s directions. The lower limit of detection of serum T-IgE and allergen s-IgE were 2 kU/L and 0.01 kUA/L, respectively. Serum T-IgE > 60 kU/L and allergen specific IgE > 0.35 kUA/L were considered abnormally elevated , 15.Atopy was assessed by serum levels of specific IgE (s-IgE) generated to a panel of common aeroallergens  and food allergens . Atopy was defined when any of the serum s-IgE tested was > 0.35 kUA/L .Fractional exhaled nitric oxide (FeNO) was measured using a nitric oxide analyzer  at a flow rate of 50 mL/s via the oral cavity. The exhaled gas was continuously routed into the analyzer via a side port. The procedure was repeated three times and a mean concentration of FeNO was calculated .1)/forced vital capacity (FVC)%, and FEV1%predicted (FEV1%pred) were measured before bronchodilator (BD) treatment and 15 min after inhalation of 400 μg salbutamol, respectively.Spirometry  was performed to determine the lung function measurements and bronchodilator reversibility. Pre- and Post-bronchodilator forced expiratory volume in 1 s (FEV2) and partial pressure of carbon dioxide (PaCO2) using a blood gas analyzer . Blood gas analysis was completed within 5 min after collection of the blood sample.Samples of arterial blood (2 ml) were withdrawn during normal air breathing and assessed for partial pressure of oxygen . Leukocyte count and eosinophil (EOS) differentiation in anticoagulated blood samples were performed on an automatic blood analyzer .High resolution computed tomography (HRCT) of the chest was performed using a 64-row, multiple-detector CT scanner . An experienced radiologist blinded to the clinical and laboratory data reviewed the CT scans. A diagnosis of bronchiectasis on chest HRCT was made if bronchial wall thickening was present and the ratio of the diameter of bronchus to that of the accompanying pulmonary artery was greater than 1.1 (signet ring sign), or there was lack of tapering of bronchi (tramline sign). Mild bronchiectasis only visible in a single pulmonary segment was not taken into consideration, as this may exist in a significant percentage of healthy population . BronchiSinus CT was performed using a 64-row, multiple-detector CT scanner . The radiographic severity of CRS was assessed, by an experienced radiologist blinded to the clinical and laboratory data, using the Lund-Mackay CT staging system (0–24) . The LunSputum induction was performed in all the patients and the samples were prepared for routine clinical examination, according to the method described before . Briefly2-agonist (LABA), leukotriene receptor antagonist (LTRA), long-acting muscarinic anticholinergics (LAMA), theophylline and anti-histamines; but not drugs such as short-acting beta2-agonist (SABA); within 72 h before enrollment was recorded as “No medication”.The medications used by the patients within 72 h before enrollment were recorded. No usage of inhaled corticosteroids (ICS), long-acting betaAsthma severity was assessed during follow-up using the stepwise approach for adjusting asthma treatment in adults, the GINA criteria . Thus, m2 test. P values less than 0.05 were considered as statistically significant. For multiple comparisons among three clusters , P values less than 0.017 were considered as statistically significant.Statistical analyses were performed using the SPSS 23.0 statistical software package . A two-step cluster analysis was used to identify homogeneous groups of cases which were not previously known, based on a combination of different types of variables; Schwarz’s Bayesian Criterion (BIC) was chosen in the clustering criterion . Data we2. Overall, 87.5% (125/143) of patients had an asthma onset age ≥ 18 years; with the mean age of asthma onset being 39.8 years. A total of 67.1% of patients had comorbid CRS and 16.8% patients comorbid NP, and a mean Lund-Mackay score of 7. Blood gas analysis demonstrated mean PaO2 and median PaCO2 values of 76.9 mmHg and 40 mmHg, respectively; the median FEV1/FVC values before and after BD were 72.4% and 74.2%, and the mean of FEV1% predicted before and after BD were 72.5%, and 78.6% respectively. Bronchiectasis was present in 18.9% of the patients; the average values of T/D ratio and WA% were 0.248 and 0.736, respectively. A total of 46.1% patients demonstrated atopy , and blood EOS percentage, blood EOS count and FeNO values of 4.8%, 0.32 × 109/L and 39.2 ppb respectively. Sputum eosinophils were found in only 24.4% (35/143) of the patients. Majority of the patients were using inhaled corticosteroids  and long-acting beta2-agonist , whereas 20.9% of patients were not on the specified medication at enrollment  and 93 were female (65.1%), with a mean age of 55 (20 ~ 90) years and BMI of 24.7 kg/m, with blood EOS counts ≥ 300/µl in 86% (37/43) of the patients.The predictive importance of 22 demographic and clinical variables included in the cluster analysis is shown in Fig. P = 0.033) and sex ratio (P = 0.003) within the 3 clusters. The patients in cluster 3 were significantly younger than in cluster 1 (P = 0.011); however, the patients in these 2 clusters were not significantly different in age compared to those in cluster 2 . The proportion of males in cluster 3 was higher than in cluster 1 (P = 0.008) and cluster 2 (P = 0.001), with no difference between clusters 1 and 2 (P = 0.634). The three clusters were not significantly different with regards to asthma onset age (P = 0.338) or BMI (P = 0.484) (Table There were significant differences in age (P < 0.001) and NP (P < 0.001) were seen within the 3 clusters. Presence of comorbid CRS in cluster 1(2.2%) was much lower than in cluster 2 (100%) and cluster 3 (95.3%) (both P < 0.001), with no statistical difference between clusters 2 and 3 (P = 0.378). The presence of comorbid NP in cluster 3 (46.5%) was significantly higher than in cluster 1 (0%) and cluster 2 (7.4%) (both P < 0.001), with no statistical difference between clusters 1 and 2 (P = 0.170). A notable difference was also found in the Lund-Mackay score (LMS) within the 3 clusters (P < 0.001). The LMS was highest in cluster 3 and lowest in cluster 1, with significant differences between any two clusters.  (Table Striking differences in comorbidity of both CRS P < 0.00 and NP P < 0.00 and NP (2 and PaCO2 (both P < 0.001) within the 3 clusters , was much lower than that in cluster 1 (P < 0.001) and cluster 2 (P < 0.001), with no significant difference between clusters 1 and 2  and cluster 3 (P < 0.001), with no significant difference between clusters 1 and 3    and WA% (P = 0.009), but no difference was seen in the prevalence of bronchiectasis within the 3 clusters , but not significantly different between cluster 1 and 2 , or between cluster 1 and 3  , serum T-IgE (P < 0.001), log (T-IgE) (P < 0.001), blood EOS count (P < 0.001), blood EOS percentage (P < 0.001), sputum EOS percentage (P = 0.006), and FeNO (P < 0.001) within the 3 clusters (Table P < 0.001) and cluster 2 (P = 0.004), with no difference between clusters 1 and 2 (P = 0.285). Serum T-IgE was elevated in cluster 3 compared with cluster 1 (P < 0.001), but not significantly different between clusters 1 and 2 (P = 0.028), or between cluster 2 and 3 (P = 0.033). However, the value of log (T-IgE) was the highest in cluster 3 and the lowest in cluster 1, with significant differences between any two clusters   and 2 (both P < 0.001); and the levels of eosinophils in cluster 2 were significantly higher than those in cluster 1   and 2 (P = 0.002) , but not statistically different between clusters 1 and 2, or clusters 2 and 3  or long-acting β2-receptor agonists   and 2 ; however, no statistical differences were found within the three clusters in the proportions of patients taking no medication, taking leukotriene receptor antagonists (LTRA), theophylline, or antihistamines  Table . The proP < 0.001) (Table P < 0.001). The difference in the proportion of moderate asthma among the 3 clusters were not significant (P = 0.436). The highest proportion of severe asthmatics and the lowest proportion of mild asthmatics were found in cluster 3, when compared with those in cluster 1  and 2 (both P < 0.001). No significant difference in asthma severity was found between cluster 1and 2 (P = 0.493).A total of 133 patients were assessed during follow-up for asthma severity; including 42 patients in cluster 1, 48 in cluster 2, and 43 in cluster 3. There was statistical difference in asthma severity within the 3 clusters (P = 0.007), IL-4 (P = 0.001), IL-13 (P = 0.002), IL-33 (P < 0.001), IFN-γ (P = 0.013), TNF-α (P = 0.002), and IL-17 (P = 0.012) were significantly different within the 3 clusters. However, no differences were found in the levels of IL-10 or IL-25 within the 3 clusters   and cluster 2 . Although the levels of IL-4, IFN-γ and IL-17 were different between cluster 3 and cluster 1, these were not statistically different   features], asthma with mild airflow limitation and CRS , and eosinophilic asthma with severe airflow limitation and CRS . Further investigation of sputum cytokines showed that compared with the other 2 clusters, patients in cluster 3, the most severe T2 subgroup, had significantly increased levels of IL-33 and traditional Th1/Th2/Th17 cytokines  in airways, accompanied by relatively deficient production of IL-10. To the best of our knowledge, this is the first study to comprehensively explore clinical patterns of uncontrolled asthma in terms of comorbid CRS, severity of airflow limitation and airway inflammation, inflammatory type of asthma, and sputum profile of Th1/Th2/Th17 and related epithelium-derived cytokines. Furthermore, this is the first study to show that uncontrolled eosinophilic asthma with severe airflow limitation and comorbid CRS (often with NPs) is characterized by enhanced collaborative expression of IL-33 and Th1/Th2/Th17 cytokines in the airways.The concept “one airway, one disease” maintains that inflammatory processes of the upper and lower airway often co-exist and share common etiopathogenic mechanisms . Asthma The features of mild asthma in cluster 2 and the severe asthma in cluster 3 indicated according to clinical characteristics of patients in the present study were further supported by significant differences in sputum levels of traditional Th1/Th2/Th17 cytokines  and the related epithelium-derived cytokine (IL-33); however, the sputum EOS counts were comparable between these two clusters. This is in accordance with the findings of a recent study from Japan, which demonstrated that the percentages of mixed inflammatory phenotype as well as systemic eosinophilic inflammation were increased in asthma patients with severe CRS; whereas, patients with asthma and mild-moderate CRS mainly demonstrated eosinophilic phenotypes . This isOur finding that sputum IL-33, but not IL-25, was significantly higher in cluster 3 compared with clusters 1 and 2, suggests that enhanced T2-biased inflammation in cluster 3 may be regulated by IL-33 rather than IL-25. Although the immunologic functions of IL-25 and IL-33 appear to overlap almost entirely, one large-scale genome-wide association study (GWAS) of asthma has indicated a more pronounced role for IL-33 in asthmatic patients . FurtherOur study suggests that Th1 cytokines  and Th17 cytokines (IL-17) may cooperate with Th2 cytokines  to aggravate the airway inflammation in patients within cluster 3. Indeed, Th1 cytokines including TNF-α and IFN-γ, have been observed to disrupt the tight junction of human airway epithelium and promote inflammatory cytokine release . IFN-γ iThe findings from this study, however, are somewhat limited. The sample size was relatively small, and as a cross-sectional and single-center study, there might be some data deviation and bias of case enrollment. The unicentric nature of the study may also jeopardize the external validity of these results. Although the severity of asthma could be discriminated by the clinical characteristics to a large degree, the status/severity of uncontrolled asthma was not numerically evaluated by asthma control test (ACT) or asthma control questionnaire (ACQ), which would have addressed the potential for significant variations in sputum levels of cytokines. Due to the retrospective nature of the study, exacerbations could not be absolutely excluded, especially for the patients with intermittent symptoms, which were more severe during night, and for patients who suffered from chronic asthma and showed poor perception of symptoms. Also, the percentages of the other inflammatory cell types in sputum sample were not analyzed, and sputum cytokines were detected in small sample of patients. Despite distinct clinical characteristics, no significant differences were found in the traditional Th1/Th2/Th17 and related epithelium-derived cytokines between clusters 1 and 2. Thus, further investigation of the possible inflammatory mechanisms operating in cluster 1 is warranted. In the current study local drug therapy for nasal disease was also not recorded. However, compared with those with mild CRS, patients with severe CRS have been shown to have a better compliance with medication and ask for medical help more often .Three clinical patterns of uncontrolled asthma were identified; based on united airway concept, cluster analysis of clinical characteristics, and expression patterns of Th1/Th2/Th17 and related epithelium-derived cytokines; which should be helpful for accurate diagnosis and treatment options for patients with uncontrolled asthma. A united-airways approach may be necessary for management of asthmatics with T2 features, especially those with severe comorbid asthma and CRS. Considering the complicated inflammatory network in patients in cluster 3, developing biologics targeting the factor/s , which may play a central role in the pathophysiology of disease in these patients, should lead to improvement of both the treatment and prognosis of patients with comorbid asthma and CRS. However, further prospective multicentre studies with large sample size will be useful in confirming the findings of this study.Additional file 1.Figure S1: Comparison of characteristics associated with comorbid rhinosinusitis within the 3 clusters.


In unadjusted analyses, we found a positive association between plasma FGF23 and 24 h urinary tetrahydroaldosterone excretion . In multivariable regression models adjusting for age, sex, body mass index and GFR, this association remained robust . Mineralotropic hormones, 24 h urinary sodium and potassium excretion as surrogates for sodium and potassium intake or antihypertensive drugs did not affect this association. Our data reveal a robust association of RAS activity with circulating FGF23 levels in kidney stone formers. These findings are in line with previous studies in rodents and suggest a physiological link between RAS system activation and FGF23 secretion.The spectrum of diseases with overactive renin–angiotensin–aldosterone system (RAS) or elevated circulating FGF23 overlaps, but the relationship between aldosterone and FGF23 remains unclarified. Here, we report that systemic RAS activation sensitively assessed by urinary tetrahydroaldosterone excretion is associated with circulating C-terminal FGF23. We performed a retrospective analysis in the Bern Kidney Stone Registry, a single-center observational cohort of kidney stone formers. Urinary excretion of the main aldosterone metabolite tetrahydroaldosterone was measured by gas chromatography–mass spectrometry. Plasma FGF23 concentrations were measured using a C-terminal assay. Regression models were calculated to assess the association of plasma FGF23 with 24 h urinary tetrahydroaldosterone excretion. We included 625 participants in the analysis. Mean age was 47 ± 14 years and 71% were male. Mean estimated GFR was 94 ml/min per 1.73 mThe online version contains supplementary material available at 10.1007/s00240-022-01317-2. Cardiovascular complications are a major cause of the high morbidity and mortality in chronic kidney disease. Both cardiovascular and kidney disease have a broad spectrum of etiologies and clinical presentation, but during progression of each disease, two hallmarks are an activation of the renin–angiotensin–aldosterone system (RAS), and a rise in serum concentrations of fibroblast growth factor 23 (FGF23) .In patients with advanced heart failure, a direct association between plasma aldosterone and FGF23 was observed, but almost half of the patients were on aldosterone antagonists . Only inWe and others have previously shown in rodent models that salt depletion not only caused RAS activation but also increased circulating FGF23 , 7. ViceWe hypothesized that the difficulty to reproduce the reported association between aldosterone and FGF23 concentration in humans could arise from heterogeneity of the analyzed patient populations, a variability of the assays used , from thQuantification of steroid hormones in timed urine collections allows sensitive determination of secreted hormone quantities over time . Based oThe Bern Kidney Stone Registry (BKSR) is a single-center, observational cohort of kidney stone formers at the Department of Nephrology and Hypertension, Bern University Hospital, Bern, Switzerland. The BKSR adheres to the Declaration of Helsinki and was approved by the ethical committee of the Kanton of Bern . Inclusion criteria for the BKSR are (i) written informed consent, (ii) age ≥ 18 years, and (iii) at least one past stone episode. All variables employed for study analyses were verified by manual review of the original patient charts. In this study, we included BKSR participants who had urinary steroid profiles available and who had 24 h urine creatinine excretion that was within the 2.5th and 97.5th percentile of expected creatinine excretion . Among t2D were previously described [Patients were instructed to collect two 24 h urine collections on a random outpatient diet and a spot urine and a fasting blood sample were obtained in the morning after the second of the 24 h urine collections. Plasma C-terminal FGF23 was measured at the laboratory of TECOmedical AG  by the second-generation C-terminal assay  with plasma initially frozen after sampling and stored at − 80 °C. C-terminal FGF23 was chosen due to its lower diurnal variability in comparison to intact FGF23 . All othescribed . The gloescribed . Urinaryescribed , 21. Perescribed . Completβ-glucuronidase/arylsulfatase and extraction on Sep-Pak C18 cartridge. Steroids were derivatized using methoxyamine HCl 2% in pyridine at 60 °C for 1 h after adding Stigmasterol and 3β5β-TH-aldosterone standards, followed by derivatization with Tri-methyl-silylimidazole (TMSI) at 100 °C for 16 h, and gel filtration on a Lipidex 5000 column. Samples were quantified using mass spectrometric analysis on a gas chromatograph 7890A coupled to a mass-selective Hewlett-Packard 5975C detector . Quality control of the method was ensured by comparison with parallel measurement of samples from healthy volunteers, and by monthly participation in external quality control as previously reported [Urinary excretion of urinary tetrahydroaldosterone in μg/24 h was assessed in-house using an established GC–MS method as previously described , 24, 25.t test, and p values < 0.05 were considered statistically significant.All statistical analyses were conducted using R software, version 4.0.4  . The disTo assess the associations of log C-terminal FGF23 with urinary tetrahydroaldosterone, we computed a univariable linear model. This association of log C-terminal FGF23 with urinary tetrahydroaldosterone was further analyzed by eight multivariable linear models adjusting for sex, age, body mass index (BMI), eGFR (multivariable model 1), model 1 parameters and parathyroid hormone, 25OH-vitamin D and 1.25(OH)2-vitamin D (multivariable model 2); model 1 parameters and 24 h sodium and potassium excretion (multivariable model 3). Multivariable linear model 4 was adjusted for model 1 parameters and seven classes of concurrently prescribed antihypertensive drugs  participants met the predefined eligibility criteria and were included in this study (for details see N = 322) [p = 0.21), eGFR (p = 0.82) or urinary tetrahydroaldosterone (p = 0.13). The distribution of plasma FGF23 was normal with long right tail in both men and women with a median level of 68.7 and 91.0 relative units/ml (interquartile range 36.0 and 66.9) in men and women, respectively  was observed in univariable analysis  using a multivariable linear regression model. In this model, the association of tetrahydroaldosterone with plasma FGF23 remained robust , p = 0.03. This finding remained robust  when PTH was additionally added in the model.Because parathyroid hormone (PTH) and vitamin D are important modulators of FGF23 secretion , 30, we β − 0.047 and p = 1.9 × 10–4) as expected [β: 0.082 and p = 0.047, as expected [Dietary intake of sodium or potassium is both associated with a decrease in circulating FGF23 independent from PTH or 25-hydroxy vitamin D3 . We therexpected  , thiazide diuretics , potassium-sparing diuretics , RAS inhibitors , alpha-blockers , beta blockers , and calcium antagonists  in multivariable linear model 4 . Adjustment for mGFR instead of eGFR did not alter any of the observed associations with plasma FGF23 in multivariable models .Finally, we assessed the degree of the outlined correlation using measured GFR (mGFR) by creatinine clearance instead of eGFR (CKD-EPI) for kidney function adjustment. Because of the exclusion of participants with urine collections outside the 2.5th and 97.5th percentile of expected creatinine excretion , the assIn the present study, we found that the major urinary metabolite of aldosterone, tetrahydroaldosterone, quantified in 24 h urines by a sensitive and specific GC–MS assay .This observation has previously been provided in a first study by Imazu et al.  that is We confirm the earlier study by Imazu et al. in patients with heart failure patients and/or early kidney disease of whom 43% were prescribed aldosterone antagonists . In thatFurther, our analyses demonstrate the suitability of the urinary metabolite tetrahydroaldosterone to assess clinical context or biomarkers associated with RAS activation. This has been previously suggested by others and even proposed as a screening tool for primary hyperaldosteronism . For othThe present study has some limitations. With regard to the population studied, the present results are limited to stone formers. Stone formers constitute a somewhat heterogeneous population often exhibiting disadvantageous life styles and chronic diseases predisposing for stone formation with varying levels of kidney function.Whether the association between aldosterone activation and plasma FGF23 exists beyond kidney stone formers remains to be validated, e.g., in populations of healthy volunteers and of patients with chronic kidney disease or congestive heart failure.Further, some variables, such as plasma renin activity or plasma aldosterone, were not available in the current study. However, results from a comparative study showed that urinary tetrahydroaldosterone excretion is the most reliable parameter to predict primary hyperaldosteronism . AnotherIn conclusion, our data reveal a robust association of RAS activity with circulating FGF23 in kidney stone formers. These findings are in line with previous studies in rodents and suggest a physiological link between the RAS system activation and FGF23 secretion.Supplementary file1 (PDF 363 KB)Below is the link to the electronic supplementary material.


Specify the risk rate of incorrect patient classification based on the night-to-day ratio specification from singular 24-h ABPM in comparison to the results of 7-day ABPM monitoring  1197 24 h cycles were enrolled in 171 subjects in the study and divided into 4 groups: group 1 , group 2 , group 3 (40 patients with ischemic coronary artery disease without exercise), and group 4 (51 patients with ischemic coronary artery disease following cardiovascular rehabilitation). The subject of the evaluation was the percentage rate of incorrect subject classification  based on the mean blood pressure values for 7 days and from seven independent 24-hour cycles . p < 0.594; 56% vs. 54%) or physical activity  of the monitored individuals.  In the case of the individuals included in the monitored groups, the mean night-to-day ratio-based  classification accordance ranged between 59% and 62%. Only in singular cases did the accordance reach 0% or 100%. The accordance size was not dependent on the health or cardiovascular disease . Although blood pressure measurement in outpatient care is standardised and governed by accurately defined principles, there is a statistically significant probability of erroneous hypertension diagnosis , 2. OtheMost authors base the previous classification according to the night-to-day ratio solely on 24-hour blood pressure monitoring. Night-to-day ratio may be specified by evaluating the mean blood pressure values from the seven monitored days as well as by evaluating the individual 24-hour cycles . The purIn total, 1197 24-h cycles were enrolled in 171 subjects in the study and divided into 4 groups. The first group included 40 subjects (20 men and 20 women)  without chronic medication. The second group of healthy exercise-training individuals included 20 men and 20 women (mean age 29 ± 7.8 yrs and mean BMI 22.3 ± 5.18) without chronic medication. The third group included 40 patients with chronic ischemic coronary artery disease . The fourth group included 51 patients with chronic ischemic coronary artery disease  following cardiovascular rehabilitation. The first part of the study involved evaluating the 40 healthy individuals of the first group without chronic medication and 40 patients (group 3) with chronic ischemic coronary artery disease without exercise. The second part of the study focused on assessing night-to-day ratio changes in the healthy individuals following controlled combined aerobic-resistance exercise (group 2) and in the patients with chronic ischemic coronary artery disease (group 4) following cardiovascular rehabilitation. All patients (third and fourth groups) were treated with beta-blockers, ACE inhibitors, and statins. They were symptomatically stable and their medication was not changed during rehabilitation or during ambulatory monitoring.The ambulatory monitoring (7-day ABPM) was performed with ambulatory blood pressure monitoring devices TM–2430  based on both the cuff-oscillometric and Korotkoff sound method. The device automatically recorded all the regular measurements for the period of continuous seven days, between 6:00 a.m. and 10:00 p.m. every 30 minutes and between 10:00 p.m. and 6:00 a.m. every 60 minutes. Such short intervals are necessary to obtain a sufficient number of representative measurements. The monitored individuals recorded their daily activities, their sleep times, their subjective problems, and their pharmaceutical intakes throughout the monitoring period. To make the blood pressure values objectively comparable for all tested individuals, the time interval in which the blood pressure values corresponded to the sleep/awake times needed to be defined. For that purpose, the mean nocturnal blood pressure value for individual days was calculated for the time interval between 1:00 and 6:00 a.m., and the daily blood pressure means for the time interval between 10:00 a.m. and 10:00 p.m. Blood pressure values for the periods between 7:00 and 9:00 a.m. and 10:00 and 12:00 p.m. were excluded from night-to-day ratio calculation for the purpose of data standardisation. This way, the time intervals for blood pressure recording corresponding to the night sleep and day awakening periods were unified for all individuals enrolled.max). The minimum time span between the workouts was 24 hours. The workout consisted of a 10-minute warm-up, 25 minutes of aerobic exercise (spinning bicycle or bicycle ergometer), 15 minutes of resistance exercise on gym machines  with 40–50% 1-RM (one repetition maximum) intensity (3 series of 10 exercises), and a 10-minute cool-down (stretching of the main muscle groups). The cardiovascular exercise (group 4) took the form of sixty-minute workouts scheduled two to three times weekly. The nature of the workouts was similar, combined aerobic-resistance exercise. The workout intensity was set at the level of the first ventilation threshold (VAT-1), 666 corresponding to the following workout parameters: load (W) and heart rate (HR) [Combined aerobic-resistance exercise for 40 healthy individuals (group 2) was scheduled twice weekly in the form of 60-minute workouts with a load intensity at the level of submaximum heart frequency (75–85% SFate (HR) . The resday − SBPnight)/SBPday [t-test assuming unequal variances was used. P value = 0.05 was considered as statistically significant. Differences between the percentage of accordance of the overall mean for 7 days and the percentage of accordance of the mode were tested by paired t-test.The arithmetic mean was calculated for every hour from all measured systolic blood pressure (SBP) and diastolic blood pressure (DBP) values obtained by the 7-day monitoring, plus weighed means from the individual 24-hour cycles and the whole 7-day interval. The night-to-day ratio was calculated using the following formula: 100 × (SBP)/SBPday . Each stp < 0.0017, 62% vs. 55%).p < 0.062).p < 0.007, 59% vs. 53%).p < 0.004).1p < 0.833; 55% vs. 54%). The difference in the accordance size between young healthy individuals . The difference in the accordance size between patients without exercise .The difference in the accordance size between the exercising subjects  Tables  and 4 anexercise  and patiexercise  was not p < 0.818; 55% vs. 56%) in the night-to-day ratio-based categorisation accordance rate as a consequence of the performed physical activity.In addition, in the case of the comparison between the group of healthy individuals without physical activity  and the There are studies pointing to ethnic differences in blood pressure response to physical activity –19. LikeFurthermore, the next part of the study evaluating healthy subjects with controlled physical activity  found thInsufficient blood pressure decrease during night sleep (nondippers) is certainly a significant predictive factor for mortality, but other coincident risk factors  must also be taken into account , 29, 30.The same applies to risk groups, i.e., seniors, diabetic patients, obese individuals, or pregnant women , 33. The1Night-to-day ratio specification for each day from 7-day ABPM also represents a doubtless advantage in that it allows for the recording of individual variability and frequency of occurrence of high-risk days. Discussions with the examined individuals can then find which particular activity of the subject caused a blood pressure response of the nondipper (ND), extreme dipper (ED), or reverse dipper (R) type.Although the relationships between circadian blood pressure variability and physical activity are not yet quite clear, most studies dealing with this issue point to the positive effects of physical activity on the cardiovascular system and blood pressure values , 38.According to the results of our study combined training does not change the variability of blood pressure .Due to lifestyle in the so-called “civilized” world, the percentage of the urban population with blood pressure higher than 140/90 mmHg or who uses antihypertensive drugs increases with age. The high prevalence of cardiovascular risk factors in populations is significantly associated with life conditions. Abnormal dipping patterns is important prognostic markers for future cardiovascular morbidity in resistant hypertension patients. Extreme dipping is a protective factor in younger individuals but a hazardous factor in the elderly and in individuals with previous cardiovascular diseases . High caIn contrast, the findings in the isolated populations  showed that neither blood pressure elevation with age is inevitable, nor is the high prevalence of hypertension .On the basis of the obtained results, the following procedure can be recommended for clinical practice. If the standard 24-hour monitoring is used, then obtain at least 3 mutually independent 24-hour cycle data for every examined individual. If at least two of them result in the same night-to-day ratio and the third night-to-day ratio is only slightly different, the thus obtained index can be considered trustworthy. Otherwise, the correct night-to-day ratio can only be obtained by 7-day ABPM and, in addition, the resulting night-to-day ratio calculated from the mean values obtained in the course of the 7 days must be compared to the result modes obtained for the individual monitoring days. Our own clinical experience teaches us that there are subjects whose accurate night-to-day ratio-based classification is difficult due to the high-value variability between days. Therefore, the conclusion can be drawn that the mean value of the night-to-day ratio found by ambulatory BP monitoring across 7 days is a much more accurate method of valid value specification when compared to 24-h ABPM. In the case of the individuals included in the monitored groups, the mean night-to-day ratio-based  classification accordance ranged between 59% and 62%. Only in singular cases did the mean accordance reach 100%. The accordance size was not dependent on the gender, age, health, or cardiovascular disease, or physical activity of the monitored individuals.