BackgroundChronic kidney disease (CKD) causes significant morbidity and mortality in patients and incurs a huge burden on healthcare expenses globally. Renal replacement therapy becomes imperative when patients reach end-stage renal disease. Kidney transplant is the best modality of choice for the majority of patients, and deceased donor kidney transplantation is the major contributor in the majority of countries. We present an outcome study in Sri Lanka for deceased donor kidney transplantation.MethodologyThis is an observational study conducted at the Nephrology Unit 1 at the National Hospital of Sri Lanka, Colombo, in patients who had undergone deceased donor kidney transplantation from July 2018 to mid-2020. We studied the outcomes of these patients for one year, including delayed graft function, acute rejection, infection, and mortality. Ethical clearance was obtained from the ethical review committee of the National Hospital of Sri Lanka, Colombo, and the University of Colombo.Results2. Delayed graft function occurred in 25.9% of the recipients, and 22.2% had acute transplant rejection. Postoperative infection was observed in 44.4% of recipients. One year after transplantation, 22% of the recipients died. Infection was the cause of death in 83% of recipients (five of six patients). The causes of death in the study sample were pneumonia (50%), including pneumocystis pneumonia (17%), myocardial infarction (17%), mucormycosis (16%), and other infections (17%). There was no significant association between outcomes at one year with age, gender, causes of CKD, or postoperative complications.The study included 27 participants with a mean age of 55 ± 9.519 years. Diabetes mellitus (69.2%), hypertension (11.5%), chronic glomerulonephritis (7.7%), chronic pyelonephritis (7.7%), and obstructive uropathy (3.8%) were the etiological factors of CKD. Basiliximab was used as an induction agent, and a tacrolimus-based triple-drug regimen was used for maintenance in all patients. The mean cold ischemic time was 9 ± 3.861 hours. The majority (44%) of recipients had an O-positive blood group. At one year, the mean serum creatinine was 1.40 ± 0.686 mg/dL, and the mean estimated glomerular filtration rate was 62 ± 21.281 mL/minute/1.73 mConclusionsOur study found that the one-year survival rate following deceased donor kidney transplantation in Sri Lanka is relatively low, with infections being the leading cause of mortality. The high infection rate during the early post-transplant period underscores the need for enhanced infection prevention and control measures. Although we did not observe any significant association between the outcomes and the variables studied, it is important to note that the small sample size of our study may have influenced this finding. Future research with larger sample sizes may provide more insights into the factors influencing post-transplant outcomes in Sri Lanka. Chronic kidney disease (CKD) is a growing problem worldwide, including in Sri Lanka, where CKD of uncertain origin threatens to reach epidemic proportions. Globally, the main contributors to CKD are diabetes and hypertension, which are also prevalent in Sri Lanka, along with various forms of glomerulonephritis. The increasing prevalence of non-communicable diseases, especially diabetes and hypertension, is expected to further burden the healthcare system of Sri Lanka ,2.End-stage renal disease (ESRD) is characterized by permanent kidney failure, requiring renal replacement therapies, such as dialysis or kidney transplantation, to sustain life. Kidney transplantation is the treatment of choice for most patients with ESRD as it improves the quality of life and reduces mortality risk compared with maintenance dialysis, and its superiority in prolonging the longevity of patients with ESRD is well established -5.However, the biggest challenge in kidney transplantation is organ shortage, which makes the use of deceased donors increasingly important. In Sri Lanka, the number of living donor kidney transplantations has remained unchanged for years, while more than 2,000 patients died due to renal failure while awaiting transplantation in 2017 ,7. In coLimited research has been conducted on deceased donor kidney transplantation in Sri Lanka, with most studies focusing on living donor kidney transplantation. A study by Galabada et al., conducted at the Nephrology Unit 1, NHSL, found that the five-year death-censored graft survival rate for kidney transplant recipients from living donors was 93.5%, and the five-year patient survival rate was 82.2%, which is comparable to global transplant programs. This study identified the number of acute rejection episodes as an independent risk factor for graft survival . In a reA study conducted by Gopalakrishnan et al. in India analyzed 173 cases of deceased donor renal transplants and identified the attainment of graft function immediately after transplant as the most crucial factor determining both graft and patient survival rates. The study reported an incidence of delayed graft function (DGF) of 48.5% and acute rejection of 21.8%. At one year, patient- and death-censored graft survival rates were 80% and 82.6%, respectively, while at five years, these rates were 76% and 80%, respectively . AnotherSince the establishment of the national deceased donor kidney transplant program in Sri Lanka, the number of deceased donor kidney transplants has increased significantly. The NHSL is among the few government hospitals with transplant facilities in Sri Lanka that has witnessed a recent surge in transplant operations after the launch of the national transplant program.In the early transplant period, complications of renal transplantation can arbitrarily be thought to occur within the first three months of transplant surgery. During this period, several complications occur, including DGF caused by tubular necrosis, acute allograft dysfunction from various causes , adverse side effects of drugs at higher doses , surgery-related complications, and various infections that are more prevalent early in the transplant course.This is the first study from Sri Lanka that focuses on deceased donor renal transplants. Our objective was to assess non-surgical complications that are specific to graft function and related to immunosuppressant medications. Specifically, we will examine DGF, acute allograft rejection, and infection, in addition to first-year mortality.This study was a single-center, descriptive study of deceased donor kidney transplant recipients who underwent transplantation between July 2018 and September 2020 at the NHSL, Colombo. All patients who underwent deceased donor kidney transplants during the study period fulfilled the eligibility criteria and were included and followed up for one year. Ethical clearance for the study was obtained from the ethical review committees of the National Hospital of Sri Lanka, Colombo, and the University of Colombo .Patient demographic and clinical data were obtained from medical notes, clinical records, electronic records, and direct communication with patients. Written informed consent was obtained from all study participants. The baseline demographic characteristics were analyzed using descriptive statistics. Follow-up data were recorded on a Google spreadsheet, which included a preset checklist for monitoring complications during each patient review.Our study included 27 patients who received deceased donor renal transplants between July 2018 and September 2020 and fulfilled the inclusion criteria. The mean age of the patients was 55 ± 9.519 years. Of the study sample, 22 (81%) were male and five (19%) were female, indicating a higher representation of males.All patients received basiliximab-based induction agents and a tacrolimus-based triple-drug regimen for maintenance. After undergoing renal transplants, patients were managed in the surgical intensive care units and then moved to the vascular and transplant wards, where they were kept until discharge. However, in subsequent admissions for any reason, patients were admitted to general medical wards as we did not have a dedicated renal ward at that time.Table Figure Pneumocystis jirovecii pneumonia. One (16%) patient died of mucormycosis, one (17%) patient died of myocardial infarction, and another patient (17%) died of another opportunistic infection. Notably, five of the six (83%) patients who died had infections as a contributing factor to their death.The pie chart in Figure The pie chart in Figure The data presented in Table Based on the horizontal bar chart in Figure The information presented in Figure The horizontal bar in Figure Table According to the data presented in Table Figure Owing to various etiological factors, CKD has become a significant health concern in Sri Lanka . The worOur study included all patients (n = 27) who underwent deceased donor kidney transplantation during the enrollment period. The mean age of the study sample was 55 ± 9.519 years, and there was a higher proportion of male patients.The median CIT in our sample was 9 ± 3.861 hours. Many studies have revealed the importance of reducing CIT in the prevention of post-surgical complications. It was found that a CIT of more than 20 hours has a higher risk of developing DGF; however, there was no difference between patients with a CIT of more than 20 hours and less than 20 hours at the one-year follow-up ,19. The The blood group in the majority of the patients (44%) was O+, 22% were A+, 19% were AB+, and 15% were B+. ABO compatibility is an important factor in finding a kidney donor. However, recent studies have described that ABO-incompatible kidney transplantation can also result in better outcomes when the required amount of medical care is provided and can be used when compatible donors are not found ,21.When comparing our results to those of a previous study conducted by Awan et al. in the United States, we found that the leading cause of one-year mortality following kidney transplant was cardiovascular disease (24.7%), followed by infectious causes (15.2%). However, in a previous study, only 3.2% of patients died within one year of kidney transplantation. These differences in results can be attributed to variations in the sample size and follow-up duration between the two studies .2. Both of these investigations can be used as prognostic assessments in post-kidney transplantation patients. The median measured GFR, one year following kidney transplantation, was 55 mL/minute/1.73 m2, and eGFR values were found to be different from the measured GFR. These findings occur as a result of using different equations with different biochemical findings to calculate eGFR [At one year of transplantation, the mean serum creatinine of the sample was 1.40 ± 0.68 mg/dL, and the mean eGFR was 62 ± 21.28 mL/minute/1.73 mate eGFR .Following transplantation, 25.9% of our sample had DGF and required dialysis support. DGF is a salient factor in determining the survival of both patients and the graft and develops due to the progression of acute kidney injury in the grafted kidney. Anticipation of DGF during surgery and early recognition and management is recommended to prevent morbidity in organ recipients . Acute tThe leading cause of death among post-kidney transplant patients in our study was infection (83%), particularly pneumonia (50% (n = 3) of total deaths; 17% (n = 1 ) had pneumocystis pneumonia). Other infectious causes of death included mucormycosis (16%) (n = 1) and other infections (17%). Myocardial infarction accounted for 17% (n = 1) of the total deaths, while one-year mortality was observed in 22% of our study sample.No significant difference was found between demographic factors , causes of CKD, and outcome  following kidney transplantation. There was no association between the development of postoperative complications, such as acute transplant rejection, infections, and DGF, and survival at one year. Data from our study demonstrated that within 2.5 months of kidney transplantation, 50% of the patients developed an infection. The blood group, DGF, CIT, and age failed to predict the survival of patients following kidney transplantation. However, some studies have demonstrated that DGF is a risk factor for mortality and reduces the frequency of one-year survival . A JapanDeceased donor kidney transplantation is an efficacious treatment option for end-stage renal failure, which results in long-term survival and an enhanced quality of life. Predicting complications due to kidney transplantation is important for the survival of patients and for reducing the healthcare burden of the country.Our study had several limitations that must be considered when interpreting the findings. One major limitation was the high incidence of infections post-transplant, which was likely because most post-transplant patients were admitted to general medical wards after the initial postoperative period, for any indication, as our center lacked dedicated renal wards. This lack of specialized care likely contributed to the higher rates of infections and mortality, leading to relatively low one-year survival rates in our study population.Additionally, our study had a relatively small sample size as deceased donor kidney transplantation was only recently initiated at our center. A larger sample size with a better probability and sampling technique would improve the generalizability of our findings and allow for a more robust investigation of deceased donor kidney transplantation outcomes in our population.Another limitation of our study is the potential for interviewer bias as the data were collected using an interviewer-based method. Future studies should employ more objective data collection methods to mitigate this limitation.Overall, despite these limitations, our study provides valuable insights into the outcomes of deceased donor kidney transplantation in our center and highlights the need for dedicated renal wards and enhanced infection prevention measures to improve post-transplant outcomes in our population.Kidney transplant is a lifesaving treatment modality for end-stage renal failure. However, complications due to surgery, immunosuppression, and host factors determine morbidity and mortality following kidney transplantation. Maintaining a lower CIT, taking adequate precautions to minimize the risk of infections, and minimizing the occurrence of DGF may improve patient and graft survival.


This study aimed at determining the prevalence of the eosinophilic phenotype defined as an eosinophil count ≥ 300 cells/mmThe Lebanese Chapter of the PREPARE study was a national, multicenter, cross-sectional observational study. Patients aged ≥ 12 years with severe asthma were identified and prospectively enrolled during clinic visits and completed the Global Initiative for Asthma (GINA) assessment of asthma control questionnaire. Patients’ health characteristics were collected from medical records and blood samples were obtained for measurement of serum IgE levels and blood eosinophils count.Overall, 101 patients  with severe asthma were included and, among them, 37% had eosinophilic phenotype, 67.3% had atopic phenotype with IgE > 100 IU/mL and 25.7% patients had overlapping atopic and eosinophilic phenotypes. Close to 80% had late-onset asthma, beyond 12 years of age, and around 85% had at least one severe exacerbation in the 12 months prior to study enrolment. The majority of participants [64.4%] had uncontrolled asthma, 24.7% had partially controlled symptoms and 10.9% had controlled symptoms. 19.8% of participants were on chronic oral corticosteroids, 78.2% had short course treatment of corticosteroids and all were prescribed a combination of inhaled corticosteroids and long-acting beta-agonist.The majority of patients with severe asthma were uncontrolled of which 37% present with an eosinophilic phenotype, which should be taken into consideration for better management of these patients in view of the novel phenotype-specific therapeutic options. Asthma is a leading cause of morbidity with a global prevalence of approximately 300 million and is expected to increase to 400 to 450 million people worldwide by 2025 . In LebaDespite the availability of multiple therapeutic options, 5–10% of asthmatic patients experience severe disease associated with substantial morbidity.Severe asthma poses a great burden on the healthcare system , 5 that Severe asthma is currently considered a heterogeneous disease, with various phenotypes, owing to the variety of inflammatory, clinical and functional characteristics that it can present with. One of the most studied phenotypes is severe eosinophilic asthma , 10. Eos3, have been linked to increased asthma exacerbations, and adult-onset asthma patients with blood eosinophil counts ≥ 300 cells/mm3 is a distinct phenotype of severe asthma characterized by frequent exacerbations and poor prognosis ), aged between 12 and 77 years old, with an average age of 46.3 ± 17.0. Table 3, and only (37 [36.6%]) patients had an eosinophilic phenotype with an eosinophil count ≥ 300 cells/mm3   patients had a blood eosinophil count ≥ 150 cells/mm3  had available spirometry results. On average, the most recent tests date back to 3.58 ± 4.15 months with a median of 2.30 months. Spirometry results are summarized in Table The majority of patients (65 [64.4%]) had uncontrolled asthma, 11 patients [10.9%] had controlled symptoms and 25 patients [24.7%] had partially controlled symptoms.A total of (67 [66.3%]) patients had a history of atopy. Around (41 [83.7%]) out of the 49 patients showed positive results for skin prick test, (29 [90.6%]) out of the 32 patients for aeroallergens, and 21 cases [72.4%] out of 30 patients had a positive specific IgE test.The majority of patients presented comorbidities [78.2%]: rhinitis (48 [60.8%]), atopic dermatitis 12 [15.2%], nasal polyps (11 [13.9%]), asthma associated with non-steroidal anti-inflammatory drugs  and other comorbidities (37 [46.8%]). The other associated morbidities included metabolism and nutrition disorders in 17 (16.8%) patients, gastrointestinal disorders in (14 [13.9%]) patients, vascular disorders in (13 [12.9%]) patients and other less frequent morbidities.Asthma treatment in the 12 months prior to study enrollment included chronic OCS, burst/short course corticosteroids, ICS + LABA. Out of the 101 study patients, the majority of patients (79 [78.2%]) needed burst/short course treatment of corticosteroids to up to 10 times over 12 months with an average of 2.3 ± 1.5 per year. All patients were prescribed ICS + LABA Table . AdditioTable The PREPARE study was an observational, cross-sectional and multicenter study that aimed primarily at reporting the prevalence of the eosinophilic phenotype among Lebanese patients with severe asthma, aged 12 years and beyond enrolled in 21 medical centers.3, was identified among 37% of Lebanese patients with severe asthma. This matches regional and global prevalence figures for the prevalence of this phenotype in severe asthma patients. In Saudi Arabia, 45% of patients with severe asthma had the eosinophilic phenotype and half of them had an overlapping atopic phenotype [The eosinophilic phenotype, defined as an eosinophil count ≥ 300 cells/mmhenotype . In Japahenotype . Prevalehenotype .Close to 80% of the patients had late-onset asthma; i.e., beyond the age of 12 years old, and, on average, patients in this study were diagnosed with severe asthma for 15 ± 12 years.Late-onset asthma has been associated with various risk factors of which gender, BMI and smoking status, which drive airway inflammation in asthma . In thisFurthermore, the highest rate of exacerbations occurred among overweight patients, further underscoring the importance of weight control among asthma patients , 31. WhiBesides, uncontrolled severe asthma poses a major economic burden on the healthcare system , 5 and aIn accordance with the GINA 2021 updated recommendations for severe asthma treatment, 60% of patients were on formoterol combined to ICS while 71% were also on montelukast, a leukotriene receptor antagonist endorsed in GINA Step 5 asthma management .Despite the adequate treatment application and intensification, the majority of patients had uncontrolled asthma. Hence, the importance of severe asthma classification and the application of targeted phenotype-specific treatments. For atopic asthma, many monoclonal antibodies were developed and showed potential effects: Omalizumab  and DupiRegarding eosinophilic asthma, several biologics targeting IL-5, mepolizumab  or its rThis study presented some limitations. First, the cross-sectional nature does not permit to establish causality between clinical asthma characteristics and variables reported in the study . Second, the relatively small sample size (further reduced by the exclusion of patients on biologics) might not be representative of the whole population with severe asthma. Third, patients who were on biologic treatment were not included in this study. Patients were enrolled in 21 different sites covering all the regions in Lebanon with a representative sample size adequate for each site though. While the updated GINA 2022 guidelines recommend biologic therapy for eligible asthma patients , this obIn conclusion, this study suggests that a substantial proportion of severe asthma patients in Lebanon present the eosinophilic phenotype and have poorly controlled disease even when treated with medium and high doses of ICS/LABA; they frequently required OCS maintenance and experienced a high frequency of exacerbation. This study highlights the importance of identifying and evaluating this group of patients for phenotype-specific treatment strategy.


Background: This study aimed to examine the changes to choroidal blood flow velocity using laser speckle flowgraphy (LSFG) in healthy eyes after warm water immersion at 40°C.Methods: Data regarding the right eyes of 23 healthy volunteers were included. The mean blur rate (MBR) of the macula, which represents the choroidal blood flow velocity, was evaluated using LSFG. Intraocular pressure (IOP), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), ocular perfusion pressure (OPP), and MBR were assessed at baseline, immediately after immersion (0 minutes), and 10, 20, and 30 minutes later.Results: At 0 minutes, SBP, DBP, MBP, and OPP values were lower than those at baseline. The MBR significantly declined immediately after immersion to -6.0 ± 5.2%. However, there were no changes in these parameters after 10, 20, or 30 minutes. A significant positive correlation was observed between the MBR, SBP, DBP, MBP, and OPP values. In healthy individuals, the dominant parasympathetic activity induced by warm stimulation reduced the choroidal hemodynamic rate in the macula and decreased systemic circulatory dynamics, which normalized after 10 minutes.Conclusions: These findings suggest that the dominant parasympathetic activity induced by warm water immersion at 40°C may lead to a reduction in the systemic circulation rate and choroidal blood flow rate in the macula. These findings may help prevent and treat various retinal choroidal diseases, in which sympathetic hyperactivity is involved in the pathogenesis of the disease. The autonomic nervous system includes the sympathetic and parasympathetic systems. Cold stress activates the sympathetic nervous system and the release of norepinephrine, resulting in increased blood pressure (BP), heart rate (HR), and decreased choroidal thickness, measured with enhanced depth imaging optical coherence tomography. These findings are referred to as pressor responses and cold pressor tests are used to evaluate sympathetic responses in systemic cardiovascular dynamics -6. This In contrast, thermotherapy provides physical benefits such as increased skin temperature and blood flow and psychological benefits such as pain relief and comfort, which can reduce pain and anxiety levels ,10. WarmThe choroid is a blood-rich tissue of the intraocular blood flow and is characterized by poor autoregulation -15. InteA recent study has shown that increased sympathetic nervous system activation elicited by the cold pressor test in healthy young individuals increased the macular MBR alongside an increase in systemic circulatory dynamics . HoweverParticipantsThis study was approved by the Ethics Committee of Fukuoka International University of Health and Welfare  and adhered to the tenets of the Declaration of Helsinki. Written informed consent was obtained from all participants. In this prospective investigation, the right eyes of 23 healthy individuals (nine men and 14 women) without ophthalmic or cardiovascular disease were included , fundus photography, intraocular pressure (IOP), BP, HR, and LSFG.Warm water immersionExaminations were performed at room temperature (24 ± 1°C) and a humidity of 47 ± 3% in a quiet examination room ,19,21. DLaser speckle flowgraphy measurementThe LSFG-NAVI  was used to measure the hemodynamics of the posterior fundus. The LSFG uses an 830-nm diode laser to illuminate the fundus and detect moving red blood cells in the deep choroidal vessels. Each LSFG measurement was taken three times at baseline, immediately after immersion (0 minutes), and every 10 minutes up to 30 minutes after immersion. Changes in choroidal blood flow velocity were evaluated by excluding large retinal vessels in the macula  at the same site where the circle was set at baseline. The change in the average MBR was evaluated as the change relative to the baseline value, which was set at 100% , 20-21.Intraocular pressure and hemodynamicsThe IOP, systolic BP (SBP), and diastolic BP (DBP) were examined at baseline, immediately after warm water immersion (0 minutes), and after 10, 20, and 30 minutes. The IOP measurements were performed using a non-contact tonometer. The mean BP (MBP) was calculated from the SBP and DBP, and the ocular perfusion pressure (OPP) was calculated from the MBP and IOP, according to the following equation:MBP = DBP + 1/3(SBP - DBP) (1)OPP = 2/3MBP - IOP (2)StatisticsAll data are reported as the mean (standard deviation: SD). Friedman and Scheffe’s paired comparison tests were used for continuous changes in IOP, SBP, DBP, HR, MBP, OPP, and MBR. Spearman’s rank correlation test was utilized to determine the relationship between the rate of change in MBR and other studied factors. P-values of < 0.05 were considered indicative of statistical significance in all tests.The average participant age was 23.9 ± 7.3  years. All participants had a BCVA score of ≥ 1.0 .The IOP, SBP, DBP, HR, MBP, and OPP valuesChanges in the IOP, SBP, DBP, HR, MBP, and OPP values are summarized in Tables The SBP, DBP, MBP, and OPP values significantly decreased immediately after warm water immersion compared to those at baseline. They did not change thereafter Table . The IOPThe LSFG dataThe changes in MBR are shown in Tables Correlation between MBR and IOP, SBP, DBP, HR, and OPPThe rate of change in MBR was correlated with the change in IOP, SBP, DBP, HR, and OPP from baseline to immediately after warm water immersion. The MBR was significantly correlated with SBP, DBP, MBP, and OPP values. However, MBR did not correlate significantly with IOP and HR Table .In the present study, the SBP, DBP, MBP, OPP, and MBR values reduced significantly after foot immersion in warm water at 40°C for 60 seconds, with no further changes observed after 10 minutes or later. Furthermore, the MBR had statistically significant positive correlations with SBP, DBP, MBP, and OPP.Central serous chorioretinopathy (CSC) is an ocular disease precipitated by increased sympathetic nervous system activity and a stressful personality and has been reported to completely resolve subretinal fluid within six months. The BCVA significantly improved at six months compared to the initial BCVA, and the average macular MBR significantly decreased at three and six months, respectively, compared to baseline. Thus, macular choroidal blood flow velocity decreases concurrently with CSC regression . In addiThe temperature at which heat-induced pain occurs, where the sympathetic nervous system dominates, is considered to be 43°C or higher . In wateOverall, the evidence from the previous and present reports suggests that warm stimulation at approximately 40°C, where parasympathetic activity is dominant, reduces choroidal blood flow velocity, following a decrease in systemic hemodynamics. In addition, these results may help prevent and treat various retinal choroidal diseases, such as CSC, in which sympathetic hyperactivity is involved in the pathogenesis of the disease.There are some limitations to this study. First, the participants were mainly young, healthy adults, and the only stimulus condition was immersion of both feet up to the ankle in water at 40°C for 60 seconds. Second, because of measurement time constraints, choroidal thickness examination and evaluation have not been performed. Further research should examine how elevated parasympathetic activity affects choroidal changes in healthy individuals of different sexes and ages, considering various stimulus conditions.Our data suggest that in healthy individuals, the dominant parasympathetic activity induced by warm water immersion reduces macular choroidal blood flow velocity as well as systemic dynamics. These new observations suggest that the LSFG may provide a new method for evaluating parasympathetic nerve activation and intrinsic vascular reactivity in the eye. Future research should examine whether parasympathetic dominance contributes to preventing CSC onset or improving symptoms.


New-onset atrial fibrillation (NOAF), an important postoperative complication, has pertinent inflammatory links. Motivated by the encouraging literature on the prognostic role of hypoalbuminemia, leukocytic indices , systemic inflammation response index (SIRI=NLR×monocyte) and platelet-leukocytic indices [PLIs: platelet-to-lymphocyte ratio (PLR)], systemic immune inflammation index (SII=NLR×platelet), aggregate index of systemic inflammation (AISI=NLR×platelet×monocyte), we sought to investigate the NOAF-predictive value of preoperative albumin-adjusted indices (aa-LIs and aa-PLIs) in an off-pump coronary artery bypass grafting (OPCABG) setting.P wave in the first week postoperatively).Of 899 patients, 151 patients (16.79%) developed the primary outcome i.e. NOAF that was analyzed further retrospectively for its predictors instead of the highlighted text perioperative data of 899 patients undergoing elective OPCABG, were retrospectively analyzed. The study participants were categorized into non-NOAF and NOAF groups . aa-NLR ≥1.32, aa-PLR ≥52.64, and aa-SII ≥344.38 predicted NOAF with the respective AUC;sensitivity;specificity of 0.66;63.6%;73.3%, 0.63;66.2%;59.0%, and 0.65;58.3%;78.2%. Preoperative aa-NLR, aa-PLR and aa-SII also positively correlated with CHA2DS2-VASc score .One hundred and fifty-one patients (16.79%) developed NOAF. On univariate analysis: age, smoker status, The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, systemic hypertension, diabetes mellitus, prior congestive heart failure (CHF), and a higher preoperative NLR, PLR, SII, and albumin were significant predictors of NOAF. While age, CHF, and EuroSCORE II retained predictive significance in multivariate analysis, LI-PLIs and albumin did not emerge as independent NOAF predictors. Notably, aa-NLR, aa-PLR, and aa-SII independently predicted NOAF on the computation of model-estimates in the regression analysis (Odds ratio; 95% confidence interval: 31.05;15.75-70.61, 1.04;1.02-1.05, 1.12;1.10-1.14, respectively, The independent NOAF predictive value of aa-NLR, aa-PLR, and aa-SII reiterates the inflammatory relationship of the arrhythmic complication following OPCABG. The secondary objectives of the study were to derive the NOAF predictive cut-offs of aa-LIs and aa-PLIs and evaluate the correlation of preoperative hematological inflammatory indices with the CHA2DS2-VASc score14 (a scoring system widely described to be associated with an elevated NOAF-risk).Hypoalbuminemia too has considerable significance from the inflammatory standpoint and its’ association with poor cardiac surgical outcomes (including NOAF).-1, unavailability of hematological investigations within 72 hours of surgery, hepatic dysfunction , end-stage renal disease , undergoing either concomitant valve surgery and emergency CABG were excluded at the beginning of the study. Apart from these any condition affecting leukocyte counts and albumin levels were also excluded eg. active infection, patient on steroids, lymphoproliferative disorders, or systemic hypoalbuminemic disorder.After obtaining the ethical approval by Institutional Ethics Committee of Atal Bihari Vajpayee Institute of Medical Sciences & Dr. Ram Manohar Lohia Hospital [554(90/2021)/IEC/ABVIMS/RMLH/735], the present retrospective case-control study was conducted at our tertiary care referral center, on patients scheduled for elective OPCABG surgery between January 2017 and October 2021. Patients with pre-existing arrhythmia or amiodarone therapy, pre-existing neurological deficit, thyroid disorder, anemia with hemoglobin (Hb) <10.0 g dL15 The albumin-adjusted LIs and PLIs were computed by dividing the corresponding values by serum albumin levels, eg: aa-NLR=NLR/albumin. Intraoperatively duration of surgery, the total number of grafts, vessel grafted, and number of blood and blood product units transfused were noted.Preoperative demographical characteristics evaluated were age, sex, history of smoking, hypertension (HTN), diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), peripheral vascular disease (PVD), history of prior congestive heart failure (CHF), history of previous myocardial infarction (MI), hyperlipidemia. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was evaluated for each patient from the calculator available on official website www.euroscore.org. A detailed preoperative drug history was also recorded. Preoperative laboratory investigations compared between the groups were Hb, total leukocyte count, differential leukocyte count (DLC), platelet count, blood urea, serum creatinine, albumin, SGOT and SGPT levels, triglycerides, and on echocardiogram, left-ventricular ejection fraction and regional wall motion abnormality were noted. From the DLC, NLR, PLR, MLR, SII, SIRI and the AISI values were derived.Postoperatively, the parameters recorded were duration of mechanical ventilation (DOMV), length of intensive care unit (LOS-ICU) stay, length of hospital stay (LOS-H), postoperative mean lactate levels, mean vasoactive inotropic score (VIS), incidence of major adverse cardiac events (MACE), cerebrovascular accident (CVA), acute kidney injury (AKI), intra-aortic balloon pump (IABP) insertion, and in-hospital mortality.-1 min-1)+dobutamine (µg kg-1 min-1)+milrinone (µg kg-1 min-1)×10+ epinephrine (µg kg-1 min-1)×100+norepinephrine (µg kg-1 min-1)×100+ vasopressin (µg kg-1 min-1)×10000.15VIS was calculated as dopamine (µg kg-1 m2), and cardiac-arrest.15 Perioperative CVA was defined as any new temporary or permanent, focal or global neurologic deficit in accordance with the standardized Valve Academic Research Consortium-2 guidelines for cerebrovascular events after Trans Catheter Aortic Valve Implantation.16 New-onset renal failure was defined according to Kidney Disease: Improving Global Outcomes Foundation as an increase in serum creatinine by ≥0.3 mg dL-1 (≥26.5 µmol L-1) within 48 h; or an increase in serum creatinine to ≥1.5 times the baseline value, which is known or presumed to have occurred within the prior 7 days; or urine volume < 0.5 mL kg-1 h-1 for 6 h.17MACE was characterized by any of the following: ST-segment elevation Myocardial Ischemia, low cardiac-output syndrome , diabetes, sex, history of stroke (assigned a score of 2), and vascular disease. Higher the CHA2DS2-VASc score, higher the stress on the atria and hence an increased incidence of NOAF and subsequent stroke.14CHA-1 fentanyl, 0.2 mg kg-1 etomidate, and 1.2 mg kg-1 rocuronium, titrated to hemodynamics. Patient was put on volume control mechanical ventilation at a ratio of inspired oxygen and air at 1:1, tidal volume 6-8 mL kg-1 to maintain end-tidal carbon dioxide at 34-35 mmHg. Central venous line and pulmonary artery catheter were placed. Anaesthesia was maintained with fentanyl, rocuronium, and isoflurane. Arterial blood gas analysis was performed at regular intervals to monitor arterial oxygen concentration, electrolyte balance, mixed venous oxygen saturation (ScVO2), Hb and hematocrit, and blood sugar levels. Temperature was monitored and maintained at 35-36°C. Blood sugar values were maintained between 140-180 mg dL-1 by using insulin infusion if required. Blood and blood products were transfused if Hb below 10 g dL-1 or hematocrit <28-30% and based on Sonoclot ACT machine results respectively.The anaesthetic induction and maintenance were as per institutional protocol. After standard premedication, arterial line was inserted and the patient was induced with 3-5 µg kgAfter midline sternotomy, the left internal mammary artery (LIMA) was harvested. Simultaneously saphenous venous graft too was harvested. Heparin 200 IU kg was administered after LIMA harvest to achieve an activated clotting time of >300 sec. The Octopus Evolution Tissue Stabilizer  was used to stabilize the target coronary artery and after placing intracoronary shunts as to prevent distal ischemia and maintain graft patency, distal anastomosis was performed with 7-0 prolene suture, and for proximal anastomosis 5-0 prolene sutures were used.P wave on 12 lead ECG or as recorded in the case files, in the first 7 days postoperatively.18At the end of anastomosis, heparin was reversed with protamine in a ratio of 1 mg/100 IU of heparin and the patient shifted to ICU for elective mechanical ventilation, and extubated once the extubation criteria were satisfied. Strict hemodynamic monitoring was followed in the ICU using invasive pressure monitoring and rhythm monitoring. In addition, a 12-lead electrocardiogram was performed daily, and on the detection of arrhythmias. Occurrence of NOAF was defined as a new onset atrial arrhythmia with irregular RR intervals without discernible P value less than 0.05 is considered significant.For descriptive statistics, after dividing the patients into NOAF and non-NOAF groups, continuous variables are expressed as mean, median, and standard deviation and compared across the groups using Mann-Whitney U test , while categorical variables are expressed as number and percentage of patients and compared across the groups using Pearson’s chi-square test for independence. Odds ratio (OR), 95% confidence interval (CI) and significance level is provided for variables significant in the univariate logistic regression analysis. Multivariate analysis was done using binary logistic regression. Furthermore, for the analysis of albumin-adjusted parameters three multivariate binary logistic regression analysis models were designed for variables discriminating two groups. The threshold value effect of albumin, each hematological parameter, and albumin-adjusted ratios on NOAF was observed by receiver operating characteristic (ROC) curve, and calculated relative predictive powers as measured by area under the curve (AUC). The sensitivity, specificity, and predictive values were reported using these generated cut-offs. Association between continuous variables is captured by Spearman’s rank correlation coefficient. The statistical software SPSS version 22 has been used for the analysis. An alpha level of 5% i.e. any Out of total 1121 patients initially inducted, after accounting for the exclusion of 134 patients at the baseline, 70 patients due to intraoperative conversion to on-pump, and concomitant unavailability of adequate follow up data in 18 patients; 899 patients were eventually included in the study. The patient enrolment is illustrated in P < 0.001), EuroSCORE II , and history of prior CHF  were independent predictors of NOAF (P < 0.001).Subsequent to univariate regression analysis, factors predicting NOAF after OPCABG were: advanced age, higher EuroSCORE II, smoker status, comorbidities viz systemic HTN, DM, prior CHF, and a higher NLR, PLR, SII and serum albumin level as outlined in  of NOAF . HoweverP=0.350).Subsequently, ROC analysis of serum albumin, LI-PLIs revealed the cut-off values for the development of NOAF following OPCABG as illustrated in 2DS2VASc, and aa-LIs and aa-PLIs, a significant linear correlation  was revealed between the two parameters as depicted in On applying Spearman’s correlation analysis between CHA19 The 16.79% incidence of NOAF in our study relates closely to the existing literature on the research subject.1 As far as postoperative NOAF predisposition is concerned, the risk-factors emerging from our retrospective analysis are also largely comparable to the NOAF literature in cardiac surgical arena.20The index elucidation of an independent NOAF-predictive significance of the aa-LIs and aa-PLIs in an OPCABG setting , is congruent with the recent studies from non-operative settings suggesting an augmented inflammatory prognostic potential of a combined account of the leukocytic and albumin levels.21 The postoperative inflammatory atrium is “anisotropic” i.e. variegated with cells having different refractory periods and conduction velocities, enhancing its susceptibility to aberrant electrical activity.2 A 2014 systematic review by Jacob et al.3 highlighted the importance of white blood cell elevations in predicting NOAF after cardiac surgery. Furthermore, the 2020 meta-analysis by Liu et al.4 distinctively addressed the research subject of NLR predictive value of AF in cardiac surgery by a pooled analysis of 12 studies and 9,262 patients. They outlined preoperative NLR as a significant predictor of NOAF  and concluded that the former emerges as a promising NOAF prognostic marker but simultaneously flagged the residual potential sources of heterogeneity.4 Our study also delineated preoperative NLR as a NOAF predictor in univariate but not in multivariate analysis. The preoperative NLR cut-off of 4.01 derived in our study, also corroborates with the threshold NLR values described in the studies included in the Liu et al.4 meta-analysis. Interestingly, the Liu et al.4 meta-analysis additionally demonstrated that an elevated postoperative NLR fails to predict NOAF. Meanwhile, OPCABG is considered to be associated with lower incidence of NOAF in view of the absence of side effects of extracorporeal circulation and inadequate myocardial protection as well as due to advances in the OPCABG techniques.22 The incidence of AF in our study is 16.79%, commensurate with that in the literature and less than on-pump CABG which is 21.7%.22Inflammatory conditions such as pericarditis, postoperative period, and histological findings of inflammatory infiltrates in cases of lone AF suggest inflammation is intimately associated with the occurrence of AF, the major research element in the index study.5. Nonetheless, there is a dearth of literature on PLR cut-offs for post-cardiac surgery NOAF prediction in order to draw holistic comparisons. As far as preoperative SII is concerned, our cut-off value of 1066.22 mm3 adds to the recent studies by Selcuk et al.7 and, Ata and Abanoz23 highlighting NOAF-predictive SII cut-offs of 807.8 mm3 and 986 mm3, in their respective operative settings of isolated CABG.Ahead of NLR, PLR and SII have received research attention in the purview of NOAF prediction following cardiac surgery. A preoperative NOAF-predictive PLR cut-off of 174.74 emanating from our study exceeds the 119.3 cut-off of PLR outlined by Gungor et al.11 outlined significantly lower albumin levels of 2.87 ± 0.34 g dL-1 in NOAF-patients versus 3.77 ± 0.47 g dL-1 in non-NOAF patients. The corresponding NOAF-predictive cut-off was 3.05 g dL-1 in the Akgül et al.11 study whereas 2.85 g dL-1 emerged as the NOAF-predictive albumin cut-off in our OPCABG cohort. More importantly, the higher OR of C-reactive protein (CRP) albumin ratio  in comparison to the serum CRP and albumin levels alone  outlined by Karabacak et al.24 in 830 CABG patients, epitomizes the basic concept of our study propounding the need for a comprehensive inflammatory assessment.Specific to the post-CABG NOAF links of hypoalbuminemia, Akgül et al.13 recently highlighted the association of systemic inflammation score  with AF in 376 pairs of cases and controls using a propensity score matching system. However, our study evaluated a homogeneous surgical cohort (CABG) and adjusted the individual leukocytic ratios and the indices to the albumin levels motivated by the recent Yoon et al.12 elucidation of the co-existence of lower albumin levels with higher SII, in cardiac surgical patients.Appropriate to the context of the prognostic value-addition owing to a combined account for hypoalbuminemia and inflammatory leukocytic alterations, Zhang et al.4 Alongside the comprehension of an inflammatory alliance of neutrophilia and lymphocytopenia, albumin also has vital physiological functions including the maintenance of vascular endothelial integrity, anti-oxidative and anti-inflammatory properties.25 From a NOAF-pathophysiological perspective, perioperative inflammation renders the myocardium as a tissue mosaic of varying refractory periods and/or conduction velocities which enhances the susceptibility to aberrant electrical-activity, and conduction re-entry - the so called “anisotropic” atrium.2The perioperative inflammatory response plays a pivotal role in the genesis of NOAF.2DS2-VASc score, adds further credibility to the research findings. It is worthwhile to point out that the CHA2DS2-VASc score employs certain patient-risk factors such as age  as categorical parameters for the scoring purposes (eg: age >75 years: scored 2 and age 65-74 years scored as 1).14 Nonetheless, we studied such risk-parameters in their original continuous statistical connotations.To the best of our knowledge, the index study classifies as a seminal research endeavour focusing on the NOAF-predictive value of aa-LIs and aa-PLIs in OPCABG. Needless to say, the large homogeneous surgical cohort is the major strength of the study. Moreover, the additional evaluation of the correlation of the preoperative aa-LIs and aa-PLIs with well-established patient-centric NOAF-risk scoring systems like the CHA26 Although, as mentioned above, the Liu et al.4 meta-analysis failed to attribute NOAF-predictive value to the postoperative NLR, the inclusion of postoperative LIs and PLIs in our study could have rendered the analysis more comprehensive. With that said, the isolated evaluation of an off-pump patient subset in our study potentially prevents the hematological and biochemical perturbations associated with the conduct of extracorporeal circulation. The lack of echocardiographic data on the concomitant atrial dimensions of the study participants, is also an important limitation considering NOAF was being evaluated as the primary outcome.27 Lastly, inclusion of other markers like CRP could have further strengthened the inflammatory relationship proposed in the present research endeavour.24The study had its’ own limitations given the retrospective design being peculiarly susceptible to residual confounding.The independent NOAF predictive value of aa-LIs and aa-PLIs reiterates the inflammatory relationship of the arrhythmic complication following cardiac surgery. While awaiting future prospective literature in this area of clinical importance, it only becomes imperative to reflect upon the need of an inflammatory account in the comprehensive risk-stratification and subsequent positive risk-modulation, aligned with the ultimate goal of improving postoperative outcomes in cardiac surgical subset.


Rheumatic and musculoskeletal disorders (RMDs) are associated with cardiovascular diseases (CVDs), with hypertension being the most common. We aimed to determine the prevalence of high blood pressure (HBP), awareness, treatment, and blood pressure control among patients with RMDs seen in a Rheumatology clinic in Uganda.We conducted a cross-sectional study at the Rheumatology Clinic of Mulago National Referral Hospital (MNRH), Kampala, Uganda. Socio-demographic, clinical characteristics and anthropometric data were collected. Multivariable logistic regression was performed using STATA 16 to determine factors associated with HBP in patients with RMDs.2 (interquartile range (IQR): 24.8 kg/m2–32.9 kg/m2). The prevalence of HBP was 61% , with the majority  being aware they had HTN. The prevalence of HTN was 47% , and none had it under control. Factors independently associated with HBP were age 46-55years : 2.5, 95% confidence interval (CI): 1.06–5.95), 56–65 years , >65 years , obesity , overweight .A total of 100 participants were enrolled. Of these, majority were female  with mean age of 52.1 (standard deviation: 13.8) years and median body mass index of 28 kg/mThere was a high burden of HBP among people with RMDs in Uganda with poor blood pressure control, associated with high BMI and increasing age. There is a need for further assessment of the RMD specific drivers of HBP and meticulous follow up of patients with RMDs. Hypertension (HTN) is a significant public health concern globally, with its prevalence continually rising in developing countries. According to the World Health Organisation, an estimated 1.28 billion adults aged 30–79 years worldwide have hypertension, with about two thirds living in low- and middle-income countries such as Uganda [Patients with rheumatic and musculoskeletal diseases (RMDs) such as rheumatoid arthritis (RA), systemic lupus erythematous (SLE), osteoarthritis (OA), gout and Sjogren’s syndrome are at an increased risk of developing HTN, with chronic inflammation as the main driver –6. ChronAnyfanti and colleagues, in a study conducted among patients with RMDs attending Rheumatology Outpatient Clinics in Greece, showed a high prevalence of HTN, estimated at 54.5%, with 21.7% being unaware that they had HTN . In addiTherefore, in the present study, we aimed to determine the prevalence of high blood pressure (HBP), awareness, treatment, and BP control among patients with RMDs seen in a Rheumatology clinic in Uganda.Using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, we conducted a cross-sectional analytical study. Data were collected prospectively between January and April 2022. The study was conducted in the Rheumatology Clinic of Mulago National Referral Hospital (MNRH), Kampala, Uganda. MNRH, located in the capital city, Kampala, is the largest public health facility in Uganda serving as a national specialized hospital with over 1800-bed capacity. The clinic is run by a rheumatologist (MK) assisted by other medical officers and registered nurses and has over 200 patients with various RMDs. The clinic is the largest in the country and serves as the national referral center for patients with RMDs across the country.We included patients of Ugandan nationality aged 18 years and above, with a confirmed diagnosis of RMD, irrespective of the gender, attending the MNRH Rheumatology Clinic after having given the consent to participate. The RMDs of interest were: RA classified according to 2010 European League Against Rheumatism (EULAR)/ American College of Rheumatology (ACR) criteria , gout clData classified into socio-demographic, clinical  and anthropometric  were collected using an interviewer administered semi structured questionnaire and direct measurements taken by the interviewers. The questionnaires were printed out and administered by the interviewers to the respondents at the Rheumatology clinic, to ensure that the respondents understand the questions. Three BP measurements were taken on the same day on two occasions, four hours apart, on both arms using a manual sphygmomanometer because it is the recommended method for accurately assessing BP . Each paAwareness was assessed by asking the patient whether they were hypertensive or not using a single question.2), where N = 150, and e is 5%, a final sample size of 130 participants was obtained [The sample size of 194 participants with RMDs was calculated using the modified Kish and Leslie formula  for finiobtained .Data was cleaned, coded and entered into Microsoft 2016, and exported for analysis using the STATA version 17.0 analysis software. Numerical data were assessed for normality using Shapiro-Wilk test. Continuous variables were expressed as mean and standard deviation for parametric variables or median and interquartile range for non-parametric variables. Categorical data were presented as frequencies and percentages. Chi-square or Fischer’s exact tests were used to compare categorical variables as appropriate and student t-tests or Mann-Whitney U for numerical variables. Modified Poisson regression was used to determine the factors associated with HBP and association was measured using the prevalence ratio because the prevalence of HBP is high, which may bias odds ratio values –32. We c140/90 on the day of the current clinic visit (day of the interview).HBP was defined as an office systolic blood pressure (SBP) ≥ 140mmHg and/or diastolic blood pressure (DBP) ≥90 mmHg . HBP awaDeclaration of Helsinki-2013.Ethical approval was sought from Mulago Hospital Research and Ethics Committee . Approved by MHREC, a modification was made to the initial protocol from targeting only patients with RA to include patients with RMDs. All participants provided written informed consent by signing a consent form appended to the questionnaire. The study was conducted in observance of the 2 (IQR: 24.8 kg/m2-32.9 kg/m2). Fifty-nine participants were employed (59%), from urban residency , majority had no history of smoking  or use of alcohol  and forty-nine had family history of hypertension (49%). Eight (8%) participants had diabetes mellitus. Overall, the median SBP and DBP were 129.3(IQR: 118.3–144.7) mmHg and 81.3(IQR: 74–90.7) mmHg, respectively. The trends of systolic and diastolic blood pressure in participants are shown in Of the anticipated 130 participants, 110 participants turned up at rheumatology clinic during the study period. However, only 100 participants met the eligibility criteria and were enrolled, resulting in a positive response rate of 100/110. No significant differences were observed between the participants and non-participants in terms of age, gender, or disease severity. The majority of participants were female , with mean age of 52.1(SD: 13.8) years and median BMI of 28 kg/mThe prevalence of HBP was 61% . Out of the 61 participants with HBP, the majority  were aware they had HTN. The prevalence of HTN was 47% , and none had it under control. The most frequent RMDs were RA (80.3% in patients with HBP versus 76.9% in those without) followed by OA (9.8% in patients with HBP versus 12.8% in those without), gout (8.2% in patients with HBP versus 0% in those without) and other RMDs which are SLE, spondyloarthropathies, sjogren’s syndrome and ANCA-associated vasculitis (1.6% in patients with HBP versus 10.3% in those without). Individuals with HBP were older (p = 0.001) and had higher BMI (p<0.001) and median waist-to-hip ratio  compared to those without Factors independently associated with HBP were age 46-55years : 2.5, 95% CI: 1.06–5.95), 56–65 years , >65 years , obesity , and overweight  In this study, we aimed to determine the prevalence of HBP, awareness, treatment, and blood pressure control among patients with RMDs seen in a Rheumatology clinic in Uganda. However, comparability of our findings with data from the literature of RMDs is limited because, apart from one study conducted in Greece , this isWe found the prevalence of HBP to be 61%, with the majority (77%) of those aware that they had HTN, however, only 44.7% of participants had it under control. These findings align with results of the study conducted by Anyfanti and colleagues in Greece among patients with RMDs attending Rheumatology Outpatient Clinics . The stuIn our study, obesity was independently associated with HBP, consistent with previous studies conducted in both patients with RMDs and the general population , 38, 39.Our study revealed a significant association between increasing age from 36 years and HBP among participants. This finding could be explained by the higher proportion of older participants in our study. Aging is characterised by physiological changes in the cardiovascular system, including arteriosclerotic structural alterations and calcification, leading to large artery stiffness. Consequently, the blood vessels become less flexible and more rigid, resulting in elevated resistance to blood flow and higher BP levels. Moreover, aging is associated with chronic inflammation and oxidative stress, which, in conjunction with the chronic inflammation associated with RMDs further augments the risk of developing HBP . InflammRheumatologists, allied health professionals, and stakeholders involved in the care of patients with RMDs should consider incorporating lifestyle changes in patient care to reduce body fat, thereby preventing obesity , 44. In Our study was not without limitations. Despite our study site being at a national referral hospital serving patients from across the country, it was a single centred study. Therefore, our findings are not generalizable to the Ugandan population. In addition, we used a non-standardized questionnaire which was however, developed based on expertise of physicians experienced in the management of RMDs in Uganda. We acknowledge that not measuring CRP levels among patients with RMDs limited our ability to directly investigate the potential link between inflammation in RMDs and HTN. Measuring CRP levels in future studies will be valuable in understanding the role of inflammation in the development and progression of HTN among patients with RMDs. In addition, we did not assess the causality of the associations observed because of cross-sectional study design. This was also the first study to assess the prevalence and factors associated with HBP in patients with RMDs in Uganda.This study shows a high burden of HBP among patients with RMDs in Uganda, with a considerable number being aware of their condition but experiencing poor BP control. The high burden was associated with high BMI and increasing age in this population. Thus, lifestyle modifications including weight management are crucial in preventing and managing HBP and its complications such as future cardiovascular disease and deaths. Continuous medical education and tailored guidelines for cardiovascular risk in RMDs are recommended.S1 Dataset(XLSX)Click here for additional data file.


In November 2017, the American Heart Association (AHA) and the American College of Cardiology (ACC) launched new guidelines for detecting, treating and controlling hypertension.The cornerstone of the new guidelines has come from the results of the Systolic Blood Pressure Intervention Trial (SPRINT). This was a large randomized clinical trial that revealed that the risks of all causes of deaths and of new cases of cardiovascular diseases were lower only at blood pressure levels lower than the previous cutoff of 140 mmHg for systolic blood pressure (SBP) and 90 mm for diastolic blood pressure (DBP).The data from SPRINT reaffirmed what had been seen in several observational studies that showed that people with prehypertension were at higher risk. The most relevant data had come from the Framingham Heart Study in 2001: the 10-year cumulative incidence of cardiovascular disease among people with prehypertensive blood pressure levels  in the age range from 35 to 64 years was 4% (women) and 8% (men); and at ages of 65 years and over, the incidence was 18% (women) and 25% (men).Briefly, based on risk findings and clinical trial experience, these guidelines recommend that for individuals with average SBP ≥ 130 mmHg or average DBP ≥ 80 mmHg, accurate outpatient clinic and home blood pressure monitoring measurements are needed. Use of drugs after the diagnosis is recommended for everyone with SBP ≥ 140 mmHg or DBP ≥ 90 mmHg. Among people presenting SBP values ranging from 130 to 139 and DBP from 80 to 89, use of medicines is recommended for those with high cardiovascular risk, diabetes, chronic kidney disease or previous cardiovascular diseases.From our point of view, there are two essential points to be discussed with all physicians and healthcare providers in Brazil.The diagnosis of hypertension does not need to be immediate. A sequence of blood pressure measurements taken at home or in an ambulatory setting should be the gold standard, and not the office blood pressure. At first glance, the impression obtained is that the range of blood pressures that are deemed to be hypertensive has been significantly increased. However, the spread of home and ambulatory blood pressure measurements will reduce the level of values obtained, in comparison with the blood pressure measured in the physician’s office, which was the source of the survey data addressing hypertension.The aim in lowering high blood pressure is to reduce the incidence and recurrence of cardiovascular diseases. Consequently, a general approach to risk factors is fundamental for all patients and mandatory for people who are tagged with the diagnosis of hypertension. Thus, the need to calculate the overall risk will demand information about smoking, diabetes, renal function and previous cardiovascular diseases.It is always necessary to remember that the most crucial issue regarding lowering of blood pressure to curb the burden of cardiovascular diseases relates to primordial prevention. Thus, there remains the need to reduce the high intake of salt in Brazil,It now becomes necessary for the previous analyses in several Brazilian epidemiological studies to be rerun. These studies include the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil),


Patients with paroxysmal atrial fibrillation experience low health-related quality of life which can be improved by performing yoga. The aim of this study was to evaluate gender differences in health-related quality of life, blood pressure and heart rate among patients with paroxysmal atrial fibrillation after performing MediYoga.This is a secondary analysis of subgroups, investigating the yoga groups, from two randomized controlled trials . The yoga groups performed MediYoga for one hour/week over a 12-week period in both studies. Quality of life (SF-36), blood pressure and heart rate were collected at baseline and end of study.p = 0.011), social function (p = 0.022), mental health (p = 0.007) and Mental Components Summary (p = 0.022). There were differences within the men’s group in bodily pain (p = 0.005), general health (p = 0.003), vitality (p = 0.026), social function (p = 0.005), role-emotion (p = 0.011) and Mental Components Summary (p = 0.018). Within the women’s group, differences were observed in systolic blood pressure (p = 0.010) and diastolic blood pressure (p = <0.001). The men’s group also showed improvement in diastolic blood pressure (p = 0.021).No differences were found between the women and men. Within the women’s group, there were improvements in vitality (MediYoga improved mental health as well as diastolic blood pressure in both men and women with PAF. This study suggests that both men and women, with PAF, may benefit from complementary treatment such as yoga.Clinical Trial Gov Id: NCT01789372. Modifiable risk factors associated with AF are hypertension, diabetes, hyperlipidaemia, smoking, obesity and high alcohol intake The standard treatment for PAF, rate/rhythm regulation and ablation, is not always sufficient and may be complicated, and patients seek complementary methods/treatments There is a long tradition for patients, both men and women, with cardiovascular diseases to be included in a secondary prevention  The aim of this study was to assess gender and within gender differences in patients with PAF undergoing MediYoga treatment.2This is a secondary analysis of subgroups, investigating the yoga groups, from two randomized controlled trials In the original studies, the patients were screened through medical records, at the arrhythmia department’s out-patient clinic  or referrals from one other arrhythmia department. The first study consisted of 80 patients randomized into a yoga or control group In both studies, patients with multiple concurrent serious medical conditions , cognitive dysfunction who were considered to have too many difficulties to perform yoga in a group session, and patients with difficulties understanding the Swedish language were excluded. Patients with a diabetes mellitus diagnosis and with an untreated hyperthyroidism were excluded from the second study.A review of medical records of the participants in the first study was conducted and those without symptomatic AF at the time of inclusion were excluded in this secondary analysis.All patients having undergone yoga treatment formed a dataset for the current study and were divided into two groups (according to gender). A flow chart is presented in In both studies, information was provided by letter from the principal author (PA) to those who fulfilled the inclusion criteria. The patients received a telephone call from the PA, after one to two weeks, asking if they wanted to participate in the studies. The participants attended two visits (to the PA), at baseline and after 12 weeks (visit window + 2 weeks), after completing the intervention. Data  were collected at both visits by the PA and were evaluated in the same way in the studies. Information regarding medication was obtained from the medical records and confirmed by the participants at the end of studies. The same venue was used for all visits and there were no changes over time.2.1https://mediyoga.se/) which is a therapeutic yoga form. The latter has evolved from Kundalini Yoga which is based on breathing technique, movements, and meditation. The yoga program, used in those studies, comprises of five movements together with deep breathing and meditation, which is described in All patients (in both studies) participated in MediYoga  which contains 36 questions Blood pressure and HR were measured, after the participant had a resting period of five minutes, with an automatic meter, Omron HEM-711DLXCAN.2.4https://www.wma.net).All participants provided verbal and written informed consent at baseline. The study was approved by the Regional Ethics Committee of Stockholm, Sweden  and is registered in Clinical Trial Gov Id: NCT01789372 and NCT02223156. The investigation conforms to the principles outlined in the Declaration of Helsinki , MCS (SF-36) and gender, in the two studies, and there was no interaction between the two groups (gender) t-test was used for within-groups analyses. A significance level of p < 0.05 was chosen, between and within groups. The variables in this study have been processed statistically using the data analysis program, IBM SPSS statistics version 27 .Categorical variables are presented in number and percent, and continuous variables are presented in mean and standard deviation (SD). Comparisons between the two groups (men and women) were performed with chi-square tests for proportions and one-way ANOVA for analysis of SF-36 , blood pressure and HR. The Student’s 3The participants in the current study totalled 64 patients with symptomatic AF who completed MediYoga as an active intervention, 36 (56 %) women and 28 (44 %) men. The mean age for women was 66 ± 8 years and 62 ± 9 years for men.More women, 22 (61 %), had higher hypertension than men, 12 (43 %) but this difference was not statistically significant. There was also no statistical significance in the MY attendance rate; women’s median 10 (5–12) times and men’s median 9.5 (7–12) times.None of the participants had the need to go to the hospital for chemical reversal and/or cardio-version, of PAF, prior to the inclusion or during in the studies and none received ablation during the studies. Also, none of the participants in the studies reported previous experiences of performing yoga and there were no adverse events reported by the groups. Clinical characteristics are shown in 3.1p = 0.011), SF (p = 0.022), MH p = 0.007) and the domain MCS (p = 0.022). Also, there were improvements within the MG in subscales BP (p = 0.005), GH (p = 0.003), VT (p = 0.026), SF (p = 0.005), RE (p = 0.011) and the domain MCS (p = 0.018). No improvement was seen in PCS in either of the groups, The results showed no differences between the female group (FG) and the male group (MG) at baseline or at the end of the study in HRQoL. However, within the FG, improvements were observed in subscales VT (3.2p = 0.017) and DBP (p < 0.001), but no difference was seen in HR (p = 0.285) at the end of study. There was also improvement within the MG in DBP (p = 0.026) at end of study, but no differences were seen in SBP (p = 0.127) or HR (p = 0.760), Between the groups, there were no differences in SBP, DBP or HR at baseline or end of study. Within the FG, there were improvements in SBP  than the women . The subscales BP and GH reflect the physical function in the questionnaire SF-36, which indicates that MY practices improve it more in men than women but has no effect on PCS.None of the participants in the studies reported previous experiences of performing yoga. In addition, use of other complementary methods were not analysed in this study. However, the literature describes that women use more complementary methods than men 4.2SBP and DBP decreased in the FG as well as DBP in the MG, which may support the view that yoga practice  contributes to an increased balance in the parasympathetic nervous system 4.3However, there were no improvements in HR between or within the MG and the FG. The effects of decreased HR have been shown in other studies with yoga and PAF 4.4As mentioned, ESC guidelines emphasize that a comprehensive approach should be considered as a complement to treatment to help reduce modifiable risk factors for the recurrence of AF as well as to increase HRQoL Though our study reports improvement in MCS and blood pressure, from MY, in both women and men, we suggest the importance of including stratification by gender in future research.5As HRQoL affects patients with PAF, most prominently in their social lives, the literature strongly recommends measuring HRQoL in studies to evaluate the effects of interventions When measuring HRQoL, the literature recommends including a disease specific HRQoL questionnaire to achieve a comprehensive state of overall HRQoL . In this study, only a general HRQoL questionnaire was analysed. Therefore, the analysis of HRQoL could be improved but, despite this, can give guidance and directions regarding differences among patients with PAF after performing yoga. A suggestion for forthcoming studies is to include a disease-specific questionnaire to achieve a deeper analysis of HRQoL in gender differences, among patients with PAF, after performing MediYoga.6MediYoga appears to improve mental health as well as diastolic blood pressure in both men and women. Thus, an improved mental health may help the person to achieve an improved physical health and therefore an overall improved balance in life. This study suggests, and encourages, the use of complementary methods such as yoga for both men and women.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Historically, nutrition intervention has been primarily focused on limiting kidney injury, reducing generation of uraemic metabolites, as well as maintaining nutrition status and preventing protein-energy wasting in patients with chronic kidney disease (CKD). This forms an important rationale for prescribing restricted protein diet and restricted salt diet in patients with CKD. However, evidence supporting a specific protein intake threshold or salt intake threshold remains far from compelling. Some international or national guidelines organizations have provided strong or ‘level 1’ recommendations for restricted protein diet and restricted salt diet in CKD. However, it is uncertain whether salt or protein restriction plays a more central role in renal nutrition management. A key challenge in successful implementation or wide acceptance of a restricted protein diet and a restricted salt diet is patients’ long-term dietary adherence. These challenges also explain the practical difficulties in conducting randomized trials that evaluate the impact of dietary therapy on patients’ outcomes. It is increasingly recognized that successful implementation of a restricted dietary prescription or nutrition intervention requires a highly personalized, holistic care approach with support and input from a dedicated multidisciplinary team that provides regular support, counselling and close monitoring of patients. With the advent of novel drug therapies for CKD management such as sodium-glucose cotransporter-2 inhibitors or non-steroidal mineralocorticoid receptor antagonist, it is uncertain whether restricted protein diet and restricted salt diet may still be necessary and have incremental benefits. Powered randomized controlled trials with novel design are clearly indicated to inform clinical practice on recommended dietary protein and salt intake threshold for CKD in this new era. Nutrition intervention is a cornerstone in chronic kidney disease (CKD) management and addresses multiple goals. Dietary modification instituted in CKD management aims to slow down CKD progression, delay the need for dialysis and lessen uraemic symptom burden as CKD progresses. It ameliorates the severity of cardiovascular-, metabolic- and kidney disease–related risk factors, reduces accumulation of uraemic metabolites and optimizes nutrition status of CKD subjects as their CKD progresses with eventual transition to kidney failure requiring dialysis . GeneralThe observation of a liberalized or high protein intake causing adverse effects on the kidneys in experimental models  and in hBox 1: Experimental data showed that dietary protein restriction may ameliorate glomerular hyperfiltration, glomerular hypertension and glomerulosclerosis by afferent arteriolar constriction. Dietary protein restriction also limits inflammation and oxidative stress and upregulates Kruppel-like factor-15, thus limiting glomerulosclerosis.Combined treatment of restricted protein diet and angiotensin receptor blockade may be more effective than angiotensin receptor blockade alone in lowering proteinuria and ameliorating glomerular injury and glomerulosclerosis in experimental models.2, no difference was observed in measured GFR decline and kidney failure among subjects randomized to LPD versus those to usual protein diet over a 3-year follow-up. In CKD stage 4–5 subjects with a mean GFR 19 mL/min/1.73 m2, those randomized to a VLPD (0.28 g/kg/day) plus essential amino acid and keto-acid supplement tended to have less GFR decline than those randomized to LPD, but there was no effect on kidney failure [2 per year. Subsequent to the first 4 weeks, subjects receiving LPD showed a significantly lower decline in measured GFR compared with those receiving usual protein diet with a mean difference of 1.1 mL/min/1.73 m2 per year, suggesting a potential kidney protective benefit of LPD [2 per year slower mean decline in GFR (P = .011), equivalent to a 29% reduction in mean GFR decline. This was translated to a 41% prolongation in the time to kidney failure in subjects with advanced kidney disease [2 demonstrated efficacy of a vegetarian VLPD supplemented with ketoanalogues in lowering the risk of reaching primary composite endpoint of kidney replacement therapy or a 50% reduction in the initial GFR in both the intention to treat (ITT) analysis and per protocol (PP) analysis over 15 months of treatment. The adjusted numbers needed to treat to avoid the primary composite endpoint in both ITT and PP analysis in one patient was 4.4 (4.2–5.1) and 4 (3.9–4.4), respectively, for subjects with eGFR <30 mL/min/1.73 m2. Adjusted numbers needed to treat to avoid dialysis was 22.4 (21.5–25.1) for subjects with eGFR <30 mL/min/1.73 m2 but decreased to only 2.7 (2.6–3.1) for subjects with eGFR <20 mL/min/1.73 m2 [The experimental evidences were supported by observational studies suggesting an association between higher dietary protein intake and more rapid decline in kidney function among subjects with and without CKD . Higher  failure . The pria VLPD 0. g/kg/day disease . Several disease . A more /1.73 m2 . HoweverOver the past 20 years, several systematic reviews have evaluated RCTs of LPD or VLPD in CKD . In the On the other hand, a few systematic reviews have attempted to examine LPD/VLPD in diabetic CKD but the studies included all had a very small sample size and were not designed to examine death or kidney failure. Thus, it remained inconclusive whether LPD/VLPD modifies diabetic CKD , 42. On In a recent pragmatic RCT from Italy, 229 advanced CKD subjects were randomized to receive VLPD (0.35 g/kg/day) or LPD (0.6 g/kg/day). Patients were followed for a median of 74.2 months. The primary outcome was time to kidney death, defined as the first event between kidney failure and all-cause mortality; secondary outcome was cardiovascular events. The study showed no additional benefit of prescribing a VLPD on kidney or survival outcomes in patients with advanced CKD under regular nephrology care. Furthermore, adherence to protein restriction is low and poses a key practical barrier in widespread acceptance and implementation of LPD in CKD .Box 2: Recent systematic review pooling the randomized trials in the last 20 years or so showed that VLPD probably slowed the progression to ESKD but the benefits of LPD were marginal, with no benefits for kidney failure. LPD or VLPD did not influence death.There are some hypothetical metabolic benefits that restricted protein diet may have beyond its effects on the kidneys. Protein and sodium are frequently associated in many foods. Thus, a restricted protein diet also lowers sodium intake and improves blood pressure control in subjects with advanced CKD . Restric2 who consumed a diet with higher proportion of plant-sourced proteins was associated with lower all-cause mortality over an average follow up of 8.4 years [Emerging data from observational studies has suggested that the quality and source of protein may matter in CKD. There are some suggestions that plant protein may prevent an increase in FGF-23  and redu.4 years . On the .4 years , 65. HowBox 3: Although there are theoretical metabolic benefits of a plant-based protein diet compared with an animal-based protein diet for CKD, the overall quality of evidence remain low and clinical implications of these studies remain uncertain.One potential reason for the negative findings in several of the trials and a key contributor to barriers in implementing LPD/VLPD in clinical practice relates to patients’ acceptance and adherence to LPD/VLPD, especially in the long-term. These barriers will only increase in the future, especially with the availability of more effective drugs in retarding CKD progression . AdherenBox 4: There are practical barriers to the widespread application and implementation of a restricted protein diet in CKD patients. The significant global shortages of dietitians/renal dietitians/personnel with specialized training in renal nutrition especially in low resources settings pose an important barrier to the effective delivery of kidney nutrition care in CKD population.In the late 18th century, salt was not tainted with the stigma of causing water retention, oedema and kidney disease. The idea that salt restriction rather than salt excess may be noxious for human health prevailed in those years . At the et al. in 2018 retrieved 11 trials, including 738 stage G1–4 CKD patients testing low salt diets vs various comparator diets [Long-term studies suggest low sodium intake contributes to retard kidney disease progression in diabetic patients treated with an angiotensin receptor blocker. This was nicely demonstrated in the ‘Irbesartan in Diabetic Nephropathy Trial’ (IDNT) and the ‘Reduction of Endpoints in Non-insulin-dependent diabetes mellitus with the Angiotensin II Antagonist Losartan’ (RENAAL) trial . On the or diets . Urinaryor diets  or urinaor diets , had onlor diets  and evenor diets . In clinBox 5: The long-term sustainability and adherence to a low-salt diet is a major barrier to long-term dietary salt reduction. The high sodium content of processed foods coupled with the scarce attention given to reading the labels of processed food by patients, and general low awareness of the health risks associated with a high salt intake, concur with a low adherence to low salt diets.On the other hand, we should not forget the value of diuretics in CKD. A randomized, 6-week crossover trial in 26 stage 3–4 CKD patients testing a hydrochlorothiazide/amiloride combination vs a 60 mMol/day sodium diet showed that the diuretic combination was non-inferior to dietary sodium restriction in reducing blood pressure and extracellular volume . FurtherBox 6: Diuretics were shown to be non-inferior to dietary sodium restriction in reducing blood pressure and extracellular volume.A more pragmatic sodium target of about 150 mM per day coupled with judicious use of diuretics may be a more rational approach in limiting sodium and volume excess in CKD patients but warrants further evaluation in a randomized trial setting.The scientific basis of a restricted protein diet and a restricted salt diet in CKD has been recognized for at least half a decade. However, high quality clinical evidence to guide recommendations and thresholds level for dietary protein and salt intake in CKD patients are still lacking. A key barrier to building quality evidence examining hard outcomes in this area as well as patients’ acceptance and long-term adherence to a restricted diet prescription in CKD patients relates to practical difficulties in achieving sustainability of a ‘restricted’ salt and ‘restricted’ protein diet, and practical difficulties in adopting the same restricted diets across different patients population and racial groups. Many patients find the restricted diet unpalatable. Being able to enjoy good food without restrictions is an important aspect that impacts patients’ quality of life and needs to be taken into consideration in the delivery of kidney nutrition care. Many patients also do not recognize the hidden salt, phosphate and other additives in processed foods, and seldom read food labels. Kidney nutrition care thus requires a highly personalized approach involving shared decision-making with patients/carers, taking into consideration patients’ wishes, lifestyle, life goals, pre-existing dietary habits, health literacy, incentives and motivations, as well as CKD stages and other pre-existing comorbidities. Patients and carers’ education are crucial to bridge the knowledge gaps many patients and carers may have as to what constitutes a ‘healthy kidney diet’. Patients should be promoted and engaged in self-management tools of dietary intervention, for example utilizing mobile technologies. With the advent of novel drug therapies for CKD management, studies will be needed to evaluate the incremental role of a restricted protein and a restricted salt diet in improving clinical outcomes and patient-centred outcomes in CKD patients.


The relationship between lean body mass (LBM) and blood pressure (BP) is controversial and limited. This study investigated the associations between LBM indexes and BP in adults of different ages and with varying body fat distribution.The data for the present analysis was obtained from a cross-sectional survey of 1,465 adults  aged 18–70 years conducted in Beijing, China. Regional LBM and fat distribution, including fat mass (FM) and android to gynoid fat ratio (AOI), were assessed using a dual-energy X-ray bone densitometer. Generalized Liner Model (GLM) was employed. Confounders, including age, sex, height, weight, smoking, and alcohol use, were evaluated through questionnaires and physical examinations.p > 0.05). However, arms LBM  and trunk LBM  were significantly associated with SBP. The association of LBM on DBP was stronger with increasing ages, and stronger in females than in males (p < 0.001). The association between adults’ arms LBM and SBP was stronger in the high level FM group (β = 2.74 vs. β = 1.30) and high level AOI group (β = 1.80 vs. β = 2.08).Males had higher rates of hypertension (11.19% vs. 4.92%) and prehypertension (21.57% vs. 14.59%) than females. The mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 122.04 mmHg and 76.68 mmHg. There were no significant associations between LBM and DBP .The online version contains supplementary material available at 10.1186/s12889-023-17312-0. Multiple studies have shown that lean body mass (LBM) or total skeletal muscle (TSM) play a key role in energy metabolism, and enhancing LBM and muscle strength has been advocated for preventing age-related weakness and sarcopenia –3. HowevSome studies have found an adverse relationship between LBM and hypertension –9, whileIn addition, body fat mass or fat distribution is closely related to LBM , 15, makA cross-sectional survey was conducted among adults aged 18 to 70 in Beijing, China, in Otc, 2020. The inclusion criteria were healthy adults and to avoid including fitness enthusiasts, athletes, pregnant women, and special groups who are undergoing diet or exercise intervention, and the signed prior informed consents. Following the exclusion criteria, adults who individuals with a history of various important organs , abnormal physical development such as pygmyism or gigantism, physical impairments or deformities, or acute disease symptoms in the past month and had not yet recovered were excluded . In addiAs shown in Figs. The participants reported their birth date, sex, and medical history. We obtained their age by subtracting their birth date from the recorded individual examine date. Height was measured using a uniform and calibrated mechanical stadiometer , without shoes, to the nearest 0.1 cm. Weight was measured using a uniform and calibrated electronic weight scale  to the nearest 0.1 kg. When measuring weight, participants were required to wear only light clothing and no shoes. Both height and weight were measured twice, and the mean values were recorded. Smoking was measured by the item “Do you smoke?“ and coded as “0 = never, 1 = currently smoking or have quit smoking”. Alcohol use was measured by the item “Do you drink alcohol?“ and coded as “0 = never, 1 = currently drinking or have quit drinking”.Blood pressure was measured at least twice after 5 min of rest in the sitting position using an auscultatory mercury sphygmomanometer. The average of the two recorded measurements was used. Hypertension was defined as having a systolic blood pressure (SBP) ≥ 140 mm Hg or diastolic blood pressure (DBP) ≥ 90 mm Hg or the use of antihypertensive medication, whereas prehypertension was defined as having an SBP ≥ 130 mm Hg and < 140 mmHg or DBP ≥ 85 mmHg and < 90 mm Hg.We measured adults’ body composition using professional medical personnel with a GE Healthcare Lunar iDXA dual-energy X-ray bone densitometer, in accordance with the standard use process and program requirements described by the instrument, we scanned the whole body and collected images. The participants were placed as required, lying flat on the scanning bed, with the body in the middle of the instrument, with the thumb facing up, and the palm facing, but not touching, the leg. All measurements were carefully checked before the examination. During each on-site physical examination, a special person was assigned to conduct on-site supervision to ensure that the measurement methods and records of each measurement index were correct and standardized.TSM was computed based on age and appendicular LBM according to the existing equations with high validity in Chinese adults samples . Other rDescriptive statistics  were calculated for all variables in this study. Differences by BP categories  were examined by analysis of variance (ANOVA) tests for continuous variables and Pearson’s chi-squared test for categorical variables.We used a generalized linear model (GLM) adjusting for age, sex, height, weight, smoking, and alcohol use. The roles of sex and age were also analyzed. Then, the continuous body fat composition were categorized into two groups, using the 50th percentile as a cutoff point (the low-level group vs. high-level group). The cutoff values were 20.00 for BF and 0.53 for AOI. We assessed the effects of each LBM index (independent variable) on blood pressure (dependent variable) separately in the low-level group and the high-level group of body fat composition (stratification variables) after adjustment for confounders. Furthermore, we examined the role of age distribution on these associations.All analyses were performed using R (version 4.0.3). The “glm” and “psych” were used to fit the GLM model. Statistical significance was defined as a two-sided p-value of less than 0.05. The “ggplot2” and “cowplot” were used to draw the figures.p < 0.0001). And males had higher rates of hypertension (11.2% vs. 4.9%) and prehypertension (21.6% vs. 14.6%) than females with a statistically significant difference (p < 0.001).Table ps < 0.001). Also, there were significant differences in BMI, height, weight, smoking, alcohol use, and other sociodemographic factors based on BP category (ps < 0.001).The mean SBP and DBP were 122.04 ± 15.98 mmHg and 76.68 ± 10.59 mmHg. The mean TSM or LBM were higher in participants with hypertension and prehypertension than in those without (p > 0.05). Arm LBM  and trunk LBM  were significantly associated with SBP.As shown in Table p < 0.001), and the association of LBM indexes on DBP was stronger in females than males (p < 0.001). In order to visualize the role of age, the continuous variable age was transformed into categorical variables. A scatter diagram and its fitted lines showed the visual association between the LBM and blood pressure with different age groups , between FM and legs LBM (p = 0.001) on SBP were significant. Additionally, the interaction between AOI and TSM (p = 0.037), between FM and legs LBM (p = 0.030) on SBP were also significant. High FM/AOI and LBM were associated with higher SBP. The visual results presentation of the modified effects by FM and AOI were shown in Fig. The interactions of TSM with both FM and AOI on SBP were shown in Table Previous studies focusing on the relationship between body composition and blood pressure have overemphasized the harmful effects of body fat and obesity, while ignoring the effect of LBM as a higher percentage of body weight. Our study found that TSM and local LBM indexes, especially arms LBM, were significantly associated with SBP and showed an interaction with fat distribution, with some differences in age groups and sex.A low proportion of LBM is generally considered to be a risk factor for morbidity and mortality in old age . HoweverThis study also found interactions between fat composition and LBM that influences blood pressure. For adults with high FM or AOI, arms LBM has a stronger positive association SBP. Previous researches on the associations between obesity and blood pressure have been based on BMI , 25, whiTo our knowledge, the mechanism by which LBM is positively correlated with blood pressure is not clear. One possible explanation is the role of carotid intima-media thickness (c-IMT). Studies have found that the increase of LBM is significantly correlated with the rise of c-IMT . MultiplIn the present study, our results show that TSM and arm LBM are positively correlated with increased blood pressure in Chinese adults, based on the measurement of DXA. And these associations are more obvious in females and in group with high FM and high AOI groups as age increases. These results remind us that we should be aware of the potential negative effects of skeletal muscle elevation or muscle gain. Although physical exercise is an essential component of a healthy lifestyle, it is important to note that exercise, particularly in the arms, can have a significant impact on blood pressure, especially SBP. Skeletal muscle and fat status in the elderly, particularly in females, should be the focus of intervention for blood pressure control.Body composition is a better indicator of fat and non-fat distribution than BMI. The study had significant advantages, including its advanced assessment of body composition (DXA) , large sAlthough LBM and increased muscle strength are considered key factor in preventing age-related problems, the potential negative impact of increased LBM on blood pressure cannot be ignored. This study found that an increase in skeletal muscle mass, especially in the upper extremities, may have adverse effects on blood pressure. The association was found to be more pronounced in females and individuals with high FM and high AOI as they aged. The gold standard for DXA is used to distinguish the different effects of LBM on blood pressure in different fat distribution groups, which is of great significance for the profound understanding of the association between obesity and hypertension. In addition to controlling fat content, future LBM gain from should be considered as part of a policy to strengthen adult cardiovascular health systems, which includes not overly focusing on physical exercise, particularly upper body training.Below is the link to the electronic supplementary material.Supplementary Material 1