NOS3 gene, which encodes eNOS, represents an interesting candidate for contribution to the phenotype. The most clinically relevant polymorphisms in the NOS3 gene are rs1799983 in exon 7 (encoding Glu298Asp), a variable number tandem repeat (VNTR) in intron 4, and rs2070744 (T-786C) in the promoter region. This study aims to investigate the association between these three polymorphisms in the NOS3 gene and EH in Sudanese patients.Essential hypertension (EH) is influenced by various environmental and genetic factors. Nitric oxide is important for the functional integrity of the vascular endothelium and is produced in endothelial cells by the enzyme endothelial nitric oxide synthase (eNOS). EH has a strong genetic component, and the n = 157) > 18 years of age with established hypertension from various hospitals in Khartoum, and controls (n = 85) > 18 years of age and with blood pressure measurements <140/90, were included in this case control study. Genotypes at the NOS3 variants were determined using TaqMan and polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) analyses. Genotype and allele frequencies were compared between the two groups by χ2 analysis, and differences were expressed as odds ratios with 95% confidence intervals (CIs). P values <0.05 were considered statistically significant.Hypertensive patients . Considering a dominant inheritance model, the frequency of TC + CC genotypes in patients was significantly higher than that in the control subjects , with an odds ratio (95% CI) of 2.14 (1.23–3.74). In addition, the C allele was more frequent in the patients than the control group ). The c allele of intron 4 VNTR was reported in >1% of the Sudanese population under study.The rs2070744 polymorphism in NOS3 may be a genetic susceptibility factor for EH in the Sudanese population. The c allele of intron 4 VNTR is not rare in the Sudanese population.The results of this study indicated that the rs2070744 polymorphism in The online version of this article (10.1186/s12881-017-0491-7) contains supplementary material, which is available to authorized users. Essential hypertension (EH) is a multifactorial disease caused by various environmental and genetic factors. The estimated genetic contribution to EH ranges from 25% to 60%, and high blood pressure occurring before the age of 55 years of age is 3.8 times more frequent in individuals having two or more first-degree relatives with high blood pressure (BP) , indicatThe prevalence of Hypertension continues to rise despite recent advances in diagnosis and treatment. Approximately 40% of the global adult population aged 25 and above suffer from hypertension . HyperteNitric oxide (NO) is important for the anatomical and functional integrity of the vascular endothelium, which is essential for the prevention of atherosclerosis, hypertension, and other CVDs . NO mediNO is produced in endothelial cells by the enzyme, endothelial nitric oxide synthase (eNOS), which catalyzes the conversion of the amino acid arginine to NO and citrulline . HyperteNOS3, has been mapped to human chromosome 7q36 and spans approximately 23 kilobases of the genome [NOS3 represents an interesting candidate gene in relation to EH. The association between NOS3 and EH has been widely studied, and the disruption of the gene leads to hypertension in mice [The gene encoding eNOS, e genome . NOS3 re in mice .NOS3 have been identified and investigated. The most clinically relevant NOS3 variants are rs1799983 ; a variable number tandem repeat (VNTR) in intron 4; and rs2070744 (T-786C) in the promotor region. These variants are associated with CVD, including coronary artery disease [Several polymorphic variations of  disease , myocard disease , 14, hyp disease , 16, andNOS3 gene polymorphisms and their role in hypertension will improve understanding of EH, its common predisposing factors, and potential treatment options. The potential contribution of NOS3 polymorphisms to the development of hypertension in Sudan has received no attention to date, and no previous studies have addressed this subject. This study aimed to investigate the association of the three polymorphisms in the NOS3 gene with EH in the Sudanese population.Additional knowledge of n = 260) were enrolled in the study from Samir Health Centre, Soba Teaching Hospital and Fath El Rahman El Bashir Referral Clinics in Khartoum. Patients were selected according to the following criteria: (1) age ≥ 18 years; and (2) established hypertension, defined either by chronic therapy or by blood pressure ≥ 140/90 mmHg according to the National Institute of Health and Care Excellence guidelines [This case control study was conducted in Khartoum, and samples were collected between February 2014 and February 2015. Hypertensive patients  were recruited mainly from Faculty of Medicine - University of Khartoum and other different institutes in Khartoum and volunteered to participate in the study.Controls (As patients and control groups differed significantly in their age (patients were much older), we omitted all participants with age less than 30 and more than 65 years old. Thereby, 157 patients and 85 controls were included in the statistical calculations.EH patients and normotensive individuals were consulted about their willingness to participate in the study, and written consent was obtained. Each study participant was interviewed about demographic data, duration of hypertension (for hypertensive patients), family history of hypertension, risk factors for hypertension, medication taken for EH, other medication, smoking, alcohol consumption, and other EH-associated chronic diseases, such as diabetes mellitus, MI, renal diseases, hypercholesterolemia, and stroke, using a structured questionnaire  was drawn from each subject. DNA extraction and genotyping were performed at the Institute for cardiogenetics, University of Lubeck, Germany. DNA extraction was performed using a Qiagen Gentra Puregene Blood Kit .NOS3. Two alleles of the VNTR in intron 4 have been identified, the larger allele (b) consists of five tandem 27 bp repeats (GAAGTCTAGACCTGCTGCAGGGGTGAG), and the smaller allele (a) consists of four such repeats. Two other rare alleles have been reported, c with six, and d with three, 27 bp repeats. rs2070744 (T-786C) is a polymorphism in the promoter region of NOS3. Those three polymorphisms are the best studied in the NOS3 gene, so they were chosen for genotyping in this study. The literature review done to select these polymorphisms was conducted in 2011. Therefore, recent polymorphisms in NOS3 associated with EH were not included.rs1799983  is a missense variant in exon 7 of DNA genotyping was performed using TaqMan and polymerase chain reaction restriction fragment length polymorphism (PCR-RFLP) assays. rs1799983 were genotyped using PCR-RFLP as the samples were undetermined with the Taqman method possibly due to multiple variations within the sequence. Two hundred nineteen and 15 samples were genotyped for rs2070744 using Taqman and PCR-RFLP respectively. Genotyping of the VNTR was performed only by PCR-RFLP.TaqMan assays were performed using a 7900HT Fast Real-Time PCR System , and Sequence Detection System (SDS) software was used to call alleles based on florescence measurements. Genotyping was run in duplicates and the duplicate concordance rate was 100%.PCR reaction mix (for PCR-RFLP) of 10 μL was prepared. The touch down 61 program was used for the PCR in a Sensoquest thermocycler .BanII and MboI for the rs1799983 SNP, and MspI for the rs2070744 polymorphism. No restriction enzyme was used for the VNTR. Next, the products were mixed with loading dye and SYBR green mix and run in 1.2% (rs1799983 and rs2070744) and 1.8% (VNTR) agarose gels. Estimation of product sizes was carried out with peqGOLD 100 bp DNA ladder . A Bio-Rad gel documentation system  was used for gel image capture. The results of the RFLP were determined by two persons reading the gels and in case they disagree about the result, genotyping was repeated. The results of the BanII and MboI restriction were consistent and concordant.The resulting amplification products were incubated with the restriction enzymes, Escherichia coli cells, according to instructions of the TOPO® TA Cloning® kit . Next, PCR was performed using bacterial colonies directly as template. PCR products were visualized by agarose gel electrophoresis, and samples with different lengths were cleaned-up for sanger sequencing . The FASTAQ files of the sequencing were aligned with a reference sequence of NOS3 from Ensemble [Primers, restriction enzymes and fragment lengths are presented in Table Ensemble .Table 1P2 test, and odds ratios (OR) with 95% confidence intervals (CIs) were calculated. Differences in genotype distributions under autosomal dominant and recessive models were also determined using χ2 test, and ORs were calculated. Multinomial and binary logistic regressions were performed in genotype comparisons with age, gender, BMI and smoking included as covariates. A χ2 test with one degree of freedom was used to determine deviation of genotype distributions from Hardy-Weinberg equilibrium. Values of P < 0.05 were considered statistically significant. To eliminate any confounding factors affecting the genetic association study, we also analyzed the distribution of genotypes according to the clinical and demographic characteristics of both groups, including age, gender, BMI, smoking, systolic and diastolic BP, and the presence of complications alongside hypertension , using ANOVA for continuous data and χ2 or Fisher’s Exact tests for categorical data. Linkage disequilibrium between the three polymorphisms was examined by χ2 analysis. The extent of disequilibrium was expressed as D′ = D/Dmax and Pearson squared correlation coefficient (r2).Statistical analyses were performed using Statistical Package for the Social Sciences for Windows  software. Genotype and allele frequencies were compared between groups by χThe study included 157 hypertensive patients and 85 controls. The age of hypertensive patients ranged from 32 to 64 years, with a mean of 52.7 years, and that of controls ranged from 31 to 63 years with a mean of 42.1 years. Around 32 % of patients and 81% of controls were male. The systolic BP of patients ranged from 90 to 210 mmHg with a mean  of 139.8 ± 19.2 mmHg, while that of controls ranged from 90 to 140 mmHg with a mean ± SD of 120.2 ± 10.3 mmHg. The diastolic blood pressure of patients ranged from 60 to 115 with a mean ± SD of 84.6 ± 11.6 while that of controls ranged from 60 to 95 with a mean ± SD of 77.8 ± 8.5. Patients had higher age, BMIs, systolic and diastolic blood pressures, and included a lower percentage of males and smokers than the control group .The distributions of each of the three variants across the study were consistent with Hardy-Weinberg equilibrium , are presented in Fig. The VNTR in intron 4 was genotyped in 154 patients and 83 controls (95% of the samples)    compared with the control group 14.6%), although the difference was not significant with .6%, althThere were no significant differences found between the two groups in the distribution of genotypes of the VNTR under dominant and recessive models. The minor allele (a) was more frequent in patients 24.8%) compared with controls (19.9%), although the difference was not statistically significant  of 2.14 (1.23–3.74). There was no significant difference observed under the recessive model. The minor allele (C) was more frequent in patients (29.6%) than controls (20.1%); and the difference was significant  = 1.84 (1.15–2.93)) . No significant association was found between any of the three polymorphisms with the studied variables.2 = 0.06). Weaker associations between rs1799983 and rs2070744 and rs2070744 and VNTR were also detected   Table .Table 5PNOS3 gene were genotyped in hypertensive and control groups, to study their association with EH in the Sudanese population.In this study, three polymorphisms in the Regarding rs1799983, the observed minor T allele frequency (MAF) of 0.17 was similar to the global minor allele frequency at this SNP reported by the 1000 genomes project (0.18), although it differed from the reported frequency in the African population (0.07) . Our resThe cause of the association between the rs1799983 variant and CVDs is not well characterized; however, it has been suggested that the resulting replacement of Glu with Asp results in changes to the structure of the eNOS enzyme, increasing its susceptibility to proteolysis . It has In the current study, no direct relationship was found between the VNTR and EH. Our results indicate that three hypertensive patients (1%) and five controls (3%) carried the c allele at this locus, which was previously reported by Thomas et al. to be present in Africans and African Americans, but not in Caucasians . In theiNOS3 with coronary artery disease and renal disease have been reported [Associations of the a allele of the VNTR in intron 4 of reported –37. Howereported , 38–40. reported  and incrreported  associatThe lack of association between either the rs1799983 or VNTR with EH in the Sudanese population could be due either to the small sample size in this study or a genuine indication of a lack of association between these variants and EH in the Sudanese population.p = 0.02). The patients group also had higher frequency of TC + CC genotypes compared with the TT genotype considering a dominant model of inheritance  = 0.639 (0.420–0.973)) (Table p = 0.03). There was no association between this genotype and the confounding factors, age, sex, BMI, smoking status, presence of diabetes, MI, stroke, renal failure, or hypercholesterolemia. The observed minor C allele frequency of 0.26 is similar to the global MAF reported by the 1000 genome project (0.23) but different from the MAF for the African population at this SNP (0.14) [NOS3 is associated with coronary spasm [NOS3 reduces its rate of transcription by 50%, both under baseline conditions and in response to hypoxia, and is associated with decreased serum levels of nitrite/nitrate [In the present study, the hypertensive group had a significantly higher frequency of CC genotype of the rs2070744 polymorphism compared to the control group , and (rs2070744 and the VNTR). It is unlikely that the VNTR itself has a functional role, as it is in an intronic region. However, it has been suggested to act as a marker for other functional variants elsewhere in the gene. Nakayama et al. first reported that the VNTR is in linkage disequilibrium with rs2070744; hence, the effect of VNTR on NOS3 mRNA expression, eNOS protein concentration, and enzyme activity is likely to be mediated by the differences in transcriptional efficiency associated with the rs2070744 polymorphism [NOS3 gene.In this study, we found that all three included morphism –51. The NOS3 gene promoter is associated with EH in the Sudanese population. We also report the presence of the c allele of the intron 4 VNTR in the Sudanese population and it is not rare. These data indicate that the rs2070744 polymorphism in NOS3 may be a factor influencing genetic susceptibility to EH in the Sudanese population. Further studies with larger sample sizes and family-based analyses are required to confirm this association.In conclusion, in this study we demonstrate that the rs2070744 polymorphism in the


Chronic refractory hypotension  is a rare but serious problem encountered in patients on hemodialysis. Patients with chronic hypotension are often disqualified by transplant teams from renal transplantation. This is due to the possibility of an enormous risk of ischemic complications.We describe a 44-year old female patient with severe refractory hypotension , which appeared after bilateral laparoscopic nephrectomy of the infected kidneys. The kidney transplantation from a deceased donor, with infusion of the two pressor amines  was performed without technical complications and the blood pressure measurements were 100–120/70–80 mmHg. The immunosuppression regimen was tacrolimus (TAC) + mycophenolate mophetil (MMF) and steroids (GS). Pressor amines were discontinued on the 18th day after the transplantation. Because of delayed graft function, 4 hemodialysis treatments were performed. The patient was discharged from the hospital on the 22nd day with good function of the transplanted kidney (the concentration of serum creatinine 117 μmol/l). During one-year follow-up, the patient has been remaining stable with a very good graft function (serum creatinine 84 μmol/l) and normal blood pressure (115/70 mmHg).Proper preparation and adequate perioperative treatment allowed for safely performing kidney transplantation in the patient with severe IDH. Dialysis hypotension  is a frequent complication in patients undergoing chronic hemodialysis (HD). It is estimated that it affects approximately 10–70% of patients. Significant differences in the incidence are associated with various definitions of this disease. KDOQI  defines IDH as a decrease in systolic blood pressure > 20 mmHg or a decrease in mean arterial blood pressure (BP) of > 10 mmHg with associated clinical symptoms . According to the KDOQI definition, IDH applies to approximately 20–30% of dialysis session [IDH may occur as a form of acute (episodic), recurrent  or rarely chronic dialysis hypotension, which is associated with the occurrence of BP <100 mmHg between HD sessions in 5–10% of patients. IDH is more common in elderly patients with cardiovascular disease, on long-term dialysis, in patients with diabetes, low levels of albumin, a high body mass index (BMI) in women, as well as in patients with low blood pressure before dialysis. The clinical consequences of IDH include primarily a deterioration in the quality of life and increased mortality due to cardiovascular complications. The effects of IDH are also associated with a lack of obtaining adequate dialysis, which is associated with the shortening of the dialysis session. The problems involve a vascular accesses - frequent clotting of arteriovenous fistulas , 3.The occurrence of IDH is related primarily to the lack of an adequate volume of circulating blood during the dialysis session, which on the one hand results from insufficient refilling plasma, and the other – an impaired hemodynamic response from the myocardium and blood vessels.Factors affecting the presence of IDH are dependent on the patient: being on antihypertensive medications, the presence of cardiovascular diseases, a considerable weight gain between dialyses, as well as on the manner of HD application , and on additional factors, such as anemia, hypoxia or intercurrent infections.To date, the pathophysiology of IDH has not been completely understood. On the one hand, it is suggested that a reduced response of the cardiovascular system to vasopressor agents is associated with the occurrence of a reduced response to stimuli from the adrenergic receptors - there are indeed elevated levels of norepinephrine, but with a reduced density of alpha2 adrenergic receptors. In addition, there is a reduced response of alpha1 adrenergic receptors. Long-term dialysis treatment is also associated with an impaired baroreceptor function. Also reduced density and a response from the beta1 and beta2 adrenergic receptors have a clinical value. Another factor associated with the occurrence of IDH is an increased production of vasodilators (adrenomedullins and nitric oxide) as a result of an increased production of proinflammatory cytokines. Repeated episodes of organ hypoperfusion, the effect of IDH, are associated on the one hand with hypertrophy and myocardial fibrosis, and on the other - with an increase in the level of endotoxins, which in turn leads to an increased production of proinflammatory cytokines, oxidative stress and dysfunction of endothelial cells . AnotherThe occurrence of chronic IDH usually leads to disqualification of a patients from the kidney transplantation procedure. To date, there are few reports in the literature of a successful kidney transplantation with an improved BP control in patients with chronic IDH.A 44-year-old female patient with severe intradialytic hypotension,  was qualified for renal transplantation by a team from the Department of Nephrology, University Hospital after an in-depth diagnostic management.The cause of the patient’s end-stage renal failure was rapidly progressive glomerulonephritis with anti-GBM treated in the past by plasmapheresis and Solu-Medrol pulses. In addition, since the age of 20 years, she had bilateral nephrolithiasis with recurrent urinary tract infections and hypertension. The patient was on hemodialysis for three years. One year after the commencement of dialysis, the patient underwent bilateral laparoscopic nephrectomy due to bilateral nephrolithiasis and recurrent urinary tract infections - which are an obstacle in qualifying patient for renal transplantation. Since that time, the patient has been severely hypotensive. She denied fainting, reported a significant weakness. In the course of hypotension, ischemic neuropathy with loss of vision in the right eye occurred. In addition, eye pain worsened during dialysis. Collaboration with the patient while renal replacement therapy was carried out was good, and her weight gain between dialysis sessions did not exceed 2000 ml. HD sessions were carried out in accordance with the standards for the IDH . Additionally, the adrenal CT (computed tomography) scan was normal, as well as cortisol and ACTH (adrenocorticotropic hormone) levels. Histological examination of the rectal mucosa sample excluded amyloidosis. The results of cardiac studies (echocardiogram and electrocardiography) were also normal. The orthostatic stress test and Ewing’s battery tests showed no abnormalities of the autonomic nervous system, the heart rate variability was normal during the all the tests. Treatment with mineralocorticoids and midodrin did not result in the improvement of BP, but after the dopamine infusion, her blood pressure increased to satisfactory values (120/60 mmHg). The results of most relevant laboratory and diagnostic tests performed in patient are showed in Table The kidney for transplantation was harvested from a deceased donor . The number of non-conforming HLA 2 A, 1 B and 1 DR, PRA max and the last was 0. The total time of ischemia was 22 h, and warm ischemia - 50 min. The patient used the following immunosuppression regimen: TAC + MMF + GS. Immediately prior to the transplantation procedure, her BP was 60/40 mmHg. Before the surgery, dopamine infusion at a dose of 5.3–7.4 μg/kg/min resulted in an increase of BP to 100–120 mmHg. The kidney transplantation procedure was performed without complications. In the second day after surgery, the patient was transferred to the Department of Nephrology. Due to the low value of BP < 100 mmHg, dopamine infusion and additionally dobutamine infusion at a dose of 2.4–3.6 μg/kg/min was ordered  prior to the IDH, the lack of co-morbidities, such as diabetes, autonomic neuropathy, and the correct state of the cardiovascular system  indicate a good hemodynamic response from the myocardium and peripheral vasculature in our patient.Rogan et al., reported the beneficial effects of exercise  on BP in a patient with IDH after bilateral nephrectomy. The exercise, performed during dialysis for 8 weeks after renal transplantation, contributed to carrying out a successful kidney transplant. The stimulation of chemo- and mechanoreceptors during exercise improve BP control [In some cases, the beneficial effect of IDH results from the use of alpha 1-adrenergic receptor agonist - midodrin. In our patient, we did not observe any beneficial effect of the use of this drug.The correct answer to the test use of the pressor amines (dopamine) before surgery allowed for qualifying the patient for renal transplantation.Kim et al. describe a case of kidney transplantation in a 2-year-old child with dialysis hypotension and autonomic neuropathy, which received a transplant from an adult deceased donor. To obtain adequate perfusion of the transplanted kidney, the authors tried to achieve a value of systolic BP approx. 100 mmHg during the perioperative period. Due to the ineffective use of dopamine infusion for this purpose, the authors successfully employed an alpha agonist (neosinefrine) for a short time, despite the risk of ischemia development and the risk of thrombosis . In the A similar observation was demonstrated also by Taiwan authors . They deTo summarize, we for the first time described beneficial effect of kidney transplantation in severe hypotensive patients after bilateral nephrectomy. At the moment there are no adequate standards dealing with the qualifications and kidney transplantation in patients with chronic IDH. A successful kidney transplantation observed in our patient suggests careful valuation of all potential candidates for kidney transplantation, including patients with IDH. It is very important, especially for the young patients, on short-term dialysis and free of additional disease. The necessary condition, however, is the extensive diagnosis before the kidney transplantation. On the basis of this case, as a minimum, we suggest testing the cardiovascular system in accordance with the standards governing the qualifications and further endocrine studies  and studies of the autonomic nervous system based on the Ewing’s battery tests to exclude disorders of the autonomic nervous system. In the case of disorders of this system, it can be expected that the patient would not respond to treatment with dopamine. The use of vasoconstrictive drugs, such as phenylephrine, or high doses of norepinephrine may be associated with an increased incidence of fatal complications in this group of patients.


Ulva/Enteromorpha prolifera Müller) algal biomaterial (SBM), especially on adiponectin production, blood pressure (BP), and body mass index (BMI) in human subjects. Participants (N = 32) were divided into two equally sized groups (n = 16 for each group): SBM group  and the control group (subjects who took 3 g of a supplement made of 70% corn starch powder and 30% spinach twice a day) for four weeks. Two health survey questionnaires  were completed anonymously, saliva sampling was done for adiponectin measurement by ELISA, and blood pressure (BP) and anthropometric parameters were measured at baseline and four weeks later. Student paired t-test was performed to compare baseline and post-intervention data on outcome variables between the two study groups. Results showed a 2.24-fold increase in adiponectin level in SBM group  (p < 0.01); whereas no significant change was observed in controls  (p > 0.05). In SBM subjects, an improvement of BP profile was noted with a significant decrease in systolic BP (p < 0.01). A positive correlation was found between SBM supplementation and adiponectin level, whereas an inverse correlation was noted between SBM supplementation and blood pressure, and also BMI. These findings suggest that SBM-increased adiponectin level and improved BP in a sample of Japanese young adults, and has the potential to improve blood pressure in humans.The replenishment of adiponectin—an adipocyte-derived hormone with salutary health effects—has recently been proposed as a new approach to treat hypertension, also ameliorate cardiovascular and metabolic risks. We conducted a prospective placebo-controlled, non-randomized and investigator-blinded dietary intervention study to evaluate the health effects of dietary intake of Sujiaonori ( Adiponectin—an adipocyte-derived secretory factor that promotes insulin sensitivity and cell survival—is reported to decrease inflammation, regulate energy homeostasis, and exert salutary activities on cardiovascular health ,2. A preEnteromorpha prolifera Müller [Ulvacea in the order of Ulvales—is an edible green river alga that grows in Shimanto River, in Kochi, Japan. This algal species is rich in fiber (60%–65% dry weight), contains bioactive compounds , and is reported to have antioxidant, anti-inflammatory, immunostimulatory, and hypolipidemic properties [Sujiaonori—the Japanese name for a Müller ,16, whicoperties ,18,19,20operties —was usedp > 0.05). Except for alcohol intake (which was reduced in each group during the study period), no significant difference was observed with regard to the daily intake of nutrients within each group, and also when comparing SBM subjects to controls (p > 0.05). The analysis of baseline blood pressure (BP) indicated that six subjects  had a personal history of hypertension, 10  had either prehypertension (systolic BP: 120–139 mmHg) or high blood pressure (systolic BP: 140 mmHg or higher). On the other hand, nine subjects (28%) had a baseline diastolic BP between 80 and 89 mmHg or higher, including four SBM subjects and five controls. Assessment of the BMI profile of participants revealed that two (6.2%) SBM subjects were overweight (BMI ≥ 25 kg/m2); all other subjects (93.8%) had a BMI < 25 kg/m2.Of the 38 subjects enrolled, 32 completed the study, including 27 (84.4%) nursing students (age range: 20–29 years) and five (15.6%) teaching staff (age range: 31–54 years). The brief self-administered diet history questionnaire (BDHQ) survey questionnaire used in our study revealed the daily intake of different nutrients by the study participants. The estimated daily calorie intake for the SBM group was 1303.9 ± 478.9 kcal and 1480.8 ± 630.1 kcal before and after dietary intervention, respectively, and it was 1284.1 ± 461.5 kcal and 1315.6 ± 391.8 kcal in controls (p < 0.01), whereas no significant difference was noted in the control group  (p > 0.05). In addition, when both study groups were compared, a markedly higher adiponectin level was observed in the SBM group .As shown in Ulva species have indicated promising health benefits [The effects of Sujiaonori on human health have been rarely studied. Animal experiments on sulfated polysaccharides (ulvans) or ulvan fractions from several benefits ,23. Howebenefits . The admbenefits ,26.eicosapentaenoic acid (EPA)—one of the omega-3 polyunsaturated fatty acids (PUFA) that are abundant in marine fish meat and oil—induced an increase in adiponectin level in mice [docosahexaenoic acid  and canola oil [Radix astragali  have inloside I  showed tloside I . In our loside I ,33. In op > 0.05).p < 0.05), whereas a marginally significant reduction was noted in the control group (p = 0.0611). When comparing both study groups, no significant change was observed (p > 0.05) . Regarding diastolic BP, a decrease was observed in each of the study groups, but not significantly .Regarding blood pressure, after a 4-week supplementation period, a reduction in systolic BP was observed within each of the study groups. Regarding the systolic BP, a statistically significant decrease was observed in the SBM group ( > 0.05) . In addiHypertension is considered to be the greatest contributor to carotid arteriosclerosis in the Japanese population . NumerouTo summarize, our study showed that the intake of SBM supplement increased adiponectin level and improved BP in subjects with either prehypertension or high BP at baseline. The latter effect might be attributable mainly to the increased adiponectin level. Considering the beneficial health effects of adiponectin in humans ,5, and gWe conducted a non-randomized, placebo-controlled, investigator-blinded dietary intervention on the health effects of SBM dietary intake from January through August 2016 in Kochi prefecture, Japan. The participants were adult nursing students and teaching staff from the University of Kochi who satisfied the following inclusion criteria: 20 years of age or older, absence of a major health condition, taking no medication, voluntary enrollment, and provision of a signed informed consent form. Individuals with a personal and/or family history of allergy to algal product, ongoing medication, having heart, liver, major brain or kidney disease were not eligible. Of the 38 volunteers who were enrolled; 34 got registered to confirm their participation and received survey sheets, of whom 32 completed the study, including 31 women and 1 man. Two participants who did not undergo the second clinical examination and saliva sampling were excluded for the analysis related to this report .Participants were registered and assigned to study groups using their identification numbers; the SBM group comprised odd-numbered subjects who had to take 3 g SBM powder twice daily during mealtimes, control group was even numbered-subjects who received a 3 g mixture of 70% corn starch and 30% Japanese spinach powder twice daily. Dried Sujiaonori and corn starch samples were provided by a local food processing factory. The experimental period was four weeks. SBM powder and control product were prepared at our food science laboratory in the University of Kochi.At baseline and four weeks later, the “brief self-administered diet history questionnaire” (BDHQ) and the Current Health Status Questionnaire (CHSQ) were anonymously completed by participants, and anthropometric parameters and blood pressure were measured. In addition, saliva samples were collected at baseline and on day 28 of the study for the measurement of salivary adiponectin. BDHQ—which was used to assess the dietary history of participants—is a four-page fixed-portion questionnaire that asks about the intake of 58 selected food and beverage items in the previous month  . CHSQ wag for 10 min. Reagents, standards, and saliva samples were prepared at room temperature. First, the excess microplate strips were removed from the plate, and 50 μL of adiponectin standard or saliva sample was added to each of the wells. Then, the wells were covered with a sealing tape and the plate was incubated for 1 h.For saliva sampling, whole saliva (approximately 5 mL) was collected in tube with a funnel at our laboratory between 8:00 and 9:00 am, at least 60 min prior to brushing teeth, eating, or drinking. Test tubes were placed on ice just after saliva collection and stored at −20 °C. Salivary adiponectin was assayed by Enzyme-linked Immunosorbent Assay (ELISA) using a Human Adiponectin ELISA Kit  in accordance with the manufacturer’s instructions. Briefly, collected samples were centrifuged at 800× x-axis and the corresponding mean 450 nm absorbance on the y-axis. The essay was performed in duplicate. The primary outcome variable was the salivary adiponectin level, and the secondary outcome variables were blood pressure (BP), BMI, and health outcomes retrieved from the answers to survey questionnaires. In this paper, only data on salivary biomarker and a selected number of cardiovascular risk parameters  are reported. Prehypertension  and hypertension  were defined according to the American Heart Association [After each well was washed with washing buffer (200 μL), 50 μL of conjugate was added, and the plate was incubated for 30 min. After incubation, the microplate was washed as previously described. Fifty microliters of chromogen substrate were added to each well, and a 10 min incubation was performed. Next, 50 μL stop solution was added to each well, and the color changed from blue to yellow. The absorbance of the microplate was measured at a wavelength of 450 nm. The mean values of the triplicate readings for each standard and sample were calculated. A standard curve was generated, and the graph was plotted with the standard concentrations on the ociation .Ethical approval of the study protocol was obtained from the ethics committee of the faculty of Nutrition, University of Kochi . The study protocol was registered in an international trial registry (ISRCTN35616776). Additionally, each participant provided a signed informed consent. This research was conducted in accordance with the rules of the Declaration of Helsinki of 1975, as revised in 2008.p-values was set at 0.05.Stata software version 13  was used for statistical analyses. Continuous outcome variables are described as means or percentages, and comparison between study groups was performed with the use of analysis of variance (one-way ANOVA). For binary variables, data are described as proportions. A Spearman correlation test was performed to assess the association between salivary adiponectin, age, occupation, blood pressure, and BMI; on the other hand, multivariate logistic regression test was used to assess the association between salivary adiponectin and categorical variables . Statistical significance for Findings from this study suggested that the daily dietary intake of SBM supplement replenished adiponectin and ameliorated BP in subjects with prehypertension. Thus, Sujiaonori represents a source of promising bioactive materials that have a potential to improve blood pressure.


Ischemia–reperfusion injury (IRI) is a major cause of acute kidney injury (AKI) with poor outcomes. While many important functions of microRNAs (miRNAs) have been identified in various diseases, few studies reported miRNAs in acute kidney IRI, especially the dynamic changes in their expression and their implications during disease progression.The expression of miR-192, a specific kidney-enriched miRNA, was assessed in both the plasma and kidney of IRI rats at different time points after kidney injury and compared to renal function and kidney histological changes. The results were validated in the plasma of the selected patients with AKI after cardiac surgery compared with those matched patients without AKI. The performance characteristics of miR-192 were summarized using area under the receiver operator characteristic (ROC) curves (AUC-ROC).p = 0.014).MiRNA profiling in plasma led to the identification of 42 differentially expressed miRNAs in the IRI group compared to the sham group. MiR-192 was kidney-enriched and chosen for further validation. Real-time PCR showed that miR-192 levels increased by fourfold in the plasma and decreased by about 40% in the kidney of IRI rats. Plasma miR-192 expression started increasing at 3 h and peaked at 12 h, while kidney miR-192 expression started decreasing at 6 h and remained at a low level for 7 days after reperfusion. Plasma miR-192 level in patients with AKI increased at the time of ICU admission, was stable for 2 h and decreased after 24 h. AUC-ROC was 0.673 (95% CI: 0.540–0.806, Plasma miR-192 expression was induced in a time-dependent manner after IRI in rats and patients with AKI after cardiac surgery, comparably to the kidney injury development and recovery process, and may be useful for the detection of AKI. Acute kidney injury (AKI) is one of the most common complications in patients with prolonged hospital stays, increasing medical costs and poor outcomes . IschemiMicroRNAs (miRNAs) are short, endogenous non-coding RNAs, 18–22 nt long, that regulate gene expression at the post-transcriptional level by targeting messenger RNAs and inhibiting translation . MiRNAs In the present study, we analyzed miR-192 expression levels in the plasma and kidney tissues from IRI rats after miRNA profiling and verified its changes in the plasma of patients after cardiac surgery at different time points to determine whether miR-192 can be used as a tool to detect IRI kidney injury.All animal experiments were approved by the Animal Care and Use Committee of Ren Ji Hospital and carried out in accordance with the National Institutes of Health Guide for Use of Laboratory Animals. The human study was approved by the Ethical Committee of Ren Ji Hospital and in accordance with the principle of the Declaration of Helsinki. In addition, all patients signed informed written consent before cardiac surgery.Male Sprague–Dawley (SD) rats, weighing 150–200 g, were purchased from the SLAC Laboratory Animal Co. Ltd  and housed in animal cages with suitable conditions in the Animal Department of Renji Hospital. Rats were randomly grouped into the sham or IRI group. In miRNA PCR array and miR-192 validation study, nine rats in each group were euthanized after 24 h of reperfusion. In the time-course study, six rats from each group were euthanized 1, 3, 6, 12, 24 h, 3 or 7 days after surgery. The IRI procedures were performed as previously described . Blood wNinety-three patients aged 40–80 years, undergoing open cardiac surgeries in the Cardiac Surgery Division of Ren Ji Hospital from January 2014 to October 2014, were enrolled. All the patients with pre-existing end-stage renal disease requiring renal replacement therapy (RRT), cancer, diabetes, lupus nephritis, infection diseases, previous cardiac interventional therapy or minimally invasive cardiac surgery were excluded. Among them, 35 (37.6%) patients developed AKI, including 26 (28.0%) of Stage 1, 5 (5.4%) of Stage 2 and 4 (4.3%) of Stage 3. Thirty-five patients who developed AKI during the follow-up and thirty-five controls who also underwent open cardiac surgery, but did not develop AKI were matched at a 1:1 ratio based on age, sex, comorbidities and type of surgery in the subsequent study. The AKI diagnosis was defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria with a postoperative increase in plasma creatinine ≥50% from baseline or ≥0.3 mg/dL . Patientg at 4 °C for 15 min, followed by that at 12,000g at 4 °C for 15 min. The kidney homogenates were obtained by adding 400 μL of lysis buffer. RNA extraction was performed with TaqMan™ mirVana™ PARIS kit  according to the manufacturer’s instructions.Plasma was obtained within 1 h by two-step centrifugation at 3000MiRNAs were assessed by rodent TaqMan low-density array (TLDA) assay (ThermoFisher) according to the manufacturer’s instructions. An equal amount of three randomly selected samples was used to generate the pooled sample. Six pooled samples were obtained, three from each group. RNA was extracted from the six pooled samples. Reverse transcription, preamplification and PCRs were performed following the manufacturers’ protocols.® microRNA reverse transcription kit (ThermoFisher), TaqMan® Universal Master Mix II, no UNG (ThermoFisher) and TaqMan® microRNA assay (ThermoFisher) according to the manufacturer’s instructions. The 2Ct) and creatinine were detected by enzymatic method, using an automatic biochemical analyzer.Histological examination was performed as previously described . Tubulart test. Non-continuous data were presented as median (interquartile) and compared using Mann–Whitney U test. To compare categorical variables, we performed the χ2 or Fisher’s exact test, as appropriate. Multiple comparisons of variables within and between two groups of patients were compared by two-way ANOVA followed by post hoc nonparametric statistics. The AUC was calculated from a standard receiver operating characteristic (ROC) curve of microRNA for predicting AKI. p < 0.05 was considered statistically significant.All statistical analyses were performed with SPSS 16.0 software . Continuous data were presented as mean ± standard deviation and compared by using Student’s To determine the miRNA expression profile related to tissue injury and repair processes following AKI, we used a well-established model of bilateral renal IRI. After 45 min of ischemia and 24-h reperfusion, plasma BUN and creatinine were significantly elevated in the IRI group. In the sham group, BUN and creatinine were 7.67 ± 1.73 mmol/L and 23.3 ± 7.02 μmol/L, respectively. In the IRI group, BUN and creatinine increased to 29.95 ± 15.31 mmol/L and 112.05 ± 75.22 μmol/L, respectively  for plasma miR-192 at 2 h after ICU admission, indicating that plasma miR-192 can be an early marker for the detection of established AKI. When the cutoff value was 1.445, the sensitivity and specificity were 66.7 and 62.9%, respectively.To investigate the relationship between miR-192 and AKI, we observed the dynamic changes of plasma miR-192 levels in 70 patients who underwent cardiac surgery, 35 patients with AKI and 35 patients without AKI. As shown in Fig. Patient characteristics are shown in Table As shown in Table In the present study, we screened miRNAs in the plasma of IRI rats and identified 42 miRNAs with altered expression, among which 15 miRNAs were upregulated. In the time-course study, miR-192 expression in the plasma and kidney tissues of IRI rats varied in a time-dependent manner. In the clinical study, plasma miR-192 at 2 h after ICU admission presented a modest predictive value for the diagnosis of AKI.Our study showed dynamic changes of miR-192 expression in the plasma and kidney tissues of IRI rats. These dynamics correlated with histological findings of kidney injury and with increases in concentrations of known markers of renal dysfunction (BUN and creatinine). Thus, miR-192 may reflect kidney IRI. A previous study indicated that plasma miR-192 was upregulated at 6 h after reperfusion in IRI rats . MoreoveThere were several noteworthy points in our clinical study. Firstly, the plasma level of miR-192 in non-AKI patients at the time of admission to ICU (0 h) was also significantly higher than the preoperation level. This may be associated with cardiopulmonary bypass and cardiac IRI. Although miR-192 level in the heart tissue is much lower than that in the kidney, investigators showed that hypoxia induced miR-192 expression and excretion in the sera of patients with post-acute myocardial infarction (AMI) . MoreoveIn this study, the molecular mechanisms underlying the deregulation of circulating and renal miRNAs could not be determined. Previous studies suggest that miR-192 was linked to both G1 and G2/M cell cycle arrest in other contexts , 30 and The miRNA PCR array also showed that several miRNAs decreased after IRI, which have not yet investigated. The purpose of this study was to identify a miRNA with diagnostic implications for AKI after IRI. Owing to the low abundance of miRNAs in the blood, if miRNAs are further decreased under disease conditions, the level of these miRNAs may be beyond the range of detection of the existing techniques. The mechanism underlying the downregulation of these miRNAs is still not clear and should be investigated. In addition, we observed dynamic changes of plasma miR-192 levels in patients undergoing cardiac surgery and provided a time window for clinical testing.In summary, this study showed dynamic changes of plasma and kidney miR-192 levels in AKI and plasma miR-192 might be a predictor for ischemic AKI. Larger cohort studies are needed to confirm these findings, and further studies are required to identify the underlying molecular pathophysiological mechanisms.


Hypertension is a risk factor for coronary heart disease and stroke, and is one of the leading causes of death. Although over a billion people are affected worldwide, only half of them receive adequate treatment. Current guidelines on antihypertensive treatment recommend combination therapy for patients not responding to monotherapy, but as the number of pills increase, patient compliance tends to decrease. As a result, fixed-dose combination drugs with different antihypertensive agents have been developed and widely used in recent years. CCBs have been shown to be better at reducing central blood pressure and arterial stiffness than diuretics. Recent studies have reported that central blood pressure and arterial stiffness are associated with cardiovascular outcomes. This trial aims to compare the efficacy of combination of calcium channel blocker (CCB) or thiazide diuretic with an angiotensin receptor blocker (ARB).This is a multicenter, double-blinded, active-controlled, phase 4, randomized trial, comparing the antihypertensive effects of losartan/amlodipine and losartan/hydrochlorothiazide in patients unresponsive to treatment with losartan. The primary endpoint is changes in mean sitting systolic blood pressure (msSBP) after 4 weeks of treatment. Secondary endpoints are changes in msSBP, mean 24-h ambulatory mobile blood pressure, mean 24-h ambulatory mobile central SBP, mean 24-h ambulatory carotid-femoral pulse wave velocity, ambulatory augmentation index, and microalbuminuria/proteinuria after 20 weeks of treatment. The sample size will be 119 patients for each group in order to confer enough power to test for non-inferiority regarding the primary outcome.The investigators aim to prove that combination of a CCB with ARB shows non-inferiority in lowering blood pressure compared with a combination of thiazide diuretic and ARB. We also hope to distinguish the subset of patients that are more responsive to certain types of combination drugs. The results of this study should aid physicians in selecting appropriate combination regimens to treat hypertension in certain populations.ClinicalTrials.gov NCT02294539. Registered 12 November 2014. Hypertension is known to be a major contributor to coronary heart disease and stroke, which ranks second and third in causes for death in Korea . AccordiCurrent guidelines on treating hypertension state that initial therapy should include a thiazide-type diuretic, calcium channel blocker (CCB), angiotensin-converting enzyme (ACE) inhibitor, or angiotensin receptor blocker (ARB) . If the Fixed-dose combination (FDC) therapy for hypertension started in the 1960s with combination of hydrochlorothiazide (HCT) and triamterene, and since then different combinations using diuretics, CCBs, and renin-angiotensin system (RAS) inhibitors have been introduced , 8. The RAS inhibitors combined with diuretics or CCBs are one of the recommended regimens for patients unresponsive to monotherapy. Combinations with either diuretics or CCBs provide synergistic blood pressure lowering effects and lower the probability of side effects. However, according to the ACCOMPLISH trial comparing the combination of ACE inhibitor with either CCB or HCT, the ACE inhibitor/CCB combo showed better cardiovascular outcomes in high-risk patients . More reThis study was designed to compare the antihypertensive effects of fixed-dose combination therapy of losartan/amlodipine (LST/AML) with that of losartan/hydrochlorothiazide (LST/HCT) in patients with hypertension unresponsive to monotherapy with losartan. In addition, this is the first study to compare the cardiovascular protective effects of two combinations, by monitoring 24-h blood pressure and pulse wave velocity, which have correlations with cardiovascular outcome.The hypothesis of this trial is that fixed dose combination of losartan and amlodipine will be non-inferior to combination of losartan and hydrochlorothiazide in reducing blood pressure in patients with hypertension. Patient blood pressure was measured by conventional and ambulatory monitoring methods, and other vascular hemodynamic parameters were also obtained to test the hypothesis.The primary endpoint is the change in mean sitting systolic blood pressure (msSBP) after 4 weeks of treatment.Secondary endpoints are changes in msSBP, mean 24-h ambulatory mobile blood pressure (AMBP), mean 24-h ambulatory mobile central SBP (AMcSBP), mean 24-h ambulatory carotid-femoral pulse wave velocity (AMPWV), ambulatory augmentation index (AMAIx), and microalbuminuria/proteinuria after 20 weeks of treatment. Treatment compliance, response rate, and success rate are also included in the secondary efficacy evaluation. Response to treatment is defined as a decrease in systolic blood pressure exceeding 20 mmHg or 10 mmHg for diastolic blood pressure, in accordance with the Korea Food and Drug Administration (KFDA). Treatment success is defined as blood pressure reaching a target of <140/90 mmHg.Blood pressure measurements will be obtained in the sitting position with the pressure cuff placed at either the right or left brachial area, using a semi-automated sphygmomanometer . After 5 min of rest, blood pressure will be measured 3 times with an interval of 2 min, and mean pressure will be used for analysis.Ambulatory measurements of peripheral and central blood pressure, carotid-femoral pulse wave velocity (cfPWV), and augmentation index (AIx) will be performed using a previously validated, automated oscillometric device  –16.The trial has a multicenter, double-blinded, active-controlled, randomized design to compare the efficacy of fixed dose combination of losartan and amlodipine with that of losartan and hydrochlorothiazide. The detailed study design is shown in Fig. After 4 weeks of run-in, only patients with msSBP ≥140 mmHg will go through randomization and be given blinded treatment assignments. For the next 4 weeks, eligible patients are given either losartan/amlodipine 50/5 mg daily or losartan/hydrochlorothiazide 50/12.5 mg daily with a placebo drug of the other group. For patients not responding (msSBP ≥140 mmHg) to the first 4-week arm of the trial, doses will be increased to losartan/amlodipine 100/5 mg daily or losartan/hydrochlorothiazide 100/25 mg daily. The second arm of the trial will last for 16 more weeks. Patients responding to the initial dose will be maintained on their regimen.Randomization is achieved by block randomization method to avoid bias and increase inter-group comparability. Block size is determined by an independent individual not participating in the trial. Patients are randomized 1:1 to either losartan/amlodipine or losartan/hydrochlorothiazide. Randomization results are kept in a sealed envelope and opened only in case of serious adverse events. Both the investigators and study participants are blinded to treatment group. To avoid treatments being visually distinguishable, the study drug and placebo are identical in appearance.Patients are to be recruited from 20 nationwide medical centers in Korea. Men and women from ages 19 to 80, with history of hypertension or those newly diagnosed with a systolic BP ≥140 mmHg are to be included in the study.The exclusion criteria are: (1) mean sitting diastolic blood pressure (msDBP) ≥110mgHg or msSBP ≥180 mmHg at screening or randomization; (2) variability of ≥20 mmHg in SBP or ≥10 mmHg in DBP between three measurements, or differences of ≥20/10 mmHg in left-to-right brachial values of SBP or DBP; (3) secondary hypertension; (4) malignant hypertension; (5) allergies or contraindications to ARB, CCB, or sulfonamides; (6) uncontrolled diabetes mellitus (HbA1c ≥10%); (7) history of New York Heart Association (NYHA) class III to IV heart failure, angina, myocardial infarction, cardiomyopathy, arrhythmia, or aortic stenosis requiring treatment within 6 months; (8) cerebral vascular disease within 6 months; (9) serious liver or renal dysfunction; (10) symptomatic hyperuricemia or gout; (11) galactose or lactose-intolerance; (12) patients with diabetes or moderate to severe renal dysfunction on drugs containing aliskiren; (13) pregnancy or the possibility of pregnancy, or breast feeding; (14) unable to withhold current medication; (15) prescription of other study drugs within 4 weeks; and (18) abnormal laboratory results .Sample size is calculated with 90% power to detect a difference in change of SBP of 3 mmHg between two groups at a two-sided significance level of 5%. To satisfy these assumptions and allowing for a drop-out rate of 20%, a total of 238 patients (119 for each treatment arm) are required for the trial.Baseline characteristics will be compared using the Students t-test for continuous variables and the chi-square or Fisher’s exact test for categorical variables. Primary endpoint evaluation will be carried out using the two-sample t-test or Mann-Whitney test for inter-group comparison. For secondary endpoints, two-sample t-test and Wilcoxon’s rank sum test will be used for continuous variables, and the chi-square or Fisher’s exact test for categorical variables. Comparison of groups in achieving blood pressure target will be carried out using chi-square or McNemar’s test. All efficacy evaluations will be performed on the full analysis set (FAS). The FAS is a modified intention-to-treat set that includes patients receiving at least one dose of the study drug and having undergone at least one efficacy evaluation. Additional analysis will also be performed on the per protocol set. In order to minimize missing data, outcome data for patients who were discontinued from the study due to various reasons will be obtained and used for analysis. All investigators, sponsors, and regulators will aim to maximize the number of participants who are maintained on the assigned treatment until outcome data are collected.Safety analysis will be performed on all patients who has received the study drug at least once. Patients with self-reported or observed adverse symptoms will be seen by the attending physician and recorded according to treatment group and severity, and encoded to a system-organ class according to the Medical Dictionary for Regulatory Activities (MedDRA), version 16.0. The association with symptoms and drug treatment will also be evaluated. Abnormalities in laboratory results will be followed up until normalization and recorded for safety analysis.Not applicable.This study aims to compare the efficacy of two different types of losartan based combination drugs on blood pressure and vascular hemodynamic parameters. While previous studies have compared LOS/AML with LOS/HCT and have shown non-inferior antihypertensive results,  this triThe combination of ARB and CCB has proved to be beneficial beyond its additive BP reduction capabilities. ARBs selectively inhibit angiotensin II, which are potent vasoconstrictors. ARBs decrease blood pressure by vasodilation, and also decrease secretion of aldosterone, which in turn has protective effects in diabetic patients. CCBs relax smooth muscles and afferent arterioles in the kidney, leading to increased filtration in the glomerulus and finally resulting in reduced blood pressure. However, a well-known side effect of CCBs are peripheral edema and vasoconstriction. ARBs can reduce these side effects by antisympathetic effects and venous dilation. In addition, ARBs can lower the effect of increased renin-angiotensin-aldosterone (RAA) system, which rises from using CCBs . It has The difference of this study compared to other non-inferiority trials is that we aim to measure noninvasive hemodynamic parameters in addition to conventional blood pressure. Conventional, clinic measured brachial blood pressure has its limitations. Clinic blood pressure does not reflect the daily peak-trough variations and can be masked by whitecoat hypertension. Furthermore, recent studies have shown that central blood pressure might be a better predictor of cardiovascular outcomes. According to the CAFE study, even with comparable reductions in brachial blood pressure, clinical outcome tends to differ due to the difference in reduction of central blood pressure . While AArterial stiffness is also an useful tool to predict cardiovascular outcome and to evaluate subclinical organ damage in hypertensive patients . AssessmThe investigators hypothesize that the blood pressure lowering effects of LOS/AML combination will be comparable to that of LOS/HCT while having fewer side effects. Additionally, through measuring central blood pressure, augmentation index, and PWV, this trial will test the hypothesis that while showing comparable blood pressure lowering effects, an ARB/CCB combination (losartan/amlodipine) has greater cardiovascular benefits than an ARB/diuretic combination (LOS/HCT).Current hypertension treatment guidelines strongly advocate the need to use combination therapy for patients not responsive to monotherapy. However, there is no clear directive on which combination would be most effective and also have beneficial cardiovascular outcomes. The importance of this study is that it will compare central blood pressure and vascular hemodynamic parameters that have correlation with clinical outcomes. The results of this trial should aid physicians in selecting the appropriate combination drug to treat hypertension in certain populations.


Transesophageal echocardiography (TEE) is increasingly replacing thermodilution pulmonary artery catheters to assess hemodynamics in patients at high risk for cardiovascular morbidity. However, one of the drawbacks of TEE compared to pulmonary artery catheters is the inability to measure real time stroke volume (SV) and cardiac output (CO) continuously. The aim of the present proof of concept study was to validate a novel method of SV estimation, based on pulse wave velocity (PWV) in patients undergoing cardiac surgery.PWV) using the transformed Bramwell-Hill equation. The SV measured by TEE (SVTEE) was used as a reference.This is a retrospective observational study. We measured pulse transit time by superimposing the radial arterial waveform onto the continuous wave Doppler waveform of the left ventricular outflow tract, and calculated SV (SVPWV and SVTEE with the coefficient of determination (R2) of 0.71. A mean difference between the two (bias) was 3.70 ml with the limits of agreement ranging from -20.33 to 27.73 ml and a percentage error of 27.4% based on a Bland-Altman analysis. The concordance rate of two methods was 85.0% based on a four-quadrant plot. The angular concordance rate was 85.9% with radial limits of agreement  of ± 41.5 degrees based on a polar plot.A total of 190 paired SV were measured from 28 patients. A strong correlation was observed between SVPWV based SV estimation yields reasonable agreement with SV measured by TEE. Further studies are required to assess its utility in different clinical situations. In clinical practice, hemodynamic monitoring during anesthesia and in intensive care units is of paramount importance. The goal of hemodynamic monitoring is to guide interventions as well as to ensure adequate end organ perfusion and oxygen delivery by optimizing stroke volume (SV) and cardiac output (CO). Conventional hemodynamic variables such as arterial blood pressure, central venous pressure, and urine output are frequently used as surrogates for adequate end organ perfusion. However,This retrospective observational study utilized data from cardiac surgery patients who underwent surgery at The Johns Hopkins Hospital between October 2011 and September 2013. The protocol was approved by the Johns Hopkins Medicine Institutional Review Boards (IRB00088711). The requirement for written informed consent was waived by the IRB.The study included patients, 18 years of age or older undergoing cardiac surgery who had TEE images stored in the database on which the radial arterial waveform was superimposed on the continuous wave (CW) Doppler waveform of the left ventricular outflow tract (LVOT). All images were obtained before the initiation of cardiopulmonary bypass (CPB). Values of blood pressure (BP) at the time of image acquisition was recorded simultaneously. Patients with severe aortic valve stenosis, severe aortic valve insufficiency, arrhythmias, or an implanted device for cardiac rhythm management were excluded.Intraoperative care was similar in all patients, each of whom received general anesthesia with most patients receiving a combination of midazolam (2–10 mg), fentanyl (750–2000 μg), vecuronium (10–20 mg), and isoflurane (0.5–1%) after placement of a right sided 20 gauge radial arterial catheter for continuous BP measurements. A TEE probe was inserted after the induction of general anesthesia, and a comprehensive TEE examination performed by a cardiac anesthesiologist with advanced echocardiography certification using a Philips iE33 ultrasound machine . The arterial pressure and electrocardiogram (ECG) waveforms were recorded and simultaneously projected onto the LVOT CW Doppler waveform by connecting the clinical monitor  to the TEE machine, at the identical speed of 75mm/s . The CW PWV) was calculated using the transformed Bramwell-Hill equation. The Bramwell-Hill equation was introduced in 1922 allowing the estimation of PWV from an increase in the arterial volume (dV), an increase in blood pressure (dP), the arterial tree volume (V), and blood density (ρ).). Solving V × 0.11. We used V × 0.11. When theV × 0.11.17] PP w PP w2) ×eviously. We definTEE) was calculated using the formula: SV = LVOT CSA × LVOT VTI, where CSA is the cross sectional area of the LVOT and VTI is the velocity-time integral across the LVOT. LVOT VTI was measured by tracing the CW Doppler waveform across the aortic valve. Calculation of the LVOT CSA was performed by measuring the LVOT diameter from the mid esophageal long axis view, assuming a circular LVOT. In cases where more than one beat per image was captured, Δt and LVOT VTI were averaged across all beats.SV of the reference method (SVPWV was compared with SVTEE using simple linear regression to obtain a coefficient of determination (R2) and an equation defining the relation. Agreements of absolute values between the paired SVPWV and SVTEE were examined by Bland-Altman analysis. The bias (the mean difference between SVTEE and SVPWV), limits of agreement, and percentage error (PE) were calculated. The percentage error was calculated using the formula, PE = 2 SD of bias / mean value of the reference method. SVPWV was evaluated as interchangeable with SVTEE when the PE was 30% or less. SVPW SVPW20]  or less. Trending or less. The use  or less. In the p or less. Inter-obWe identified 37 patients who had images of the radial arterial waveforms superimposed on the CW Doppler waveforms of the LVOT. We excluded 8 patients with severe aortic valve stenosis and 1 patient with severe aortic valve insufficiency.A total of 190 pairs of SV data from 28 patients were included in the analysis. The mean (SD) number of SV pairs per patient was 7 (6). No arrhythmias were present in the beats analyzed. The baseline characteristics of the patients are outlined in PWV and SVTEE is shown in 2) was 0.71. A Bland-Altman analysis revealed that the bias was 3.70 ml with the limits of agreement ranging from -20.33 to 27.73 ml and a percentage error of 27.4% as presented in The correlation between SVSince analysis of the trending ability (concordance rates from four-quadrant and polar plots) requires calculation of the difference between consecutive SV measurements (ΔSV), only patients who had multiple images at different hemodynamic states could be included in this analysis. Hence 8 patients who had only one pair of SV data were excluded from the trending analysis. 162 pairs of ΔSV (%ΔSV) data were analyzed and depicted from 182 pairs of SV data from 20 patients. The four-quadrant plot for %ΔSV data is shown in The polar plot for the %ΔSV data is shown in PWV and SVTEE are clinically acceptable. Critchley et al. suggested using percentage errors of 30% or less between a novel technique and the current gold standard as clinically acceptable for showing that a new technique is clinically comparable to the gold standard. This percentage error of ± 30% arises from the assumption that the commonly used reference technique has a precision of ± 20% or less. The combination of two precisions of ± 20% equates to a total error of ± 28.3% (√[(±20)2 + (±20)2]), which is commonly rounded up to ± 30%. To a To a26] Our present study serves, as a proof of principle to determine if it is feasible to accurately estimate SV from PWV–using invasive monitors. Clinically, one can obtain pulse transit time and PWV by using only noninvasive or minimally invasive techniques. Pulse trThere are several prior studies comparing SV measured by TEE to SV measured by minimally invasive devices. Castro et al compared SVs measured by the axillary calibrated artery pulse-contour method  to SVs measured by TEE Doppler in patients undergoing aortic surgery. The percThere are several limitations to our study. The greatest downsides of our technique are inaccuracies in estimating the vascular path length and arterial tree blood volume. Vascular path length was calculated from height, age and gender, however, we did not measure it directly in each patient. The arterial tree blood volume was estimated from the predicted total circulating blood volume (TBV) as we could not measure it directly. These inaccuracies do not affect individual tracking of changes in SV under constant TBV, though they affect overall agreement and might be pronounced in states of hemodynamic disturbances. (e.g. acute blood loss). Nevertheless, we have previously published the relationship between SV, HR, BP, and PWV and found that PWV was negatively correlated with SV at the level of the single heartbeat. This sugPWV was acceptable. Moreover, there are timing and bandwidth issues that arise when comparing disparate types of waveforms (flow and pressure) and there is always the potential for hardware-related temporal lags on the two data streams (flow and pressure), which we did not account for in our study. Lastly, a potential for a hardware related confounder is the presence of bubbles in the manometer tubing which could well have damped the signal and distorted the waveform.Another limitation is that we used TEE instead of a PAC as our reference method. As such we cannot extrapolate the agreement and trending ability of our test method with the thermodilution technique. It should also be noted that we performed all measurements manually and hence our results dependent on individual observer judgment. However, two independent readers extracted data and inter-observer variability of SVSV estimated from PWV was clinically acceptable and interchangeable with SV measured by TEE. Although the trending ability didn’t reach the defined acceptable range, our PWV based SV/ CO monitor shows clinical promise since its real time, non-invasive and continuous. Further studies in patient population with rapid changes in volume status such as hemorrhage are required to investigate the clinical utility of the proposed methodology.


Invasive monitoring of pulsatile intracranial pressure can accurately predict shunt response in patients with idiopathic normal pressure hydrocephalus, but may potentially cause complications such as bleeding and infection. We tested how a proposed surrogate parameter for pulsatile intracranial pressure, the phase-contrast magnetic resonance imaging derived pulse pressure gradient, compared with its invasive counterpart. In 22 patients with suspected idiopathic normal pressure hydrocephalus, preceding invasive intracranial pressure monitoring, and any surgical shunt procedure, we calculated the pulse pressure gradient from phase-contrast magnetic resonance imaging derived cerebrospinal fluid flow velocities obtained at the upper cervical spinal canal using a simplified Navier-Stokes equation. Repeated measurements of the pulse pressure gradient were also undertaken in four healthy controls. Of 17 shunted patients, 16 responded, indicating high proportion of “true” normal pressure hydrocephalus in the patient cohort. However, there was no correlation between the magnetic resonance imaging derived pulse pressure gradient and pulsatile intracranial pressure . Pulse pressure gradients were also similar in patients and healthy controls (P = .26), and did not differ between individuals with pulsatile intracranial pressure above or below established thresholds for shunt treatment (P = .97). Assessment of pulse pressure gradient at level C2 was therefore not found feasible to replace invasive monitoring of pulsatile intracranial pressure in selection of patients with idiopathic normal pressure hydrocephalus for surgical shunting. Unlike invasive, overnight monitoring, the pulse pressure gradient from magnetic resonance imaging comprises short-term pressure fluctuations only. Moreover, complexity of cervical cerebrospinal fluid flow and -pulsatility at the upper cervical spinal canal may render the pulse pressure gradient a poor surrogate marker for intracranial pressure pulsations. Incrpatients , 4, 5.The disadvantage with invasive monitoring of pulsatile ICP is the risk of severe complications such as cerebral bleeds and infections, which may occur in about 1%, and treA non-invasively obtained marker for pulsatile ICP has been proposed, namely the PC-MRI-derived peak-to-peak pulse pressure gradient (MRI-dP), which is calculated from the cerebrospinal fluid (CSF) flow velocity change during one cardiac cycle at the upper cervical spinal canal. Image aUse of MRI-dP has previously shown promise in studies on computational fluid dynamics, baboonsIt has previously been validated that over-night measurements of pulsatile ICP are comparable with measurements at daytime and are therefore neither sensitive to head position of the patient, unlike mean ICP .The purpose of this study was therefore to assess the feasibility of MRI-dP by comparison with overnight invasive monitoring of pulsatile ICP in iNPH patients under clinical work-up for surgical shunting. We also compared MRI-dP derived from patients and healthy controls.The study and patient consent procedure was approved by the Institutional Review Board of Oslo University Hospital (07/5869) and Regional Ethics Committee (REC), South-East, Norway (S-07237). Each study participant was given written and oral information about the study and signed the consent form prior to inclusion in the study. All research was conducted according to the principles expressed in the Declaration of Helsinki. The institution that granted permission was Oslo University Hospital.In this prospective study, a cohort of 34 consecutive patients with clinically probable iNPH, hospitalized within the department of neurosurgery as part of their preoperative diagnostic work-up, were enrolled. PC-MRI was done at the end of a routine MR image acquisition protocol and preceded invasive ICP monitoring performed during the same hospital admission. Additionally, four healthy controls were examined with PC-MRI acquisitions at different time points during one day.All patients were scored clinically using a clinical NPH grading scale , which aThe shunt response was defined as an increase by at least 2 points on the NPH grading scale, and clinical score was assessed at regular intervals, 3, and 6–12 months following shunting.The procedure for continuous overnight ICP monitoring has previously been described. In shor2 to 0.63 x 0.63 mm2, slice thickness 7 mm, velocity encoding 6 cm/sec, and 32–40 phases with retrospective peripheral cardiac gating based on pulse oximeter plethysmography. Potential sources of inaccuracy in velocity measurements, such as eddy currents, Maxwell terms and gradient field non-linearities[For the iNPH patients, all PC-MRI images were obtained in a Philips 3 Tesla Achieva system  with a 16-channel head coil and an acquisition plane perpendicular to the upper cervical spinal canal at level C2, which is typically the closest level to the intracranial compartment where the assumption of the spinal canal as a rigid, cylindrical tube can be made when estimating MRI-dP. The PC-MRI scanning parameters were as follows: Repetition time (TR) and echo time (TE) was shortest possible, typically TR/TE = 16/11 ms, pixel size 0.56 x 0.56 mmnearities had beenThe healthy controls were scanned in a Philips 3 Tesla Ingenia system  with a 32 Channel head coil, and with identical acquisition plane,—level and—parameters as for the patients. Each healthy control was scanned with four PC-MRI acquisitions over at least two different time points during one day and with duration between time points of approximately two hours. Acquisitions within one time point were obtained consecutively without pause. All patients and controls were studied at daytime between 8 a.m. and 4 p.m.®  by use of dedicated software, nordicICE®  . Aliased velocities were treated with a filter that was activated if the temporal variation between two consecutive time steps of the examined pixel velocity exceeded a threshold value of 1.1 times the VENC. The aliased pixel was replaced by v = va ± 2 × Venc, where v is the filtered velocity, va is the aliased pixel value and Venc is the velocity encoding.Recorded velocities were converted by linear transformation from pixel values to centimeters per second by applying the velocity encoding using MATLABThe method for computation of MRI-dP (mm Hg/cm) has been described in detail previously.Mean velocities were computed by summarizing velocities at each pixel over the domain, and dividing the sum with the number of pixels.ρ = 1.0007 g/cm3 is the density of the CSF, and μ = 1.1 cP is the dynamic viscosity, and which are considered not to be affected by the iNPH condition.MRI-dP was computed according to Navier-Stokes equations for incompressible and Newtonian fluid. Velocities were recorded across an axial  plane, which reduced the Navier-Stokes equations to the z-component. Further, the flow was assumed parallel to rigid walls of a cylindrically shaped tube and the convective term was neglected. The resulting equation for the pressure gradient is given byPressure gradients for all pixels in the ROI were computed before they were averaged over the domain, resulting in one mean pressure gradient for each period. MRI-dP was calculated as the difference between the maximum and minimum pressure gradient within the cycle .ICP data, counting several thousands of observations from over-night monitoring, were assumed normally distributed, and presented in each patient with mean and standard deviation. For patients and healthy controls , PC-MRI data were assumed not normally distributed and presented with median and range. Correlations were determined by Pearson correlation coefficient, and agreement between methods was evaluated with a Bland-Altman plot. Comparisons between patients and healthy controls were performed with Mann-Whitney U test. One-way ANOVA was used to compare means of more than two groups. Reliability  of multiple quantitative measurements within individuals was estimated with the intraclass correlation coefficient (ICC). The significance level was set to 0.05. Statistical analysis was performed using SPSS Statistics version 20 .Of 34 enrolled patients, 12 were excluded from the study due to motion artifacts at PC-MRI (5/12), termination of the examination by the patient or MRI technician before completion (5/12), PC-MRI obtained at a suboptimal level (1/12) or image artifacts (1/12). Thus, 22 patients were included. Shunt surgery was performed in 17 of these, of which 16 (94%) were clinical responders. Other patient data are given in A summary of the ICP data from the iNPH patients are given in A summary of the PC-MRI data from patients and healthy controls is shown in MRI-dP at level C2 was not different in iNPH patients and healthy subjects (P = .39). Only area of the subarachnoid space (ROI area and hence number of pixels) differed between groups (P = .016).There were no associations between invasively measured pulsatile ICP and the non-invasive assessment of MRI-dP   or mean There was a high correlation between heart rates (HR) from PC-MRI and invasive ICP monitoring  , and theInvasive monitoring of pulsatile ICP has previously proven to be a precise tool to select which iNPH patients who will respond to surgical shunting. In this study, we tested the utility of PC-MRI to non-invasively assess a surrogate marker for pulsatile ICP, MRI-dP, obtained at level C2. MRI-dP did not correlate with invasively obtained pulsatile ICP from over-night monitoring, and did not discriminate iNPH patients from healthy subjects.Increased pulsatile ICP due to reduced intracranial compliance is common in iNPH , and patMRI-dP has previously been applied in a proposed method for non-invasive estimates of static (mean) ICP . With thShould a non-invasive measure such as MRI-dP be valid, it would have to reflect its gold standard of invasive measurement (pulsatile ICP). Both pulsatile and static (mean) ICP demonstrated in this study large fluctuations during the overnight monitoring, and this phenomenon is also a determining factor as to why clinical decisions based on monitoring of pulsatile ICP are made after analysis of observations from an extended time span . A PC-MRThere may be several reasons as to why MRI-dP derived from one simple PC-MRI acquisition does not reflect pulsatile ICP measured overnight. First, MRI-dP is based on acquisition of CSF velocity change at the upper cervical spinal canal, and is thus a surrogate marker for intracranial pressure change. A simplified model of a rigid, cylindrically shaped tube is desirable in order to make valid assumptions in fluid dynamic equations used in post-processing of PC-MRI data, where attempts made intracranially, with much more complex anatomy, are mostly restricted to the Sylvian aqueduct. However, even though the upper spinal canal is anatomically in close proximity with the intracranial compartment, the geometry is fundamentally different, and from computational fluid flow dynamics, it has been demonstrated that lower pressure values can be expected at level C2 than in the posterior fossa due to pressure gradients that become steep in the cervical canal.Secondly, the CSF flow at level C2 is the result of a dyssynchronous pressure pulsation causing a pulsating cranio-cervical pressure gradient pumping CSF in and out of the cranial vault. The pressure gradient estimated from MRI is relatively small, and in this study, less than 0.1 mm Hg per cm in all patients. This magnitude corresponds well with previous studies. From numerical studies, where the CSF flow has been modeled in rigid and impermeable surroundings, the fluid flow has been predominated by velocities orthogonal to the axial plane, and the observed pressure gradients at level C2 in healthy subjects is also less than 0.1 mm Hg per cm, 28. ComMoreover, the pressure gradient computation in this study is based on a number of simplifying assumptions such as rigid and impermeable surroundings and laminar flow. CSF flow patterns are, however, complex due to the anatomy of the cervical subarachnoid space, and floInterestingly, it may be noted that the healthy control with smallest CSF ROI area also had the largest MRI-dP among controls No. 2 in , and larFinally, but not least, recent studies have demonstrated respiration to have a major influence on CSF flow , 34. WitThe invasive ICP measurements of this study were not performed synchronously with PC-MRI, but overnight, as standardized according to previous empirical observations supporting this routine. In principle, our data do therefore not in principle contradict that MRI-dP may reflect pulsatile ICP in real time. The comparison with invasive monitoring for a prolonged time period is, however, highly relevant, because clinical decision making is rarely based on ICP monitoring from a time interval as short as the duration of a PC-MRI acquisition. It has previously also been validated that over-night and daytime measurements of pulsatile ICP are comparable, unlike measurements of static ICP.Another limitation was that technically adequate PC-MRI was obtained in less than 2/3 of enrolled patients, while all examinations in healthy subjects were successful. NPH patients are typically elderly and suffer from discomfort during long MRI scan times, and the experimental PC-MRI acquisitions were performed towards the end of the imaging protocol. In iNPH, dementia is a common feature, which may be a challenge to patient cooperation throughout the scan. MRI-dP from PC-MRI may therefore seem more feasible in subjects that cooperate well rather than in patients where compliance to instructions from the MR technician can be a challenge. The inability to exam patients with the poorest level of cooperation skills may have introduced bias to the study, because more severely affected patients might have been more likely to be excluded.Moreover, the velocity encoding gradient (venc) was set at a low level for the PC-MRI acquisitions in patients and healthy controls. Because of flow heterogeneities, flow aliasing was quite frequent. We consider, however, this potential source of error to be small because of the aliasing correction procedure and that flow velocity values from each time point represent the average of velocities from the entire region of interest. Pixels with any inaccuracies of flow velocity measurements should therefore not have contributed substantially to the calculated MRI-dP.As for PC-MRI based measurements of CSF flow in general, a major concern with the technique would be the extraction of data from a limited time interval to make a diagnosis in patients where well-known physiological fluctuations are present. In the present study, all PC-MRI exams may be assumed to have been performed within normal physiological boundaries, as they were obtained within a normal range for heart rate Tables  and 3, aInvasively obtained pulsatile ICP with level above thresholds has previously been demonstrated to predict a beneficial shunt response in 9 of 10 patients with iNPH. In our study cohort of iNPH patients, patient selection with this method yielded a beneficial shunt response in 94%. However, pulsatile ICP was not associated with its non-invasive counterpart, the PC-MRI derived MRI-dP. Moreover, MRI-dP did not discriminate between patients with either preoperative values of pulsatile ICP above or below thresholds, and neither patients from healthy subjects. MRI-dP obtained at level C2 was therefore not found feasible to replace invasive monitoring of pulsatile ICP in selection of iNPH patients for surgical shunting. Unlike invasive, overnight monitoring, MRI-dP comprises short-term pressure fluctuations only. Moreover, complexity of cervical CSF flow and -pulsatility at the upper cervical spinal canal may render MRI-dP a poor surrogate marker for intracranial pressure change.S1 TableResults from ICP monitoring in each of the iNPH study patients.(DOCX)Click here for additional data file.S2 TableResults from PC-MRI in each of the iNPH study patients.(DOCX)Click here for additional data file.S3 TableResults from PC-MRI in each healthy subject at each time point. PC-MRI exams (MRI-1 and MRI-2) within one time point (e.g. “Time1”) were performed with the possible closest proximity in time. The distance in time between two time points (e.g. “Time1” and “Time2”) was approximately two hours.(DOCX)Click here for additional data file.S1 FileExtended set of clinical patient data.(XLS)Click here for additional data file.S2 FileCalculated pressure gradients and mean velocities from single time points are given for all patients and healthy controls.(ZIP)Click here for additional data file.