Asthma is a chronic inflammatory disease that is very common among youth worldwide. The burden of this illness is very high not only considering financial costs but also on emotional and social functioning. Guidelines and many researches recommend to develop a good communication between physicians and children/caregiver and their parents. Nevertheless, a previous Italian project showed some criticalities in paediatric severe asthma management. The consensus gathered together experts in paediatric asthma management, experts in narrative medicine and patient associations with the aim of identify simple recommendation to improve communication strategies.Participants to the consensus received the results of the project and a selection of narratives two weeks before the meeting. The meeting was structured in plenary session and in three working groups discussing respectively about communication strategies with children, adolescents and parents. The task of each working group was to identify the most effective (DO) and least effective practices (DON’ T) for 5 phases of the visit: welcome, comprehension of the context, emotions management, duration and end of the visit and endurance of the relationship.Participants agreed that good relationships translate into positive outcomes and reached consensus on communication strategies to implement in the different phase of relationships.The future challenges identified by the participants are the dissemination of this Consensus document and the implementation of effective communication strategies to improve the management of pediatric asthma. Asthma is a heterogeneous chronic inflammatory disease that affects airways causing respiratory symptoms including wheeze, breathlessness, chest tightness, and cough , 2. AsthPoorly controlled asthma doesn’t affect only the expenses but also lead to an increase in morbidity and mortality . At the In order to improve asthma management, guidelines recommend developing partnership between healthcare providers, patients and their parents.Despite this evidence, children and adolescents are rarely engaged in discussion during medical visits, accounting for only 3–15% of the total medical visit interactions . Indeed In 2016, ISTUD Foundation led a project named SOUND  to investigate doctor-patient relationship in severe asthma through the narrative medicine methodology . NarratiThe results of the SOUND project highlighted the need to improve the communication to children and adolescents with severe asthma and their parents since paediatricians recurred more frequently to judgemental words compared to providers caring adult patients and this endanger the building of mutual trust .In view of what emerged from the SOUND project, it was considered that the “Consensus” was an appropriate method to identify first and then share a series of attitudes and behaviours to be adopted in daily clinical practice, in order to obtain effective relationships with paediatric patients with severe asthma and their families.The methodology of building consensus is a decision-making process that aims to identify what is preferable for a group through a face-to-face debate among stakeholders . The con11 paediatricians with strong expertise in paediatric severe asthma management ;6 paediatricians who already participated in the SOUND project and which showed a strong disposition to communication;3 representatives of patient association which are patients or parents of children and adolescents with asthma.The results of the SOUND project and a selection of narratives collected within the project were sent to the members of the Paediatric SOUND group two weeks before the meeting to allow all participants to analyse the evidences and make their own opinion. The consensus meeting was performed on the 14 September 2017 and held at the headquarters of the ISTUD Foundation in order to reduce the influence provided by the location since it was new to any participant. The participants were representative of three different groups of experts:The researchers of ISTUD Foundation, due to their expertise on narrative medicine and on the SOUND project, had the role of facilitator of the meeting.The first plenary session of the meeting was aimed to reaffirm the main results of the SOUND project. Subsequently, the objectives of the day and the Consensus methodology were shared with practical examples linked to work previously carried out by the ISTUD Foundation. Three working groups were therefore set up, based on the professional and roles of the participants involved to maintain wide representativeness. This promoted the mutual exchange of experience, good practice, and new ideas.The groups worked on three specific macro-topics related to the theme of communication in the care pathway for severe asthma, respectively focusing on communication to children, communication to adolescents and communication to parents.The task of each working group was to identify the most effective (DO) and least effective practices (DON’ T) for 5 phases of the visit identified by the ISTUD Foundation researchers: welcome, comprehension of the context, emotions management, duration and end of the visit and endurance of the relationship.The communication phase of the diagnosis and the phases most linked to the disease were not considered in an analytical way, as the project SOUND did not reveal any particular critical points in the management of this type of communication for Italian scenarios.During the subdivision of the working groups, each participant had a few minutes to write their own proposals of DOs and DON’Ts for each phase of the visit. Subsequently, the facilitators of the groups gathered the written ideas and the whole group discussed the ideas to arrive at a series of actions to do and not do for each phase. At the end of the group work, participants voted anonymously on the degree of consensus reached for each phase using a scale from 1 to 10, only the proposal that reached at least a degree of 8.5 where selected . All theAfter the meeting, the results of the consensus were collected by ISTUD Foundation and shared with the Paediatric Sound Group, which had one month to review all the results and confirm, or not, their degree of consensus.From reading the results of the SOUND project, the consensus participants agreed that the relationships and the ability to communicate empathically with patients and their families are the aspects that cross all the collected narratives. In particular, the ability to establish positive relationships affects not only people’s experiences but also the outcomes of the therapeutic plan .During the course of the meeting, members from all groups actively worked together to develop proactive proposals and strategies to improve the relationship between physicians and patients with severe asthma.Tables In particular, all participants agreed to maintain a warm and reassuring attitude towards the children by trying to involve them in all phases, while adolescent patients should be treated as adults by directing the interest of the examination to them and not to their parents. Other recurring themes are the use of open questions and, especially in the early stages of the visit, not strictly related to asthma management, and the ability to contain negative emotions.One important challenge identified by the children communication group is the prohibition topic: participants shared their experiences and they unanimously decided that it is important to never forbid the child anything  but find a planned compromise with the child and their clinical situation. During the plenary session, all participants agreed that these should be the correct behaviour, since prohibitions can cause trauma in patients’ experience and negatively affect the relationship.Some topics widely discussed within the groups have been the management of interruptions to visits by other doctors or phone calls and the possibility of sharing one’s mobile phone number with the patient’s parents. Initially, some doctors proposed to completely avoid answering the telephone and others that this was impossible in the daily management of the visits; at the end of the day the participants agreed that interruptions should be minimized and the visiting families should be reassured that they will benefit from the same availability.The lowest degree of consensus was reached when discussing how to maintain relationships between the visits Table . PaediatIn conclusion, the future challenges identified by the Pediatric SOUND Group are the dissemination of these suggestions and the implementation of classes addressed to pediatricians to improve communication and of effective technologies to maintain long-distance relationships.The Pediatric SOUND Group agreed that good relations translate into positive outcome on patients’ quality of life, therefore pursuing them becomes a needed professional competence, as stated by other Italian clinicians . The maiAll participants agreed firstly to maintain a warm and reassuring attitude towards the children and secondly to engage them in all phases; for adolescent patients recommendation was to address them as adults by directing the interest of the examination to them and not to their parents. This advice is supported by the studies of Giambra and colleagues  who demoRegarding the asthma management, the group agreed to the necessity for avoiding prohibitions (as having a pet or playing with plush toys) while focusing on the education of both patients and families to empower them to handle the allergen cause with a vigilant attitude. The group based this disruptive recommendation not only on their clinical experiences but also on many evidences that prohibitions could have a traumatic effect during childhood and in literature findings are already there regarding childhood obesity management , 37.The main criticalities emerged from this consensus conference were related to the management of communication. During the visit, the first problem is due to interruptions caused by phone calls by other patients; the group agreed that, even if avoiding them desirable, visit interruptions are inevitable explaining the reasons to patients and families, but pediatricians must limit that. Regarding the communication in the long-distance relationship, the unresolved issue is linked to the use of Mobile Messaging Apps and therefore sharing the private phone number. Using WhatsApp to communicate with patients, in particular with chronic patients, is becoming quite a routine not only in Italy but worldwide . Recent One limitation of this consensus was the lack of involvement of children and adolescents to the meeting; this is due to the chosen methodology, which involves the exchange of ideas among a group of experts. In order to overcome the absence of this point of view, members of the patients’ association were invited to participate as experts in patients’ and parents’ perception. Another limitation was the participation of only specialist paediatricians: in Italy routine check-ups are mainly followed by paediatricians and in our healthcare system the involvement of other professional providers is limited, with no respiratory nurses as in other countries like UK. Nevertheless, it would be interesting to involve both patient and other healthcare professionals, as nurses or physiotherapists, in future activities on this topic.Despite the limitations, this consensus provides strong suggestions that can be used to develop communication interventions in paediatric asthma management.The aim of this Consensus conference was to identify first and then share a series of attitudes and behaviours to be adopted in daily clinical practice, to obtain effective interactions with paediatric patients with severe asthma and their families. Overall, in agreement with previous studies, the communication between clinicians and paediatric patients with severe asthma and their parents was lacking , 20 withThis document offers a practical guideline that may help paediatrician optimise the relationships with both patients and parents. In conclusion, future challenges are the dissemination of these suggestions to all pediatricians through education and training on soft skills. The implementation of this advice into the life-long learning process of paediatricians will help to ensure a proper education not only on the pathways of the disease but also on listening and communication to patients and their parents.


Change in the prevalence of raised blood pressure could be due to both shifts in the entire distribution of blood pressure  and changes in its high-blood-pressure tail . Our aim was to quantify the contributions of these two phenomena to the worldwide trends in the prevalence of raised blood pressure.We pooled 1018 population-based studies with blood pressure measurements on 88.6 million participants from 1985 to 2016. We first calculated mean systolic blood pressure (SBP), mean diastolic blood pressure (DBP) and prevalence of raised blood pressure by sex and 10-year age group from 20–29 years to 70–79 years in each study, taking into account complex survey design and survey sample weights, where relevant. We used a linear mixed effect model to quantify the association between (probit-transformed) prevalence of raised blood pressure and age-group- and sex-specific mean blood pressure. We calculated the contributions of change in mean SBP and DBP, and of change in the prevalence-mean association, to the change in prevalence of raised blood pressure.In 2005–16, at the same level of population mean SBP and DBP, men and women in South Asia and in Central Asia, the Middle East and North Africa would have the highest prevalence of raised blood pressure, and men and women in the high-income Asia Pacific and high-income Western regions would have the lowest. In most region-sex-age groups where the prevalence of raised blood pressure declined, one half or more of the decline was due to the decline in mean blood pressure. Where prevalence of raised blood pressure has increased, the change was entirely driven by increasing mean blood pressure, offset partly by the change in the prevalence-mean association.Change in mean blood pressure is the main driver of the worldwide change in the prevalence of raised blood pressure, but change in the high-blood-pressure tail of the distribution has also contributed to the change in prevalence, especially in older age groups. After accounting for the difference in mean blood pressure, there is still a 3–5 percentage-point difference in the prevalence of raised blood pressure across regions, being highest in South Asia and in Central Asia, the Middle East and North Africa, and lowest in the high-income Asia Pacific and high-income Western regions.Shifts in entire distribution of blood pressure have been the main driver of the change in prevalence of raised blood pressure.There is also a measurable contribution from the change in the high-blood-pressure tail of the distribution, towards lowering the prevalence of raised blood pressure, especially in older people.Raised blood pressure, commonly defined as systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg, is used to identify individuals at high risk of cardiovascular diseases.The prevalence of raised blood pressure varies substantially across and within regions and countries, with age-standardized adult prevalence in 2015 ranging from 20% in the high-income Asia Pacific region to 33% in Central and Eastern Europe for men, and from 11% in the high-income Asia Pacific region to 28% in sub-Saharan Africa for women.,,,,,Blood pressure is a complex trait, affected by genes, fetal and early childhood nutrition and growth,We first used population-based data to estimate the association between the prevalence of raised blood pressure, defined as SBP ≥ 140 mmHg or DBP ≥ 90 mmHg, and population mean SBP and DBP among men and women aged 20 to 79 years in nine regions of the world, from 1985 to 2016. We used a linear mixed effect model to quantify the association between the prevalence of raised blood pressure and mean blood pressure. Our statistical model, described below, allowed the prevalence of raised blood pressure at any level of mean SBP and DBP to differ by age group, region and time period. We then used the fitted association to estimate the contributions of changes in the population mean blood pressure versus changes in the shape of its distribution , to the changes in the prevalence of raised blood pressure in different regions.,IJE online) and that there are no duplicates. Here, we analysed data collected from 1985 to 2016 on men and women aged 20–79 years, in 10-year age groups from 20–29 years to 70–79 years.We used data from NCD Risk Factor Collaboration (NCD-RisC) database, which contains studies that had measured blood pressure in representative samples of the national populations or of one or more sub-national regions and communities. NCD-RisC is a worldwide network of health researchers and practitioners whose aim is to document systematically the worldwide trends and variations in NCD risk factors. Our methods for identifying and accessing data sources, and the inclusion and exclusion criteria, are described in recent publications.We first calculated mean SBP, mean DBP and prevalence of raised blood pressure for these age groups by sex in each study, taking into account complex survey design and survey sample weights, where relevant. We excluded data points which did not cover complete 10-year age groups, e.g. those in people aged 25–29 years or 60–64 years, to avoid bias in the estimated associations. We also excluded age-sex groups with < 25 participants, because their means and prevalence have larger uncertainty.ε is the error term), separately by sex. We used probit-transformed prevalence because it provided a better fit to the data than a simple linear model or logit transformation. The model included age group (10-year age groups from 20–29 to 70–79) and the decade when the data were collected . We also included interactions between age group and mean blood pressure, between decade and mean blood pressure, and among these three terms, which allowed the prevalence-mean association to vary by age group and over time. We included regional random intercepts to account for the differences in prevalence at any level of mean SBP and DBP by region. The regions, used in previous analyses of cardiometabolic risk factors,,IJE online). The models were fitted in statistical software R version 3.4.2. Goodness of fit of the models was assessed by conditional R2, which represents the proportion of variance explained by both fixed and random factors.We then estimated the relationship between the prevalence of raised blood pressure and mean, using a linear mixed effect model, shown below in the equation  with uncertainty represented by a normal distribution for mean SBP and DBP and by a binomial distribution for prevalence of raised blood pressure. We then fitted a separate regression to each of the 1000 simulated datasets. We sampled 1000 draws from the joint distribution of the regression coefficients for each of the 1000 fitted regressions (i.e. 1 000 000 sets of regression coefficients). We report the median of the resulting 1 000 000 draws for each coefficient, and their 2.5th and 97.5th percentiles as the 95% confidence interval. We also report the median of conditional RIJE online). We report the differences between the predicted regional raised blood pressure prevalence and that of the world as a whole. These differences measure how much prevalence would vary across regions—due to geographical variations in the shape of blood pressure distribution—if they had the same population mean blood pressure.We used the fitted regressions to quantify how much differences across regions, and changes over time in the prevalence of raised blood pressure, were driven by differences/changes in mean SBP and DBP, versus by differences/changes in the prevalence-mean association. We first used the age-sex-specific global mean SBP and DBP in 2010 (∼mid-point of the 2005–16 period) in the fitted association, and estimated the prevalence of raised blood pressure by region. The age-sex-specific mean SBP and DBP values were taken from a recent comprehensive analysis of worldwide trends in blood pressure,We then decomposed total change in prevalence of raised blood pressure from 1985–94 to 2005–16 into contributions of change in mean SBP and DBP, change in the shape of prevalence-mean association and interaction of the two. The contribution of change in mean was estimated by allowing mean SBP and DBP for each age, sex and region to change over time, while keeping the decade variable fixed at 1985–94. The contribution of change in association was estimated by setting mean SBP and DBP to their 1990 levels (mid-year of 1985–94) for each age, sex and region, and allowing the decade variable to change. The interaction of the two factors is the difference between total change in prevalence and the sum of the above two components. The three components are schematically shown in We repeated the above analyses for each of the 1 000 000 sets of regression coefficients. We report the median of the resulting 1 000 000 estimates as our main result and their 2.5th and 97.5th percentiles as the 95% confidence interval. All analyses were done separately for men and women. Results were calculated by 10-year age groups and then aggregated into two age bands, 20–49 years and 50–79 years, by taking the weighted average of age-specific results; weights from the WHO standard population were used.IJE online). A total of 385 studies were from the high-income Western region, 108 from East and South-east Asia, 107 from Central Asia, the Middle East and North Africa, 106 from Central and Eastern Europe, 83 from sub-Saharan Africa, 79 from Latin America and the Caribbean, 78 from high-income Asia Pacific, 38 from South Asia and 34 from Oceania. The individual-level data were summarized into 7910 age-sex-specific pairs of mean of and prevalence of raised blood pressure. The number of data sources by country is shown in IJE online).We used data from 1018 population-based studies with 88 559 656 participants, of whom 86 187 860 were aged 20–79 years, and satisfied the above inclusion criteria (IJE online). Together, mean SBP and DBP, decade, age group and region explained most of the variation in the prevalence of raised blood pressure, evidenced by the high conditional R2 statistics of 0.918 for women and 0.871 for men.The coefficients of the regression models are listed in In 2005–16, the age-standardized prevalence of raised blood pressure in people aged 20–49 years ranged from 4%  in high-income Asia Pacific to 16% (13–19%) in sub-Saharan Africa in women, and from 14% (11–17%) in high-income Asia Pacific to 25% (21–30%) in Central and Eastern Europe in men. In those aged 50–79 years, the range was from 31% (26–36%) in high-income Asia Pacific to 56% (52–61%) in sub-Saharan Africa in women, and from 40% (36–43%) in the high-income Western region to 57% (51–63%) in Central and Eastern Europe in men.The prevalence of raised blood pressure decreased substantially from 1985–94 to 2005–16 in the two high-income regions and Central and Eastern Europe in both men and women across all ages .6 It alsAlthough in 2005–16 the ranking of regions in terms of prevalence of raised blood pressure was largely the same as the ranking of the mean, especially for women, inter-region differences in prevalence were not entirely due to those of mean blood pressure. Rather, some regions had an excess prevalence compared with what would be expected based on their mean, and others a lower prevalence compared with what would be expected based on their mean. At the same level of population mean SBP and DBP as that of the world as a whole, men and women in South Asia and in Central Asia, the Middle East and North Africa would have the highest prevalence of raised blood pressure, about 1–2 percentage points higher than the world average in different age groups . In contIn most regions where sex and age groups experienced a decline in the prevalence of raised blood pressure, the decline in mean blood pressure was the main driver of the decline in prevalence . The maiThe prevalence of raised blood pressure increased among men and women in Oceania and South Asia, and among women in sub-Saharan Africa and men in East and South-east Asia. The increase was driven entirely by rise in mean blood pressure, offset partly by the change in the prevalence-mean association. Prevalence of raised blood pressure remained largely unchanged among women in East and South-east Asia, due to opposing effects of increasing mean and the decrease brought by the changes in prevalence-mean association.We found that the trends and geographical variations in the prevalence of raised blood pressure are largely driven by shifts in the distribution of blood pressure in whole populations, rather than by the shape of the distribution. There was nonetheless an important contribution from having fewer high-blood-pressure individuals at the same level of population mean SBP and DBP over time, especially in older age groups.et al.Rose and DayThe strengths of our study include presenting the first global analysis of how much population mean and high-blood-pressure individuals have contributed to worldwide trends and variations in raised blood pressure, using a large global database with data from different regions and over time, and using methods that allowed the prevalence-mean association to vary by sex, age group, time period and region. Despite using the most comprehensive global collection of population-based studies to date, some regions had limited data, especially early in our analysis period. Further, there have been changes over time in devices used for measuring blood pressure in health surveys, with standard mercury sphygmomanometers replaced by random-zero sphygmomanometers and more recently digital oscillometric devices. These changes are unlikely to have affected our regional comparisons, and would only affect prevalence-mean association over time if they had differential effects at high versus low blood pressure.Although we found that changes in the prevalence of raised blood pressure have been mostly due to whole-distribution shifts, the behavioural, nutritional and environmental drivers of this shift remain uncertain. In high-income countries, the decline in blood pressure has occurred despite the rise in BMI,,,,,,Whereas these determinants act to lower mean blood pressure, better developed health systems are more effective in identifying and treating high-blood-pressure individuals, which would change the tail of the distribution without a major impact on its mean. The role of treatment in reducing the prevalence of high blood pressure has become increasingly important as clinical guidelines have lowered the threshold for diagnosing and treating hypertension, e.g. from having an SBP of 160 mmHg or DBP of 95 mmHg in the 1970sOur results demonstrate that changes in blood pressure both at the population and at the individual level have contributed to lowering raised blood pressure. What factors have spurred the former over the past few decades, however, remain largely unclear, and may be related to societal changes in nutrition, housing and health systems arising from social and economic development and technological progress. They also demonstrate the need for data that go beyond identifying the causes of low or high blood pressure, but also help measure how these factors change over time in worldwide populations. Learning about these factors would inform programmes that can help reverse the rise in the prevalence of raised blood pressure or accelerate its decline in low- and middle-income nations, where prevalence remains the highest, more effectively.IJE online.Supplementary DataClick here for additional data file.


Static intra-access pressure ratio (SIAPR) measurement, using haemodialysis machine transducers, is the vascular access surveillance method in patients undergoing haemodialysis. However, little is known about the relationship between the SIAPR and arterial stiffness, and the clinical usefulness of the SIAPR in predicting cardiovascular events. A total of 209 patients undergoing maintenance haemodialysis were evaluated. The SIAPRs ranged from 0.01 to 0.52 (median: 0.23). When the patients were divided into two groups according to their median of SIAPR, the incidence of previous cardiovascular disease, E/E′ ratio, and brachial-ankle pulse wave velocity were significantly higher in the patients with SIAPRs of ≤0.23 than in those with SIAPRs of >0.23. Conversely, patients with worse comorbid status had a lower SIAPR than patients without it. In the Kaplan-Meier analysis, the cumulative incidence of cardiovascular events was significantly higher in the patients with SIAPRs of ≤0.23 than in those with SIAPRs of >0.23 (P < 0.001). In the multiple Cox regression analysis, an increase in the SIAPR was associated with a reduced risk for cardiovascular events . Therefore, a low SIAPR related with arterial stiffness was a predictor for cardiovascular events. Increased arterial stiffness, commonly observed in patients receiving haemodialysis, is a known predictor of the induction of these diseases5. It results from the progression of atherosclerosis with vascular intimal and medial calcifications7. Pulse wave velocity (PWV), the speed at which the arterial pulse propagates through the circulatory system, is a good indicator of the degree of arterial stiffness9. Generally, carotid-femoral PWV (cfPWV) measurement is considered to be the current gold standard method for assessing central arterial stiffness10. However, because specialised equipment and specially trained staff are needed to measure the cfPWV, the brachial-ankle PWV (baPWV), which predominantly reflects peripheral arterial stiffness, is widely used owing to its simplicity in East Asian countries12. Its measurement only requires the wrapping of blood pressure cuffs on the four extremities. However, baPWV measurement may not be appropriate for cardiovascular risk assessment because central arterial stiffness is closely associated with cardiovascular events and mortality.Cardiovascular diseases are the main cause of death in patients undergoing haemodialysis13. Therefore, regular monitoring and surveillance must be conducted to check for vascular access failure early or to detect significant vascular access stenosis early. The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines suggest conducting regular surveillance of vascular accesses14. One of the recommended methods of vascular access surveillance is the measurement of the static intra-access pressure ratio (SIAPR), which is the static intra-access pressure normalised to the mean arterial pressure (MAP), using the transducer of haemodialysis machines without additional equipment14. Meanwhile, vascular access flow (Qa) can be calculated as follows: Qa = MAP/(Rout + Rin), where Rin and Rout denote the inflow resistance (i.e. resistance of the flow tract upstream of the venous needle), such as the arterial segment of the access, arterial anastomosis, feeding artery, and arterial tree to the heart, and the outflow resistance (i.e. resistance of the flow tract downstream of the venous needle), such as the venous segment of the access, venous anastomosis, and venous outflow to the heart, respectively15. Conversely, the SIAPR can be calculated as follows: Qa × Rout/MAP and can be expressed as Rout/(Rout + Rin)12. Generally, a high SIAPR is known to be an indirect indicator of vascular access stenosis related to outflow. A low SIAPR in the absence of inflow and outflow stenosis could be attributed to a high resistance to arterial inflow, which is related to increased arterial stiffness. Therefore, prediction of the degree of arterial stiffness using the SIAPR, without additional equipment, might be possible. In this study, we investigated the relationship between the SIAPR and arterial stiffness. In addition, because there is limited knowledge on the clinical usefulness of the SIAPR in predicting cardiovascular events, we evaluated whether the SIAPR had a prognostic value for cardiovascular events compared to known risk factors.In patients undergoing haemodialysis, maintaining an adequate vascular access is important to reduce morbidity and mortalityA total of 339 patients were on haemodialysis therapy at three dialysis clinics between January 2014 and February 2015. Two hundred ninety-one patients without vascular access dysfunction for 6 months or longer were eligible for inclusion. Eighty-two patients were excluded because of plans for referral to an interventional facility (n = 24), plans for transfer to another haemodialysis centre (n = 12), absence of PWV measurements (n = 4), use of cuffed central catheters (n = 15), and wrist-level fistulae (n = 27). Thus, a total of 209 patients who were on haemodialysis therapy were included in the analysis  vs 0.23(0.16–0.37), p = 0.05], previous peripheral artery disease , and previous cerebrovascular disease  had significantly a lower SIAPR than patients without diabetes, previous peripheral artery disease, and previous cerebrovascular disease, respectively.During a mean follow-up duration of 48.3 months, 27 patients experienced cardiovascular event. Of these, 18, 4, and 5 patients developed coronary artery disease, cerebrovascular disease, and peripheral vascular disease, respectively. Of note, 4 patients died from cardiovascular event. Additionally, of 4 patients with cerebrovascular disease, 1 patient developed another cerebrovascular disease after the event. The incidence of cardiovascular events was significantly higher in the patients with SIAPRs of ≤0.23 than in those with SIAPRs of >0.23 . The cumulative probabilities of cardiovascular events were also significantly higher in the patients with SIAPRs of ≤0.23 than in those with SIAPRs of >0.23 , the SIAPR can be expressed as Rout/(Rout + Rin). Therefore, a low SIAPR in the absence of inflow and outflow stenosis could be attributed to a high resistance to arterial inflow, which is related to increased arterial stiffness. Thereby, patients with abnormal results of vascular access monitoring or surveillance were excluded from our study. In line with this, we observed that the patients with a low SIAPR had a higher proportion of LV diastolic dysfunction related to arterial stiffness and a higher baPWV than those with a high SIAPR. Conversely, we also showed that patients with worse vascular or comorbid status had a lower SIAPR than patients without it. Of note, although patients with AVG had a higher Charlson Comobidity Index27 than patients with AVF . Written informed consent was obtained from all patients before enrollment.29. All patients regularly underwent vascular access monitoring and surveillance according to the KDOQI guidelines. Vascular access monitoring  was conducted at least once a week by qualified staff. The SIAPR, a special parameter for detecting vascular access dysfunction, was measured every 4 weeks for vascular surveillance. In addition, the patients were screened for abnormal test results suggesting vascular access dysfunction, such as elevated venous pressure, decreased blood flow, unexplained reduction in Kt/V , or elevated negative arterial prepump pressures11.For this prospective observational study, we enrolled patients undergoing haemodialysis at three dialysis clinics  between January 2014 and February 2015. Of note, based on these patients’ clinical data, we previously showed the associations between vascular calcification and various clinical characteristicsPatients were eligible if they had undergone haemodialysis without vascular access dysfunction for 6 months or longer. Of note, patients with vascular access dysfunction defined as those who referred to an interventional facility because of abnormal results of vascular access monitoring or surveillance. Patients were excluded if they fulfilled any of the following criteria: 1) plan for referral to an interventional facility because of abnormal results of vascular access monitoring or surveillance, 2) plan for transfer to another haemodialysis centere, 3) absence of PWV measurements, 4) use of cuffed central catheters, and 5) wrist-level fistulae.Cardiovascular disease was defined as a history of coronary artery disease, cerebrovascular disease, or peripheral vascular disease. Coronary artery disease was defined as myocardial infarction or angina; peripheral artery disease was defined as claudication, ischaemic limb loss, and/or ulceration; and cerebrovascular disease was defined as transient ischaemic attack or stroke. Cardiovascular events were defined as coronary artery disease requiring angioplasty or coronary bypass grafting, peripheral artery disease requiring peripheral revascularisation interventions, or cerebrovascular disease diagnosed using imaging studies.28. The measurement was performed after the end of haemodialysis session.The baPWV was measured using Vascular Profiler 1000 . Brachial and post-tibia arterial pressure waveforms were stored for 10 s using extremity cuffs connected to a plethysmographic sensor and an oscillometric pressure sensor wrapped around the arm and ankle. The baPWV was automatically calculated from the distance between two arterial recording sites divided by the transit time30. LV ejection fraction was estimated using the modified biplane Simpson’s method in apical two chamber and four-chamber views. LV mass was determined using the method described by Devereux et al.31, and the LV mass index was calculated by dividing the LV mass by the body surface area. Mitral inflow was assessed using Doppler echocardiography from the apical four-chamber view. The mitral inflow profiles were used to measure the peak mitral inflow velocities at early (E) and late (A) diastole, and their deceleration times. Doppler tissue images of the mitral annulus were also obtained. From the apical four-chamber view, the early (E′) and late (A′) diastolic peak velocities were evaluated. LV diastolic dysfunction was defined as an E/E′ ratio of >1532. Echocardiographic measurements were performed after the end of haemodialysis session.Comprehensive echocardiographic measurements were performed using an ultrasound machine  with a 2.5-MHz probe according to the imaging protocol from the American Society of Echocardiography guidelinesIA = PDC + 0.76 dH, where PIA (mmHg) is the static intra-access pressure, PDC (mmHg) is the venous drip chamber pressure, and dH (cm) is the difference in the height between the venous drip chamber pressure transducer and the venous needle in the access. Subsequently, the PIA was normalised to the MAP11. The measurement was performed at the end of haemodialysis session.After assuring that the zero setting on the pressure transducers of the dialysis delivery system has been calibrated for an accuracy within ±5 mmHg, the venous drip chamber pressure and the MAP in the arm contralateral to the access were obtained from the digital pressure display of the dialysis machine 20–30 s after turning off the dialysis blood pump. The static intra-access venous pressure was calculated as follows: PThe baseline characteristics, including demographic and clinical data, were obtained from medical records at the time of PWV measurement. The exposure for this study was the SIAPR within two weeks before and after PWV measurement. In addition, the outcome was cardiovascular events that occurred after PWV measurement. Of note, all enrolled patients were followed up until the day of cardiovascular events, loss to follow-up, death, or January 2019, whichever occurred first.All statistical analyses were performed using the Stata software . Continuous variables were expressed as means ± standard deviations or medians (interquartile ranges) and categorical variables as numbers (percentages). The Kolmogorov-Smirnov test was used to analyse the normality of the distribution of parameters among continuous variables. To compare the differences between the groups, Student’s t-test, Mann-Whitney test, the χ² test, or Fisher’s exact test was used. The cumulative incidence of cardiovascular events was calculated using the Kaplan-Meier product estimation method. The independent prognostic values for the study outcome were analysed by performing a Cox regression analysis. A multivariate analysis, which included all of the covariates with P values of <0.1 in the univariate analysis, was performed. Even though a P-value was ≥0.1, potential confounding factor that was known as significant prognostic determinant of cardiovascular events was included in the multivariate analysis. Using Harrell’s C index and the continuous NRI, we determined whether exposure had an additive value compared to the risk factors.Comorbid conditions of the study population according to vascular access type.


Background: There are many doubts with regards to accepting deceased kidneys with acute kidney injury (AKI) for transplantation.Purpose: The aim of this study was to present the 5-years outcome of kidney transplantation cases where deceased donors developed AKI before organ procurement.Methods: Two hundred twenty-six deceased renal transplants were analyzed. Data regarding donors and recipients were collected. Terminal AKI was defined as terminal serum creatinine concentration higher than 1.99 mg/dL and 66 such cases were diagnosed. All kidney transplant recipients were followed for 60 months.Results: AKI group presented more episodes of delayed graft function (DGF) compared to the non-AKI group . No differences were observed between the groups in the rate of acute rejection episodes, kidney function as well as patient and graft survival.Conclusions: Transplants with AKI present more often DGF and comparable graft survival to transplants without AKI. Kidneys with AKI can be a valuable source of organs provided attentive selection and appropriate care of deceased donors. Kidney transplantation is the first choice treatment for end-stage renal disease patients. The main obstacle in offering this treatment to everyone who needs it is an organ deficiency. There is still a discrepancy between the number of patients on the waiting list for kidney transplantation and the number of performed transplants . The neeWith the beginning of this century on the basis of Scientific Registry of Transplant Recipients a definition of ECD was obtained. An ECD definition is based on the following criteria: a donor older than 60 years or a donor older than 50 years with at least two of the subsequent: hypertension, stroke as a cause of death, or serum creatinine greater than 1.5 mg/dL . RecipieThe evaluation of expanded criteria kidneys should take into consideration the balance of risk between the transplantation of a kidney that is not considered ideal and waiting for a better kidney, resulting in a higher probability of death . The aimA high terminal creatinine concentration was historically a relative contraindication to kidney donation and transplantation because of the expected poor outcome. Nowadays, in the era of organ shortage, donors with a terminal creatinine concentration higher than 3.5 mg/dL, donors presenting with oligoanuria and even donors on hemodialysis become a matter of interest for the transplant community. After brain death, most donors are exposed to hypovolemia, hypotensive shock, hypoxic-ischemic injury, cytokine release, nephrotoxic agents, disseminated intravascular coagulation, and infections . These fThere is confusion in the nomenclature and classification of AKI. Many authors use a different definition of AKI to suit their purpose. The RIFLE criteria consists of 5 stages of renal injury  and was proposed by the Acute Dialysis Quality Initiative group . This clThis study examined organ donors presented AKI as a potentially valuable origin of kidneys for transplantation. The aim of this study is to present, that renal transplants from donors with AKI may have adequate renal function 5 years after transplantation.n = 226).A retrospective single center cohort study was conducted including all consecutive kidney transplants from deceased donor after brain death  that had been hospitalized in an intensive care unit for 1 to 14 days (mean stay = 4.5 days). The mean donor terminal serum creatinine concentration was 1.83 mg/dL . Vasopressors, most commonly dopamine, were administered in 84% of donors. More than 30% of the donors fulfilled the expanded criteria . The ter2. The mean duration of dialysis therapy prior to transplantation  was over 44 months. Most of the recipients suffered from hypertension (85%) and 14% suffered from chronic coronary disease.A total of 226 patients with end stage renal disease received a renal transplant from a deceased donor in the period between 2010 and 2011. The recipients age ranged from 19 to 76 years (mean = 47 years), they were predominantly male , and their mean body mass index (BMI) was 24 kg/min situ perfusion was performed using University of Wisconsin solution. Immediately after the organ recovery procedure and cooling to 4 °C, 21 kidneys (9%) were placed in a thermally stable container filled with preservation solution and 205 kidneys (91%) were allocated to a system for hypothermic machine perfusion . The decision of which type of storage was used was made depending upon cassette and perfusion fluid availability. Whenever possible, AKI donor kidneys were stored using machine perfusion. All 226 kidneys were transplanted to recipients from the National Waiting List. The surgical procedure was typical and a mean cold ischemia time was over 29 h.Immediately prior to surgery, donors were given heparin (25 000 IU) and a broad-spectrum antibiotic as a prophylactic. Procurement of kidneys was typical and The patient and graft survival, as well as the delayed graft function (DGF) were analyzed. Recipient kidney function was estimated with serum creatinine concentration and estimated glomerular filtration rate (eGFR) at 12, 24, 36, 48, and 60 months after transplantation. DGF was determined when there was the necessity for dialysis treatment during the first week after transplantation. eGFR was calculated with the use of the Modification of Diet in Renal Disease formula (MDRD).Most patients received triple drug immunosuppressive therapy that included steroids, cyclosporine or tacrolimus, and mycophenolate. In cases of strong immune responders, induction immunosuppressive treatment was added (basiliximab).Graft survival was established as an endpoint. Secondary endpoints included: DGF, acute rejection and kidney graft function. Patient death reflects the graft loss.t-test and Wilcoxon test were applied for differences between means and medians, respectively. The critical level for hypothesis testing was set at p = .05. Statistical analysis was performed using SAS software .Differences between groups were assessed by means of Chi-square or Cochran–Mantel–Haenszel tests. The Student’s n = 160) and recipients of kidneys from donors with terminal creatinine concentrations higher than 1.99 mg/dL .During the period included in this study, 226 patients were transplanted in our department. For the purpose of this study, two groups were selected: recipients of kidneys from donors with terminal creatinine concentrations lower than 2.0 mg/dL . The percentage of male donors in the AKI group was higher . The donors from the AKI group had a significantly higher BMI in comparison to the non-AKI group . Mean serum creatinine concentration was 1.03 ± 0.42 mg/dL in non-AKI donors and 3.82 ± 1.15 mg/dL in the AKI group at the time of kidney procurement . The mean flow in non-AKI kidneys group was significantly higher in comparison to AKI kidneys group the first hour of perfusion . The non-AKI kidneys group has also a tendency to have lower resistance compared to the AKI kidneys group the first hour of perfusion . There were no differences in the flow and the resistance between non-AKI and AKI kidneys regards next measurements during perfusion.There was no difference between non-AKI and AKI kidneys regards the method of storage  and in human leukocyte antigen (HLA) mismatch between groups . No diffp = .004). There were no differences in the rate of biopsy-proven acute rejection episodes in the first year post-transplantation . The concentration of serum creatinine was 1.69 versus 1.80 mg/dL at 12 months post-transplantation, and 1.57 versus 1.34 mg/dL at 60 months post-transplantation, in the non-AKI and AKI groups, respectively. These differences in serum creatinine were not statistically significant. Graft survival did not differ significantly between the two groups.In this current era of a growing number of patients awaiting a kidney, identifying an additional pool of donor kidneys that is suitable for transplantation is urgently needed. In this single center analysis, we found that the transplantation of kidneys procured from donors with AKI performed similarly to organs obtained from donors with normal kidney function. According to our findings, donors from the AKI group were predominantly male, were younger, and had a higher BMI. The issue of age could be explained that older deceased ICU patients with acute kidney injury are probably not taken into consideration as potential organ donors and are not referred to transplant coordinator. Higher BMI may be explained by the fact that obese people have a bigger chance of developing acute renal failure (ARF). There were no significant differences in the occurrence of biopsy-proven acute rejection episodes. The rate of DGF was significantly higher in the AKI group compared with the non-AKI group , respectively [p=ns), respectively [Kidneys procured from AKI donors have been previously reported to be more prone to develop DGF ,16 and tectively  showed tectively .p = .009), respectively. They also reported that kidney function was slightly worse in recipients of AKI kidneys; however, the eGFR was only measured during the first year after transplantation. Nevertheless, these authors suggested that donors with AKI are a viable source of organs and that these kidneys should not be discarded. Jacobi et al. [On the other hand, some authors have reported differences in survival of kidneys procured from donors with AKI. Kolonko et al.  reportedi et al.  underlini et al.  pointed i et al. , who repIn the current study, we used a simple cutoff point to determine the presence of AKI, and we did not analyze this group according to severity of AKI. Several researchers have attempted to evaluate whether the severity of AKI has an influence on the rate of kidney transplantation success. However, during long-term graft survival follow-ups, it is often impossible to proceed with such an analysis due to the small number of cases ,27. Lee It is obvious that kidney injury within the donor body is not the only important factor for success in organ transplantation. Cold ischemia time (CIT) has been widely explored as a factor that influences short-term kidney allograft function. Xia et al.  analyzedIn our opinion donors with AKI should be considered as potential kidney donors when initial (at the time of admission) kidney function was normal, the donor did not have any medical history of kidney disease and the perfusion parameters (flow and resistance) of the kidney improved during machine perfusion.Our analysis confirms that kidneys with AKI are prone to develop DGF and have comparable long-term results with non-AKI grafts. It is remarkable in our analysis, that almost 91% of all grafts were stored with the use of machine perfusion (89% in non-AKI and 95% in AKI group). In referenced studies there was no information about the type of storage, in some centers only cold storage preservation was used and in others the machine perfusion was used only for grafts with acute kidney injury. In contrast to other studies we presented results of machine perfusion during organ storage – the flow and the resistance (see above). In our opinion the machine perfusion should be used in every case of procured graft with acute kidney injury in order to assess the organ and presumably to improve results of transplantation.n = 66), it was better to compare all AKI kidneys to all non-AKI kidneys. Nevertheless, our analysis included a 5-year follow-up what increases the relevance of the conclusions.Our findings have limitations. This was a single center retrospective analysis. Many factors affect kidney graft function and survival, including donor and recipient details, methods of organ preservation, and post-transplantation treatment, making it very difficult to isolate any individual factor that influences the success of kidney transplantation. The terminal serum creatinine concentration is not an ideal kidney function marker and can be affected by many factors. The definition of AKI used in this study was simplified and did not divide the AKI group according to severity of AKI. In our opinion, due to the small number of available kidneys with AKI (In summary, we arrived at the conclusion that selected deceased donors with AKI are a significant origin of kidneys that should be used by the transplant community. Many kidneys are discarded because of an elevated terminal serum creatinine concentration. Although AKI kidneys are more likely to have DGF, they have comparable survival and function in comparison to non-AKI kidneys. Donor characteristics, machine perfusion parameters, and kidney biopsy findings are important tools to support the decision to offer kidneys with AKI. Kidneys with AKI can expand the organ pool and outcomes can be optimized provided attentive selection and appropriate care of deceased donors.


Background: Early diagnosis of delayed cerebral ischemia (DCI) in patients after aneurysmal subarachnoid hemorrhage (aSAH) still poses a leading problem in neurointensive care. The aim of this study was to analyze the effect of oral Nimodipine administration on systemic blood pressure in patients with evolving DCI compared to patients without DCI.Methods: Systolic (SBP), mean (MAP), and diastolic (DBP) blood pressures were analyzed at the time of Nimodipine administration and additionally 30, 60, and 120 min thereafter on days 1, 3, and 5 after aSAH. Additionally, the 24 h period preceding DCI and in patients without DCI day 10 after aSAH were analyzed. Statistical analysis was performed for SBP, MAP and DBP at time of Nimodipine administration and for the maximal drop in blood pressure after Nimodipine administration.Results: Thirty patients with aSAH were retrospectively analyzed with 17 patients developing DCI (“DCI”) and 13 patients who did not (“Non-DCI”). DCI patients showed a more pronounced rise in MAP and DBP over the examined time period as well as a higher decrease in SBP following Nimodipine administration. A fall of 18 mmHg in SBP after Nimodipine administration showed a sensitivity of 82.4% and specificity of 92.3% for occurrence of DCI.Conclusion: An increase of MAP and DBP after aSAH and a heightened sensitivity to Nimodipine administrations may serve as additional biomarkers for early detection of evolving DCI. Cerebral vasospasm related ischemia remains the leading cause of disability for patients with aneurysmal subarachnoid hemorrhage (aSAH) who survive the initial bleed and in whom the ruptured aneurysm has been secured , 2. RepoSeveral studies have reported that the L-type calcium channel blocker Nimodipine lowers the incidence of cerebral infarction and poor outcome in aSAH patients –9. The BEarlier studies investigating blood pressure changes after aSAH reported a more pronounced blood pressure rise in patients developing severe cerebral vasospasm or DCI –13. HoweThe aim of this study was to analyze systemic blood pressure effects of orally administered Nimodipine in patients after aSAH who develop clinically symptomatic cerebral vasospasm compared with asymptomatic patients.This is a single-center retrospective case-control study of patients with aSAH treated at the University Hospital Bern, Bern, Switzerland. Patients aged >18 years and <80 years were included.Our prospectively conducted database for patients treated with aSAH at the University Hospital Bern was retrospectively searched. Patients hospitalized between July 2012 and October 2015 were included. Inclusion criteria were:  no otherPatients were divided into two groups, those who developed DCI (“DCI”) and those who did not (“Non-DCI”). DCI was defined as acute occurring neurological deficit fulfilling the following criteria: (i) decrease of GCS and/or increase of the National Institutes of Health Stroke Scale of at least 2 points for ≥1 h; (ii) exclusion of other causes for neurological deterioration , and (iii) confirmation of hypoperfusion in a perfusion CT.TM Critical Care, General Electric Company, GE Healthcare, United States of America). The system automatically documents all hemodynamic variables in intervals of 2 min. Further data such as clinical scores, fluid balances and administered drugs are entered manually by the bedside team.Data was extracted from the institutional electronic Patient Data Management System (Centricityt0) and additionally 30, 60, and 120 min thereafter. All variables were recorded for the 6 Nimodipine administrations at day 1, 3, and 5 after aneurysm treatment, and Nimodipine administrations 24 h prior to DCI or at day 10 in Non-DCI patients (= day preceding event). In addition, GCS and Richmond Agitation Sedation Scale (RASS) scores were assessed at t0for the above-mentioned time points. The history of preexisting hypertension was directly extracted from the patient medical records.Systolic (SBP), mean arterial (MAP), and diastolic (DBP) blood pressure values and heart rate (HR) were assessed at the time point of every single Nimodipine administration  or in figures as mean ± standard error of the mean (SEM). A p < 0.05 was considered statistically significant. Diagnostic threshold values for blood pressure changes were calculated using receiver operator characteristics (ROC) curves. From the ROC curves, optimal threshold values to distinguish between patients with and without DCI were derived by seeking the best tradeoff between highest possible sensitivities and specificities.Statistical analyses were performed using SPSS Statistics 21.0  and Stata 16 . The Shapiro–Wilk normality test was used to test for normal distribution. Unpaired From July 2012 to October 2015, 224 patients were treated for aSAH in the ICU or IMC at the University Hospital of Bern, Bern, Switzerland. One hundred and ninety-four patients were excluded because they did not meet the inclusion criteria. Main reasons for exclusion were either missing blood pressure data for distinct time points or treatment with vasoactive medication. The final study population was composed of 17 patients in the DCI and 13 patients in the Non-DCI group. t0 increased over the analyzed time period in both patient groups (*time course for MAP (p = 0.027) and marginally for DBP (p = 0.049) but not for SBP (p = 0.092). When adjusting for sex and age, the interaction for SBP also reached significance (p = 0.011), whereas DBP was not significant anymore (p = 0.061). Adjustment did not change the significance level for MAP (p = 0.023). There were no significant changes in HR, GCS, and RASS values over the observation period.Blood pressure levels at t groups , Table 2p = 0.037). After correction for sex and age, this effect proved to be even more prominent (p < 0.001). HR remained unchanged in both groups after Nimodipine application.In both groups, there was a dip in systemic blood pressure after Nimodipine application , Table 2t0 as well as for Nimodipine induced SBP dips. A Nimodipine induced SBP drop of −18 mmHg showed the highest sensitivity and specificity for predicting DCI.t0), MAP, and DBP increased significantly in patients developing DCI when compared to clinically asymptomatic patients. Additionally, a heightened responsiveness of SBP to Nimodipine in patients developing DCI was found.In this retrospective study we analyzed systemic blood pressure changes in patients with aSAH after aneurysm treatment receiving Nimodipine orally every 4 h. At time of Nimodipine administration  –40 or evThe retrospective and single center study design represents the major limitation of this study. Additionally, only a small cohort of all patients treated for aSAH in our hospital could finally be enrolled into the study because of the very restrictive inclusion criteria. The major reasons for exclusion of patients were missing blood pressure data points or treatment with vasoactive medication (either catecholamines of blood pressure lowering drugs) after securing the aneurysm. In our opinion the use of well-defined and restrictive inclusion criteria bears the advantage of minimizing the natural bias of a retrospective study design to some extent. The findings of this study have to be verified with a prospective study design. Furthermore, the calculated threshold values for prediction of DCI also need to be verified with a prospective study.Our results show that an increase of systemic blood pressure after aSAH and a heightened sensitivity to Nimodipine administrations may serve as additional biomarkers for early detection of evolving DCI. Especially, SBP drops after Nimodipine administration, along with an overall rise in MAP and DBP can point toward an increased risk for DCI.The datasets generated for this study are available on request to the corresponding author.This study was carried out in accordance with the recommendations of the local ethics committee  with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the institutional review board of the University Hospital Bern and the local ethics committee .WZ'G, JB, AR, MH, and JS contributed to conception and design of the study. CFi, JG, SV, FW, DS, NS, and CFu collected the data. CFi and WZ'G performed the statistical analysis. All authors interpreted the results. CFi wrote the first draft of the manuscript. WZ'G, JS, MH, and JB wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version and provided the approval for publication of the content and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Previous studies have shown that, compared with non-stone formers, stone formers have a higher papillary density measured with computer tomography (CT) scan. The effect of increased hydration on such papillary density in idiopathic calcium stone formers is not known.Patients with recurrent calcium oxalate stones undergoing endourological procedures for renal stones at our Institution from June 2013 to June 2014 were considered eligible for enrolment. Enrolled patients underwent a baseline unenhanced CT scan before the urological procedure; after endoscopic removal of their stones, the patients were instructed to drink at least 2 L/day of a hypotonic, oligomineral water low in sodium and minerals (fixed residue at 180 °C < 200 mg/L) for at least 12 months. Finally, the patients underwent a follow-up unenhanced CT scan during hydration regimen.p < 0.001).Twenty-five patients were prospectively enrolled and underwent baseline and follow-up CT scans. At baseline, mean papillary density was 43.2 ± 6.6 Hounsfield Units (HU) (43.2 ± 6.7 for the left kidney and 42.8 ± 7.1 HU for the right kidney). At follow-up and after at least 12 months of hydration regimen, mean papillary density was significantly reduced at 35.4 ± 4.2 HU (35.8 ± 5.0 for the left kidney and 35.1 ± 4.2 HU for the right kidney); the mean difference between baseline and follow-up was − 7.8 HU . Kidney stones are an increasingly common condition, with an estimated prevalence in the United States of about 10%;  This conPatients undergoing endourological procedures for renal stones at our institution from June 2013 to June 2014 were considered eligible for enrolment. Inclusion criteria were recurrent stone disease and calcium oxalate stones . Stone composition was determined by Fourier transform infrared spectroscopy. Exclusion criteria were systemic conditions causing stones  and non-calcium oxalate stones. After signing written informed consent, patients underwent a baseline unenhanced CT scan before the urological procedure; the CT scans were performed using General Electric, Siemens, Philips and Toshiba equipment with a tube voltage variable from 120 to 140 kV, 80–643 mA and slices collimation from 1 to 5 mm. After endoscopic removal of their stones, the patients were instructed to drink at least 2 L/day of a hypotonic, oligomineral water low in sodium and minerals and rich in bicarbonate (fixed residue at 180 °C < 200 mg/L) for at least 12 months , as such that the densities of 12 renal papillae per patient were measured, and their means calculated. The images were magnified to 5× to prevent contamination of the region of interest with the fat in the renal sinus. The measurements of the renal papillae were made taking an area of 10 mmAll urine and serum analytes were measured in the central laboratory of Fondazione Policlinico Universitario Gemelli IRCCS on a Siemens ADVIA chemistry XPT with the following exceptions: urine citrate and oxalate were measured with LTA kit for enzymatic colorimetric determination.p-value < 0.05 was considered statistically significant. Statistical analyses were performed with Stata 13.1 .Continuous variables were reported as means and standard deviations; categorical variables as frequencies and percentages. Arithmetic means of right and left renal papillary density measurements for each patient were calculated and used for statistical analysis. Differences between baseline and follow-up papillary density values were analyzed with paired t-tests; correlations between continuous variables were analyzed with Spearman tests. A p < 0.001). Individual changes in papillary density are represented in Fig. Twenty-five patients were prospectively enrolled and underwent baseline and follow-up CT scans. Mean age at enrollment was 57 ± 17 years (range 18 to 78 years), 20 (80%) were males; average follow-up time was 22 ± 5 months (range 13 to 32 months); 22 patients received ureteroscopy and 3 percutaneous nephrolithotomy. All patients underwent measurements of papillary density on both kidneys except for one patient who had measurements taken only on the right kidney. At baseline, mean papillary density was 43.2 ± 6.6 HU (43.2 ± 6.7 for the left kidney and 42.8 ± 7.1 HU for the right kidney). At follow-up and after at least 12 months of hydration regimen, mean papillary density was significantly reduced at 35.4 ± 4.2 HU (35.8 ± 5.0 for the left kidney and 35.1 ± 4.2 HU for the right kidney); the mean difference between baseline and follow-up was − 7.8 HU , whose stone composition was assessed by means of the gold-standard infrared spectroscopy;  all patiOur study also has limitations. First, we did not have a control group; however, it would not have been ethical nor feasible to not recommend increased hydration after urological removal of stones. Second, follow-up time was not identical for all participants, as it was performed on routine clinical follow-up visits based on the clinicians’ judgement; however, all participants had at least 12 months of follow-up before the follow-up CT scan was performed. Third, adherence to the recommended fluid regimen was not assessed through changes in urine volume; however, the urine volume at follow-up was on average greater than 2 L, a figure higher than expected without intervention in a group of recurrent stone formers and thus likely increased compared with baseline. Fourth, we did not have a mean to assess long-term hydration habits of the patients. Fifth, the radiologist who assessed the HU value was not blinded to the patient status; this was done in order to allow the radiologist to sample the same ROI in baseline and follow-up CT scans. Finally, the documented changes in renal papillary density could not necessarily translate into reduced risk of recurrence, despite initial evidence for a predictive role of renal papillary density in stone development; future studies are warranted to investigate whether renal papillary density and changes thereof are independent predictors of incident stone formation.Increased fluid intake in patients with recurrent calcium oxalate stones is associated with a significant reduction in renal papillary density.


The temporal cross-sectional area of SCAR (SCAR-t) increased from 6414.5 ± 2218.7 µm2 at baseline to 8610.8 ± 2317.1 µm2 at T1 and to 11544.0 ± 4129.2 µm2 at T2. The expansion of Schlemm’s canal was observed after the CPT might be caused by sympathetic nerve stimulation, subsequently leading to decreased IOP.This study aimed to investigate changes in Schlemm’s canal, intraocular pressure and ocular blood circulation following the activation of the sympathetic nervous system. Twenty healthy volunteers were enrolled in this study. The cold pressor test (CPT) was adopted. Cross-sectional area of Schlemm’s canal (SCAR), superficial and deep retinal vessel densities , pupil diameter (PD), intraocular pressure (IOP), mean ocular perfusion pressure (MOPP) and heart rate variability (HRV) were measured at three time-points: baseline (T0) and 5 min (T1) and 10 min (T2) after the CPT. After cold stimulation, LF/HF index (the ratio of low frenquency and high frenquency) increased significantly. IOP decreased from 16.9 ± 1.9 mmHg at baseline to 16.4 ± 2.7 mmHg at T1 and to 15.2 ± 2.7 mmHg at T2. The nasal cross-sectional area of SCAR (SCAR-n) increased from 6283.9 ± 2696.2 µm In the eye, the intraocular pressure and ocular blood circulation were also mainly controlled by the sympathetic nervous system3. The influence of circadian rhythm in the SNS upon intraocular pressure has been a subject of interest. It was found that excision of the superior cervical sympathetic ganglion lowered, and electrical stimulation of the sympathetic nerve trunk elevated IOP4. In 1898, cervical sympathectomy became a popular operation, with most glaucoma surgeons fascinated about its results5. However, the effect on IOP was transient after interfering with the autonomic nervous system (ANS) and the mechanism by which the SNS influences IOP remains controversial.The sympathetic nervous system (SNS) is a component of the peripheral nervous system that regulates many human physiological variables including heart rate, blood pressure, respiration, digestion, and sexual arousal6. Lanigan et al. reported a significant association between retinal vessel calibre and sympathetic nervous stimulation2. After sympathetic blockage , the blood flow of the optic nerve head (ONH) and the ipsilateral retina significantly increased7; In addition, there was a report that SGB increased the retinal circulation in patients with Bell’s palsy8. However, no study evaluating the effects of SNS on the ONH and the retinal vessel density has been conducted.In general, the branches of the central retinal artery are not innervated by adrenergic fibres and the systemic control of the autonomic nervous system has a minor influence, however, there are some conflicting opinions regarding the absence of the influence of sympathetic innervation on the retina10. The insufficient retinal blood supply was also found that has a role in the development of glaucoma in recent years11. So, it is necessary to evaluate the effect of the autonomic nervous system upon the IOP and ocular blood supply.The increased intraocular pressure is the major risk factor of glaucoma, which is a leading cause of irreversible blindness in the world13. The CPT remains the most well-known test for the determination of ANS integrity14. Numerous studies have found that the CPT induces reproducible, sympathetic nervous system (SNS) activation in normal subjects17. This study aimed to examine the variations in retinal and ONH vessel density and possible mechanisms underlying IOP changes following the activation of the SNS after the CPT.Several autonomic nervous function tests are available to aid clinicians, including the hand-grip exercise, head tilt test, the cold pressor test (CPT) and the water drinking testTwenty-four participants (24 eyes) were enrolled in this study. Four participants were excluded due to unsatisfactory image quality. Finally, 20 participants  were included. Participants’ mean age was 26.75 ± 3.3 years , mean best corrected visual acuity (BCVA) was 0.98 ± 0.06 (range 0.8–1.0) and mean RE was −2.14 ± 2.01 diopter .2 at T0 to 8392.9 ± 3258.7 µm2 post-CPT at T1 and increased to 10422.0 ± 3643.8 µm2 at 10 min post-CPT. SCAR-t increased from 6414.5 ± 2218.7 µm2 at T0 to 8610.8 ± 2317.1 µm2 post-CPT at T1 and increased to 11544.0 ± 4129.2 µm2 at T2. IOP changed from 16.9 ± 1.9 mmHg at T0 to 16.4 ± 2.7 mmHg at T1 and then further decreased to 15.2 ± 2.7 mmHg at T2, post-CPT. Pupil diameter increased from 5.22 ± 0.9 mm at T0 to 5.50 ± 0.9 mm at T1 and returned to 5.11 ± 0.8 mm at T2  significantly increased from T0 to T2; MAP and MOPP significantly increased from T0 to T1 and returned to baseline at T2. The IOP significantly decreased from T0 to T2; the LF/HF significantly increased from T0 to T1 and returned to baseline at T2. The pupil diameter significantly increased in T1 and returned to baseline in T2. Both of s-RVD and d-RVD significantly decreased at T1 and returned to baseline in T2. Fig. . There w2 = 0.3106, P = 0.011), and also found between ΔSCAR-m and ΔLF/HF , but not in ΔSCAR-m and ΔPupil diameter  and ΔIOP  is the physiological variation between the R-R beat, which could provide real-time information of the peripheral autonomic nervous system non-invasively. HRV was used in our study to evaluate the SNS activity during the CPT. The frequency domains of HRV were acquired by the Fourier transform and divided into three parts: very-low-frequency , low-frequency , and High Frequency . The LF/HF was thought to represent the balance of activity of the sympathetic and parasympathetic nervous system, especially the activity of SNS23. The ocular response for the ANS mainly included the variation of pupil size, intraocular pressure and ocular blood flow. Pupillary size might be influenced by many factors, such as illumination intensity, wakefulness, emotional state etc., but mainly reflected the balance between the tonus of sympathetic (pupil dilatation) and parasympathetic (pupil constriction) nervous system. In our study, pupil diameter was found significantly dilated after cold stimulation, which means that the balance disorders of peripheral ANS occurred. IOP was found to obviously decreased during the cold pressor. The balance of aqueous humor production and outflow determines IOP. Previous studies discussed that parasympathetic and sympathetic innervation involved influenced both aqueous humor production and outflow. But the precise underlying mechanism of any observed changes in IOP is still unclear24.The autonomic nervous system maintains the physiological functions of numerous body organs, such as the heart, lungs and gastrointestinal tract25. By using a morphometric analysis system, Allingham RR et al. found that reduction in SC dimensions in POAG eyes may account for approximately half of the decrease in outflow facility26. The SC has attracted considerable interest in recent years27. In this study, SCAR was found expanded and was correlated with the activation of SNS (LF/HF index). In our previous work, SNS was stimulated by the aerobic exercise, consequently causing the expansion of the SC lumen and IOP reductions28. Histological studies have been revealed that β2-adrenergic receptors expressed in the SC. Specifically, Zhou et al. also found that endothelial SC cells softened to isoproterenol via its action on β2 adrenergic receptors30. Collectively, these findings indicated that the SNS is involved in SC regulation. Significant increases in SCAR following cold stimulation in the present study could be explained by the activation of the SNS.Schlemm’s canal is a vessel that collects aqueous humor and passes it into the bloodstream, thus serving a critical role in the maintenance of stable intraocular pressure (IOP), which is essential for maintaining the eye’s physiological functions31. An in vitro study found that increased IOP was often accompanied by occlusions to the SC lumen32. Increasing the length of the SC also improves its outflow, as observed after treatment with SC scaffolds33. By means of SC-relevant anti-glaucoma surgery, such as canaloplasty, viscocanalostomy, and SC scaffolding, significant decreases in IOP can be achieved34. Above all, there’s the close relationship of Schlemm’s canal with the maintenance of stable IOP. In the present study, IOP was found to significantly decrease. And the variation of SCAR and IOP correlated significantly in the post-CPT period. Thus, the IOP trough following CPT might arise from the expansion of SC lumen.Mathematical modeling revealed that the dilation of the SC increases its outflow facility and leads to subsequent IOP reductions35. Nagaoka T also found that the constriction of the retinal arterioles plays an important role in the maintenance of retinal blood flow in response to an acute increase in systemic BP using a laser Doppler velocimetry system36. The acute increase in MOPP may explain the decreased superficial and deep retinal vessel density in our study.There is a significantly decreased vessel density of retinal tissue after cold stimulation. In 1973, the efficient auto regulation of retinal blood flow was first proposed by Alm and Bill. Any elevation in retinal perfusion pressure is compensated by vasoconstriction in the retinal vasculature to maintain the stability of the retinal blood flow and vice versa37. The result is the same as what we found. Many studies have found that the trabecular sheets mechanically distend into the SC when an IOP of 30–50 mmHg is achieved, reducing the SC lumen38. However, in this study, we found no significant change in TMTH (trabecular meshwork thickness) following cold stimulation. Thus, the IOP decrease in this study is likely not due to variations of the TM.However, in our observation, there is no significant change in vessel density of optic disc after the activation of SNS. According to Takayama J, the velocity of ONH does not differ significantly between eyes with and without sympathetic nerve amputation; suggesting that the sympathetic system has no effect on ONH circulationWhile it offers some interesting insights into ocular physiology, the present study also has some limitations that warrant discussion. First, the results might be compared to those in abnormal, aged glaucoma populations or developmental glaucoma populations in future studies. Second, animal models might allow for more precise testing of mechanism and third, using the CPT with different models of ocular degeneration might allow further elucidation of ocular physiology.A total of 24 healthy volunteers from Tongji Hospital in Wuhan  were recruited between May 2018 and August 2018. All participants underwent an ophthalmic examination. The eye ipsilateral to the dominant hand was used for all studies.Inclusion criteria were as follows: 1) IOP < 21 mmHg and normal ophthalmoscopic appearance of the optic nerve ; 2) greater than 18 years of age; 3) no history of use of medications that affect the circulatory system within the month prior to their enrolment; 4) no caffeine consumption for at least 24 hr prior to their participation.Exclusion criteria were as follows: 1) Best-corrected visual acuity (BCVA) < 0.5 ; 2) Refractive error (RE) ≤ −6.0 D and RE ≥ + 3.0 D; 3) serious cataracts or other ocular diseases that hamper optical coherence tomography (OCT) imaging; 4) presence of other eye diseases such as age-related macular degeneration, retinal detachment, or a history of previous eye operations; 5) history or current hypertension or diabetes, or a family history of these conditions.The study protocols were approved by the ethics committee of Tongji Hospital. Written informed consent was obtained prior to enrollment from all the participants in accordance with the tenets set forth in the Declaration of Helsinki.The experimental recordings were initiated after a 5-min rest period. A baseline recording was obtained ; followed by a 1-min CPT and 10 min final recovery period . For the CPT, the dominant eye and hand were included in this study. Participants were instructed to immerse their hand into an ice water bath (0°C).The same procedure was repeated on another day. The same subjects were instructed to place their hand into an empty container for 1 min.Their IOP, BP, HR, PD, ECG recording, the profile images of Schlemm’s canal and trabecular meshwork, the retinal and optic disc angiography images on the same side were acquired successively at T0, T1, and T2.Patients fasted for at least 4 hr, after which 3 assessments were conducted. The IOP was measured using an I-care rebound tonometer . All IOP measurements were taken by the same experienced examiner (CW). A different observer (CZQ) read and recorded the IOP readings blinded to minimize any bias.SBP, DBP, and HR were recorded using an automatic sphygmomanometer . The mean arterial pressure (MAP) and mean ocular perfusion pressure (MOPP) were calculated using the following equation: MAP = [(2 × DBP) + SBP]/3; MMOP = 2/3 (MAP− IOP).Assessments described in the procedure above were obtained via swept-source optic coherence tomography (OCT) using a 1310-nm wavelength and a scan speed of 30,000 A-scans per sec and an axial resolution of less than 10 μm. 3D-angle high-definition images were obtained using volumetric scans . Nasal and temporal quadrant scans were performed independently, and subjects were instructed to stare at one of two peripheral fixation lights. Conjunctival vessels were used as landmarks to scan the same limbal area before and after cold pressor stimulation. Scans of each site were obtained at three time points  and with the best quality at each position  was chosen. All OCT tests were performed under standardized darkroom photopic conditions (ca. 3.5 lux).The Angio-Vue optic coherence tomography angiography  system uses a split-spectrum amplitude-decorrelation angiography software algorithm and acquires 70,000 A-scans per sec to create OCTA volumes consisting of 304 × 304 A-scans. A central 6 mm × 6 mm region of the macula and 4.5 × 4.5 mm region of the optic disc were captured. All OCT tests were performed under standardized darkroom photopic conditions (ca. 3.5 lux).www.tomey.com) following a 5-min rest period.Schlemm’s canal and trabecular meshwork were imaged during three time-periods  using swept-source OCT  and temporal SC  viewed at one region and the trabecular meshwork thickness (TMTH) of two regions  at three different time-points were measured using Image J software . SC was defined as being observable when a black, lucent space was found  included vessels from 3 mm below the internal limiting membrane to 15 mm below the inner plexiform layer; the retinal deep capillary network (d-RVD) included vessels between 15 mm and 70 mm below the inner plexiform layer. Indicators of retinal and optic disc RVD were measured at three time-points around CPT acquisition. Fig. .Figure 8After a 5-min resting period, subjects received the 3-leads ECG recording in the sitting position for 1 min. After the 1 min cold stimulation, the same ECG process was repeated. The R-R peak was extracted and analyzed by the Kubios HRV Premium software . The index of Low frequency divides high frequency (LF/HF index) was calculated.All measurements were taken by two observers blinded. Cases of a discrepancy of >15% were resolved by consulting the senior-most author. All data were recorded and stored for later statistical analyses.All statistical analyses were performed using SPSS software . The data are presented as mean values (Means ± SDs). One-way repeated-measures ANOVA was used to compare differences in nasal and temporal SCAR , as well as IOP, TMTH, LF/HF, pupil diameter (PD), MOPP, HR, RVD and ODVD at three different time-periods. The paired-sample T test was used to compare the parameters at two different time points in the control group. The linear regression analyses were adopted to examine the relationship between the variations of SCAR-m  and the change of IOP, the change of PD and the change of LF/HF from T0 to T2 . All tests were two-tailed. Statistical significance was defined as a P-value < 0.05.


Visceral adiposity has been reported to play a key role in hypertension compared with other measurements of regional or general obesity. The aim of current study was to evaluate the relationship between visceral fat reduction and changes in blood pressure in a group of overweight or obese Chinese individuals.An observational study was conducted with 168 participants (ChiCTR-OOC-17012000). Body composition, blood parameters and blood pressure were assessed at the beginning and end of the intervention. Males and females were categorized separately into quartiles according to changes in visceral fat during the intervention. Multiple linear regression models were used to assess the associations of changes in systolic and diastolic blood pressure with changes of visceral fat area, adjusted for potential confounders.p = 0.001) and diastolic blood pressure , but not in women after adjustment for the same potential confounders for systolic blood  and diastolic blood pressure .Changes in visceral fat was significantly associated with systolic and diastolic blood pressure in men for systolic . The online version of this article (10.1186/s12986-019-0369-0) contains supplementary material, which is available to authorized users. Cardiovascular disease is the leading cause of morbidity and mortality worldwide and hypertension is an independent cardiovascular risk factor . The incOverweight and obesity are associated with the emergence of hypertension and it has been shown that weight loss leads to blood pressure reduction , 12. ObeVisceral fat has been reported to be associated with blood pressure –17. SeveIn relation, the aim of the current study was to evaluate the relationship between visceral fat reduction and BP changes among a group of overweight or obese Chinese subjects in a 12-week meal replacement weight loss intervention.The study was approved by the Ethics Committee of Peking University Health Science Center on July 6, 2017. All of the subjects were informed of procedures and signed a consent form prior to commencement. The authors confirm that all ongoing and related trials for this intervention were carried out following the rules of the Declaration of Helsinki of 1975 and registered with the Chinese Clinical Trial Registry (ChiCTR-OOC-17012000).2 who: (1) were not actively trying to lose weight, (2) did not have allergies to any of the known food ingredients, and (3) were not pregnant or currently breast feeding were included in the study. Subjects were excluded from the study if they had: (1) physician-diagnosed cognitive impairment, schizophrenia, or depression by a physician, (2) heavy alcohol consumption, defined as 61 g alcohol drinks per day for male and 41 g alcohol drinks per day for females [Free living participants were recruited through advertisements in and around the Beijing area. Briefly, potential participants, aged 18–55 years, were required to complete a basic screening questionnaire to assess eligibility. Individuals with a BMI > 24 kg/m females , which wThis is an observational study that looked at data from a randomized controlled clinical trial that was conducted among free-living 168 overweight or obese subjects over a period of 3 months. The details of the original study have been published . BrieflyDemographic information including lifestyle, health condition, education, history of illnesses, and medication use were collected by a brief self-administered 17-item general questionnaire. Dietary habits were assessed through a self-administered 77-item Food Frequency Questionnaire (FFQ) at the beginning and last visit. Physical activity was evaluated by a self-administered 24-item questionnaire.2 and obesity was defined as BMI ≥ 28 kg/m2 according to the current definitions for Chinese adults [Height was measured using a standard wall-mounted stadiometer to the nearest 0.5 cm. BMI was calculated as weight in kilograms divided by height in meters squared. Overweight was defined as 24 ≥ BMI < 28 kg/me adults . BioelecBP measurements were determined by a validated semiautomatic sphygmomanometer (Omron HEM-705CP) by trained nurses. Two measurements were taken at 5-min intervals with participants in a seated position. Data were reported as an average of 2 measurements . HyperteTo ensure that the data met assumptions of parametric tests, these were assessed for outliers, homoscedasticity, and normality using Kolmogorov and Levene tests. One- way ANOVA was employed for multiple comparisons. Changes of VFA during the study were calculated by VFA at last visit minus VFA at baseline.Multiple linear regression models were used to assess the association of changes in SBP and DBP, with changes in visceral fat area during the intervention period, adjusted for potential confounders . Results were expressed as mean ± SD for continuous variables or percentages for categorical variables. All statistical tests were two-tailed, and the threshold for significance level was As shown in the Fig. p < 0.05).The baseline characteristics of participants are shown in Table p < 0.05) were found in BW, BMI, WC, WHtR, BFP, SBP and DBP before and after the study. Significant changes (p < 0.05) were only found in WHtR, and systolic and diastolic blood pressures.Body composition parameters  and blood pressures , stratified by genders are shown in Table p = 0.001) and diastolic blood pressure , but not in females after adjustment for the same potential confounders for systolic blood  and diastolic blood pressure .Linear regression analyses were conducted to assess the relationship between changes in VFA and changes in SBP and DBP during the study duration Table . SignifiA 12-week meal replacement intervention conducted on a group of overweight or obese Chinese subjects in and around the Beijing area demonstrated a significant reduction in visceral fat in males but not in females. After regression analysis, positive associations were found between reduction in visceral fat and improvement in SBP and DBP in males but not females. This finding highlights the importance of visceral fat reduction in interventions for hypertension and suggests further that weight loss and intervention programs for hypertension should be designed to include assessment of variability in response due to gender.In comparison to other measurements of obesity such as BMI, waist circumference and subcutaneous adipose tissue, the available studies report that the measurement of visceral fat shows more association with its increase with higher prevalence of hypertension , 29, 30.2 visceral fat decrement [Previous studies with cross sectional approaches have examined the association between visceral fat and blood pressure but limited investigations have shown the relationship between the reduction in visceral fat and improvements in blood pressure during short interventions similar to this study. Positive associations between visceral fat and hypertension were found in other populations such as Caucasian, African American, and Japanese Americans, as well as French-Canadians , 19, 32.ecrement . Anotherecrement . Other fecrement . Anotherecrement . In spitecrement .After multivariate adjustment, the association between visceral fat reduction and improvement in SBP and DBP was increased in male subjects, indicating that relationship between visceral fat reduction and BP decrement in men was independent of body weight, BMI and other potential confounders. However, such association was not found in females even after multiple adjustments, which shows that gender difference may exist when exploring the effects of visceral fat reduction on BP changes.There are several plausible mechanisms that may explain the relationship between reduction in visceral fat and improvement in BP. First, previous studies have demonstrated that visceral fat is associated with secretion of adipocytokines, which contribute to the development and progression of BP elevation , 38, 39.The differences observed between genders in the current study might be explained by multiple possibilities. First, visceral adipose tissue is lost preferentially with short term and modest weight loss, but the effect is attenuated with extension of time and greater weight loss . In our Some limitations of this study should be noted. First, the length of the intervention was only 12 weeks and a longer duration may be more informative and enhance nominally significant associations in light of our modest caloric intervention. Second, the sample size was relatively small thus it was difficult to perform further stratified analysis by quartile. Third, the self-administered food questionnaire and physical activity questionnaire are not able to provide sufficient precise data to further analyze and support the observed differences between genders. Fourth, the study was not designed to identify biochemical biomarkers, therefore we cannot analyze the potential mechanisms underlying changes in BP in response to insulin sensitivity and adipocytokines. Fifth, sodium and potassium intake are associated with studies on hypertension, however, those data were not obtained in the present study.The strengths of our work mainly include the longitudinal study design that showed the relationship between visceral fat reduction and BP improvements in a weight loss program, thus, expanded upon prior work that has shown associations between visceral fat and incident hypertension. Second, the analysis performed under each gender setting showed different results between genders which suggests that further exploration of potential mechanisms is necessary.In summary, our study found a significant correlation between the reduction of visceral fat area and improvements in systolic and diastolic BP in overweight or obese male subjects, confirming the importance of visceral fat reduction in a weight loss program on the relevant health outcome. Our findings indicate that the evaluation of changes in visceral fat may be necessary when designing intervention programs for hypertension. Furthermore, research regarding gender-specific associations between visceral fat and blood pressure changes is warranted.Additional file 1:Database of participants. (XLSX 88 kb)