Flavin containing monooxygenase 3 [FMO3] encodes dimethylaniline monooxygenase [N-oxide-forming] 3, which breaks down nitrogen-containing compounds, and has been implicated in blood pressure regulation. Studies have reported conflicting results of the association of a common nonsynonymous variant, E158K (rs2266782), with hypertension. We examined the associations of E158K, along with rare and low frequency exonic variants  in FMO3 with hypertension, systolic blood pressure (SBP), and diastolic blood pressure (DBP). We included 7,350 European Americans and 2,814 African Americans in the Atherosclerosis Risk in Communities (ARIC) study with exome sequencing of FMO3. The association of FMO3 variants with SBP and DBP was tested using single variant and gene-based tests followed by the replication or interrogation of significant variants in ancestry-specific cohorts based on Bonferroni corrected thresholds. E158K had significant association with higher SBP in African Americans in ARIC (p=0.03), and two low frequency variants had significant association with higher SBP in African Americans  and European Americans . These associations were not significant with additional samples: E158K in a meta-analysis of SBP of African ancestry  that included ARIC participants and the two low frequency variants in an independent ancestry-specific exome sequencing study of blood pressure . Our study does not support the association of E158K and low frequency variants in FMO3 with blood pressure and demonstrates the importance of replication in genetic studies. FMO3) regulates the amount of TMAO in the blood through the N-oxygenation of trimethylamine (TMA) [ FMO3, such as N61S and P153L, have been found to cause trimethylaminuria (TMAU), a condition characterized by an accumulation of TMA in the blood, due to the decreased catalytic efficiency of FMO3 [ FMO3 causing trimethylaminuria also commonly have hypertension [ FMO3, and hypertension. A study in a population of 1,649 Irish participants found no significant association of E158K  with hypertension [High levels of trimethylamine N-oxide (TMAO) have been associated with atherosclerotic lesions in mice and various cardiovascular disease (CVD) outcomes  in humans . Flavin ne (TMA) , which irtension . Studies FMO3 that may influence blood pressure. The primary aims of the present study were to characterize the number and type of variants located in FMO3 in a large cohort of European and African Americans, evaluate the association of the common variant E158K with hypertension reported previously, and detect associations of low frequency FMO3 variants with systolic blood pressure (SBP) and diastolic blood pressure (DBP).A cohort with large sample size can provide sufficient statistical power to assess the association between E158K and hypertension. In addition, exome sequencing can provide a comprehensive view of all exonic variants in a gene and provide the opportunity to discover novel variants inThe study population consists of individuals enrolled in the ARIC study, a multisite prospective cohort study aimed to discover predictors of cardiovascular disease outcomes. Detailed methods and description of the ARIC study design have been described previously . The ARI FMO3 was 7,810 participants of European ancestry, referred to as European Americans, and 3,180 participants of African Ancestry, referred to as African Americans  were found. Putative function of each variant was annotated using ANNOVAR [Whole exome sequencing was performed using Illumina HiSeq 2000  and mapped to the Genome Reference Consortium Human Build 37 (GRCh37). The quality control foru et al.  After vaThe clinical covariates were age, sex, body mass index (BMI), and study center. To control for population substructure, we included adjustment for the first 10 principal components generated with EIGENSTRAT using genotypes from whole exome sequencing . SmokingEuropean and African American participants were analyzed separately. All of the following analyses were adjusted for the first 10 genetic principal components, age, age-squared, sex, BMI, and study center unless otherwise noted. The missense variant E158K was first evaluated for an association with hypertension using multivariate logistic regression in the two ethnic groups separately. Next, to formally test the potential effect measure modification of current smoking status on the variant-hypertension relationship, current smoking status and an interaction term between current smoking status and E158K were added to these ethnic-specific models. Finally, the same analysis was performed stratified by smoking status within the two ethnic groups. An analysis of E158K with continuous SBP and DBP values was also performed using multiple linear regression controlling for the same covariates.As a secondary analysis, we performed single variant analysis for low frequency variants (MAF between 0.1% and 5%) with SBP and DBP measures as the outcome. Common variants (MAF > 5%) were excluded because rare and low frequency variants may have larger effects on blood pressure and no hypertension associations have been reported for common variants except for E158K. Variants with a MAF < 0.1% were also excluded due to power limitations. FMO3 was significantly associated with SBP and DBP [A rank-based inverse normal transformation of blood pressure values was performed as a sensitivity analysis to test the robustness of our results. This analysis prevents any large blood pressure values from influencing the estimates obtained from the single variant analysis by rank-ordering the values to ensure there are no influential points . Gene-ba and DBP . These tVariants with significant association in the ARIC study were put forward for replication or further interrogation in larger studies. For the E158K association with SBP in African Americans, we interrogated the results from a previously conducted genome-wide association study of 30,841 participants of African ancestry from the Continental Origins and Genetic Epidemiology Network Blood Pressure (COGENT-BP) consortium with ARIC as a participating study . The samUsing the same methods described above, sensitivity analyses of the E158K and single variant association with blood pressure were performed stratifying by hypertension medication use to evaluate the effect of adjusting the blood pressure values of those taking antihypertensives. In addition, we performed an analysis of the E158K and single variant associations stratified by sex. A gene-based test as described above was also performed stratified by sex.For the study of the E158K association and the gene-based tests in the ARIC cohort, statistical significance threshold was 0.05. This study of the common variant E158K (MAF of 42% in European Americans and 46% in African Americans) and hypertension had 80% power to detect an odds ratio of 1.11 in European Americans and 1.23 in African Americans. The analysis of E158K with continuous blood pressure values had 99% power to detect a difference in 1.2 mmHg for SBP and 0.7 mmHg for DBP in European Americans and 2.3 mmHg for SBP and 1.4 mmHg for DBP in African Americans. Bonferroni corrected p-values were used to determine significance in the single variant analysis of low frequency variants. At an alpha of 0.05, this study had 80% power in European Americans to detect a change of 13 mmHg, 4 mmHg, and 2 mmHg in SBP and 8 mmHg, 3 mmHg, and 2 mmHg in DBP for MAF of 0.1%, 1%, and 5% respectively. In African Americans, this study had 80% power to detect a change of 24 mmHg, 8 mmHg, and 4 mmHg in SBP and 14 mmHg, 5 mmHg, and 2 mmHg in DBP for MAF of 0.1%, 1%, and 5% respectively. In European Americans, two out of 46 variants had MAF between 0.1% and 5%, therefore the statistical significance threshold for low frequency single variant test was 0.025 (=0.05/2). In African Americans, 14 out of 68 variants had MAF between 0.1% and 5%; therefore the statistical significant threshold was 0.0035 (=0.05/14). Power calculations were performed using QUANTO [www.r-project.org).Because the FMO3 activity has been shown to decrease with increasing number of loss-of-function alleles, we used the additive genetic model for all variants . In addiIn ARIC European Americans, the mean age was 54 with 46% being male . The meaIn ARIC African Americans, the mean age was 53, with 37% being male. The mean SBP and DBP were 127 mmHg and 79 mmHg, respectively. The proportion with hypertension was 54%, and 43% were taking antihypertensive medications. The mean BMI was 30, and 28% were self-reported current smokers. FMO3  [In the ARIC study, E158K had a MAF of 42% in European Americans and 46% in African Americans and was in Hardy-Weinberg equilibrium in both populations . The association between E158K and hypertension was not significant in both European and African Americans p>0.05, . The rel p=0.43) . In the β=30.9, p=0.0003, β=2.98, p=0.006, Exome sequencing found two low frequency variants in European Americans and 14 in African Americans with MAF between 0.1% and 5%. Only one variant was found in both groups (rs75904274). Two nonsynonymous variants were found to have a statistically significant association with SBP separately in African Americans  in European Americans including 62 variants with MAF < 5% . However, after removing rs75904274 (MAC=257), the significant low frequency variant found in European Americans, the association of FMO3 with SBP, was no longer significant in either the SKAT (p=0.74) or the burden test (p=0.76). FMO3 was not associated with SBP in African Americans in either the SKAT (p=0.34) or the burden test (p=0.43). FMO3 did not have significant association with DBP in either European or African Americans using the SKAT or burden tests. In our sensitivity analysis stratified by sex, no new significant associations were identified .The replication populations for rs75904274 in European Americans included European ancestry participants of FHS, CHS, and ESP . A meta-analysis of the association with SBP was not significant (In the ARIC study, we found that E158K did not have significant association with hypertension, and the results were similar after stratifying by current smoking status. These results were not driven by differences in MAF because both populations had similar MAFs to previous studies . A signiTwo previous studies had conflicting results for the association of E158K with hypertension status . A posit FMO3 causing trimethylaminuria also have comorbid hypertension [ FMO3 are associated with hypertension. Our analysis in the ARIC study revealed that most exonic variants in FMO3 were nonsynonymous, with two of these being associated with higher SBP. However, the replication analysis of these two variants did not show significant associations. Therefore, the significant results in the ARIC study were likely due to chance. These results highlight the ever-important need for replication of significant genetic results.Previous studies have found that many individuals presenting with variants inrtension –6, 16. Mrtension , prompti FMO3 and blood pressure. A total of 25% of Europeans and 43% of African Americans included in our study were taking medication for high blood pressure. To account for this, we imputed the blood pressure for these participants by adding 15 mmHg to SBP and 10 mmHg to DBP measures in participants who were on antihypertensive drugs. This imputation may not adequately account for the effects of antihypertension drugs.Measurement errors could affect the associations between variants in FMO3 with SBP and DBP. The significant associations of rs200985584 and rs75904274 with SBP in the ARIC study were not replicated in ancestry-specific results of other cohorts. Overall, our results do not support the association of E158K and low frequency variants in FMO3 with blood pressure and demonstrate the importance of replication in genetic studies.Our study included a large cohort of African and European Americans, providing sufficient power for a definitive study for the association between E158K and hypertension. Contrary to previous report, E158K was not significantly associated with hypertension. In addition, our study examined the association of low frequency and rare variants in


P < 0.001), whereas urinary ACR was not significantly changed by sulfonylureas . The effect on albuminuria occurred even though both treatment groups had a similar change in serum glycated hemoglobin A1c . Therefore, in diabetic patients the addition of DPP-4 inhibitors lowered urinary albumin excretion compared to sulfonylureas, and attenuation of albuminuria may be a consideration when choosing between antidiabetic medications.Diabetic kidney disease (DKD) leads to substantial morbidity in patients with type 2 diabetes mellitus (T2DM). Evidence suggests that antidiabetic drug dipeptidyl-peptidase 4 (DPP-4) inhibitors may be able to attenuate albuminuria, whereas the influence of sulfonylureas on albuminuria remains unclear. This prospective open-label study investigated the effect of DPP-4 inhibitors and sulfonylureas on urinary albumin excretion, which is a marker of renal microvascular abnormality. A total of 101 participants with newly diagnosed T2DM were enrolled. In addition to metformin therapy, 45 patients were assigned to receive DPP-4 inhibitors and 56 to receive sulfonylureas. Urinary albumin-to-creatinine ratio (ACR) was significantly reduced in recipients of DPP-4 inhibitors after 24 weeks (29.2 µg/mg creatinine vs. 14.9 µg/mg creatinine,  Diabetic kidney disease (DKD) occurs in up to 40% of patients with type 2 diabetes mellitus (T2DM) . DKD leaOral antidiabetic drugs such as dipeptidyl-peptidase 4 (DPP-4) inhibitors and sulfonylureas are extensively used in the treatment of T2DM. Although both DPP-4 inhibitors and sulfonylureas effectively lower plasma glucose levels, there may be differences in their effect on the diabetic kidney. Importantly, clinical evidence has suggested that DPP-4 inhibitors may be able to attenuate the progression of albuminuria in patients with T2DM ,6. In co1c (HbA1c), and systolic blood pressure were examined.Considering that both DPP-4 inhibitors and sulfonylureas have a distinct effect on body weight and blood pressure, we hypothesized that these medications may influence the diabetic kidney differently. This study investigated the effect of DPP-4 inhibitors and sulfonylureas on urinary albumin excretion, a marker of renal microvascular abnormality, in patients with newly diagnosed T2DM. Moreover, the effect of these medications on clinical variables including body weight, serum glycated hemoglobin AIn this prospective study, diabetic patients who visited the Endocrinology clinic between March 2016 and February 2018 were screened for eligibility. Inclusion criteria were patients exceeding 20 years of age, with newly diagnosed T2DM, who had yet to receive antidiabetic medications. Exclusion criteria were patients with non-diabetic kidney disease, congenital kidney abnormalities, or end-stage renal disease. Moreover, patients receiving angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) were ineligible because these medications can modify urinary albumin excretion.1c, urinary albumin-to-creatinine ratio (ACR), and serum creatinine. Both the investigators and the participants were informed of the treatment allocation. Participants subsequently received standard clinical care, including medical nutrition therapy and diabetes educator consultation, in accordance with current diabetes management guidelines [Demographic information, including age, sex, and systolic blood pressure, was recorded at the initial clinic visit. In accordance with the recommendation by the American Diabetes Association to prescribe metformin to all patients with T2DM in the absence of contraindications , particiidelines .1c, serum creatinine, serum alanine transferase, and plasma lipid profile after a 12-hour fast. Blood tests for these clinical variables were repeated after 24 weeks of pharmacologic treatment. Blood samples were delivered to the clinical laboratory within one hour of venous sampling and assayed by Beckman Coulter UniCel DXC 800 Synchron™ Clinical Systems . The analytical precision was within 1.7 mg/dL for high-density lipoprotein cholesterol, within 3.0 mg/dL for low-density lipoprotein cholesterol, within 7.5 mg/dL for triglycerides, and within 0.1 % for serum HbA1c. For the purpose of this study, the estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease equation [At the initial clinic visit, participants received blood tests for serum HbAFor each participant, urine samples were collected in the morning after a 12-hour fast at the first clinic visit and after 24 weeks of pharmacologic therapy. The urinary ACR was measured by the turbidimetric method using Beckman Coulter UniCel DXC 800 Synchron™ Clinical Systems . The analytical precision for urinary ACR was within 2.3 ug/mg creatinine.1c, body weight, serum creatinine level, eGFR, and systolic blood pressure were considered secondary outcome measures. The primary outcome measure of this study was the change in urinary ACR after completing 24 weeks of pharmacologic treatment. The changes in serum HbAClinicalTrials.gov Identifier: NCT03983551). All participants provided written informed consent to participate in the study in accordance with the Declaration of Helsinki.This study was carried out in accordance with the World Medical Association’s Declaration of Helsinki. The study was approved by the Institutional Review Board of Changhua Christian Hospital (CCH IRB Identifier: 190512) and listed in a clinical trial registry . A two-tailed P value of less than 0.05 indicated statistical significance. The demographic characteristics and clinical outcomes of the treatment groups were compared using a Student’s independent This study screened 120 patients for eligibility. Eleven patients were excluded due to concomitant use of ACEI or ARB, and eight were ineligible because they were previously diagnosed with non-diabetic kidney disease. The enrollment process is illustrated in P = 0.5), body weight , systolic blood pressure , and serum HbA1c . Moreover, participants in both groups had similar mean urinary ACR at diagnosis . Similar proportions of patients in both treatment groups received antihypertensive medications including calcium channel blockers , beta blockers , and diuretics . Patients receiving ACEI or ARB were ineligible because these medications can modify urinary albumin excretion. All participants completed the 24-week clinical trial without loss of follow-up.The study enrolled 101 participants, with 45 recipients of DPP-4 inhibitors and 56 of sulfonylureas. Their demographic features are summarized in P < 0.001). In contrast, urinary albumin excretion was not significantly influenced by sulfonylureas relative to levels at diagnosis . Moreover, body weight was slightly reduced relative to baseline in recipients of DPP-4 inhibitors  but remained unchanged in the sulfonylurea group . In both treatment groups, serum creatinine, eGFR, and systolic blood pressure were not significantly affected by antidiabetic therapy. These findings are recorded in After 24 weeks of antidiabetic therapy, urinary ACR was significantly reduced in recipients of DPP-4 inhibitors relative to baseline levels . Regarding the secondary outcome measures, both groups demonstrated comparable changes in serum HbA1c , body weight , serum creatinine , eGFR  and systolic blood pressure  after 24 weeks of antidiabetic therapy. These findings are shown in In terms of the primary outcome measure, participants who received DPP-4 inhibitors had a significant reduction in urinary ACR relative to recipients of sulfonylureas (−14.3 µg/mg creatinine vs. 3.29 µg/mg creatinine, 1c at study completion, the effect of DPP-4 inhibitors on albuminuria may involve pathways in addition to glycemic control. As observed in this study, DPP-4 inhibitors significantly lowered urinary albumin excretion in diabetic patients after 24 weeks of therapy. In contrast, sulfonylureas had no significant effect on urinary ACR despite their glucose-lowering capacity. Moreover, recipients of DPP-4 inhibitors demonstrated a significantly reduced body weight. Since both treatment groups attained comparable levels of serum HbAHowever, this study did not detect a significant effect of either DPP-4 inhibitors or sulfonylureas on eGFR in diabetic patients. Specifically, albuminuria is often considered an early manifestation of DKD that precedes the decline in eGFR , and wheSeveral randomized clinical studies have shown that DPP-4 inhibitors may reduce albuminuria compared to placebo in patients with T2DM. In the CARMELINA study, the DPP-4 inhibitor Linagliptin attenuated albuminuria progression compared to placebo but did not have a significant effect on eGFR . SimilarDPP-4 inhibitors may attenuate the progression of albuminuria through several mechanisms. Investigators have documented an anti-inflammatory effect of DPP-4 inhibitors that can protect renal tubular cells from damage . These mIn a previous study, patients receiving sulfonylureas experienced faster deterioration of kidney function compared to recipients of metformin therapy, presumably through an increase in body mass index and systolic blood pressure . Another1c in patients with newly diagnosed T2DM. As established in previous studies, an improvement in hyperglycemia offers substantial defense against the development and progression of microalbuminuria in the diabetic kidney [As shown in this clinical trial, DPP-4 inhibitors significantly lowered serum HbAc kidney . Furtherc kidney . The curc kidney . TherefoThe observation that DPP-4 inhibitors can reduce albuminuria in diabetic patients has clinical implications. Given the insidious course and heterogeneous presentation of DKD , interve1c after antidiabetic therapy, which may lessen any confounding effect of glucose-lowering on urinary albumin excretion. Finally, recipients of ACEI or ARB were excluded due to the established effect of these medications on urinary albumin excretion. To our knowledge, this is the first study to directly compare DPP-4 inhibitors and sulfonylureas with the primary outcome of albuminuria reduction. This study reduces the potential confounding effect of previous antidiabetic mediations on albuminuria by enrolling patients with newly diagnosed T2DM. Moreover, participants had comparable levels of serum HbANonetheless, the study design has limitations. Metformin also attenuates albuminuria by reducing oxidative stress and mesangial cell apoptosis . Since aIn conclusion, the addition of DPP-4 inhibitors to metformin therapy in patients with T2DM significantly reduced urinary albumin excretion relative to recipients of sulfonylureas. Importantly, the beneficial effect of DPP-4 inhibitors occurred despite attaining similar levels of glycemic control as sulfonylureas. Overall, DPP-4 inhibitors may have a role in attenuating the progression of albuminuria, and albuminuria reduction may be an additional consideration when choosing between antidiabetic medications.


I read with great interest, the work of Jean-Louis Vincent and colleagues ‘Mean Arterial Pressure and Mortality in Patients with Distributive Shock: A Retrospective Analysis of the MIMIC-III Database’ . I congrThere are several merits of the authors work. Firstly, the database in question—the Medical Information Mart for Intensive Care (MIMIC-III) is a well validated, robust dataset with about 50,000 ICU admissions and related variables. Secondly, the authors work is novel—while we all believe that we know that hypotension in the ICU is bad and we think that we are doing a good job defending a MAP of 65 mmHg, the results reported here make it clear that we are not. As reported by Jean-Louis Vincent’s group, more than 60% of this population in question had a continuous MAP of less than 65 mmHg of at least 2 h to up to 4 h of duration. (This was after being exposed to a minimum of 6 h of preceding vasopressor therapy to stabilize blood pressure). The story is not very different when lower thresholds of defending MAPS are analyzed as well. In addition, the authors elegantly show a progressive increase in ICU mortality as the duration of exposure to MAPS less than 65, 60 and 55 mmHg is lengthened.Where does this work take us next? What MAP should I defend in the ICU, and how should I best do it? This analysis of MIMIC-III does have its own limitations. The biggest one is the lack of granularity of blood pressure data that were recorded about once per hour. This is something that most hemodynamic analytics in the ICU are faced with currently, as we report only nurse-verified ICU blood pressures which may be few and far between, and indeed may be more for only the perceived sicker patients. We as a critical care research community need to develop an effective system of conserving continuously generated hemodynamic data (or monitor data) with an inherent mechanism to filter out the noise and artifacts. This is the only way that we will be able to effectively report associations with outcomes with some degree of certainty. The other opportunities in this work concern vasopressors, and maybe something that the authors would want to reconsider for the future. It would be fascinating to analyze a MAP of 65 mmHg and even higher and lower thresholds, in the context of increasing vasopressors, specifically the use of catecholamines only versus a more multi-modal balanced approach using vasopressin and other newer analogs as well. Furthermore, the utilization of high-dose vasopressors has been associated with 50–80% 30-day and 90-day mortality, and balance of adequacy of blood pressure versus the necessity of loading vasopressors is an evolving argument [The need of the hour is larger, more granular hemodynamic datasets such as these that can allow us to precisely see what we are doing with our defense of blood pressures in the ICU. Outcomes such as mortality are important and serious; however, other critical outcomes such as myocardial injury after non-cardiac surgery also need to be considered. Clearly, if the perceived ‘magic number’ is a mean arterial pressure of 65 mmHg, we are not quite there yet, and we are not doing a good job in terms of defending it. If the number is higher than 65 mmHg, then the situation may be even more worrisome. There remain several unanswered questions in religiously defining and appropriately defending a blood pressure in the ICU.


Atrial fibrillation (AF) is the most common arrhythmia. The most common diagnostic method, 12-lead electrocardiogram (ECG), can record episodes of arrhythmia from which the type and severity can be determined. The Heart Spectrum Blood Pressure Monitor  is used to measure cardiovascular pressure change with fast Fourier transform (FFT) analysis to obtain heart rate frequency variability and accurate blood pressure data. We compared the diagnostic efficacy of the Heart Spectrum Blood Pressure Monitor to a 12-lead ECG (gold standard) for patients with AF. Three measurement methods were used in this study to analyze the heart index and compare the results with simultaneous 12-lead ECG: blood pressure; mean arterial pressure, which was calculated from individual blood pressure as a constant pressure; and a constant pressure of 60 mmHg. The physician used a 12-lead ECG and the Heart Spectrum Blood Pressure Monitor simultaneously. The Heart Spectrum Blood Pressure Monitor used FFT analysis to diagnose AF, and the findings were compared to the 12-lead ECG readings. This unblinded clinical trial was conducted in the emergency department of Taipei Medical University Hospital. Twenty-nine subjects with AF and 33 without AF aged 25 to 97 y  were included. Subjects who were exposed to high-frequency surgical equipment during testing, those with cardiac pacemakers or implantable defibrillators, and pregnant women were excluded. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 97%, 97%, 97%, and 97%, respectively, for method 1; 90%, 100%, 100%, and 91%, respectively, for method 2; and 100%, 94%, 94%, and 100%, respectively, for method 3. The sensitivity, specificity, PPV, and NPV for both methods ranged between 90% and 100%, indicating that the Heart Spectrum Blood Pressure Monitor can be effectively applied for AF detection. An estimated 2.2 million people  in the United States have AF . It is w 0.0001) .In general, the occurrence of AF with atrial degeneration is related; therefore, the older the population, the higher the incidence of AF. The estimated prevalence of AF is 0.4% to 1% in the general population, and it increases with age, up to 5% to 6% for those older than 65 y and up to 8% among those 80 y or older. Similarly, although the incidence of AF is <0.1% annually for those younger than 40 y, it increases to >1.5% annually for women and 2% for men older than 80 y [p < 0.001), and five times higher for those with AF (p < 0.001) [The incidence of stroke is more than four times higher for patients with cardiac failure (< 0.001) . Patient< 0.001) .With the aging population, the number of people experiencing AF continues to increase. The age-adjusted incidence of stroke has more than doubled for patients with coronary heart disease, and has more than tripled for those with hypertension. For those with coronary heart disease or cardiac failure, AF doubles the risk of stroke for men and triples it for women –9.Evaluation using 12-lead and dynamic electrocardiogram (ECG) can diagnose most cases of AF –12. HoweThe Heart Spectrum Blood Pressure Monitor  is a simple home-use device that can detect the pressure change in the blood vessels of the heart. The measurement undergoes fast Fourier transformation (FFT) to calculate the heartbeat frequency and obtain accurate blood pressure data. It can also analyze the heartbeat frequency to determine if AF has occurred.The purpose of this clinical trial was to compare the diagnostic efficacy of the Heart Spectrum Blood Pressure Monitor and 12-lead ECG for verification of AF. Additionally, an assessment of the clinical efficacy of both methods for the diagnosis of AF was performed.The authors confirm that all ongoing and related trials for this intervention are registered.https://clinicaltrials.gov/ct2/show/NCT03095131). The study design . Sixty-three patients were enrolled during the trial period of approximately 1 y. The trial is registered with ClinicalTrials.gov as Identifier NCT03095131 . At the emergency department, when medical staff members recruited patients with AF or without AF, they alerted the physician on duty to examine the case. The Heart Spectrum Blood Pressure Monitor was compared to 12-lead ECG  after written informed consent was obtained from the patient. Results were interpreted by the examining physician –19. FinaSubjects older than 20 y who were diagnosed with AF using 12-lead ECG or who were healthy (without AF) were included. Each trial was conducted 10 min after diagnosis by a physician. Subjects who had been exposed to high-frequency surgical equipment during testing, those with cardiac pacemakers or implantable defibrillators, and pregnant women were excluded. The complete date range for subject recruitment and follow-up was February 22, 2016 to June 23, 2016. The CONSORT flow diagram for the study is presented in The physician applied the 12-lead ECG patches to the subject’s body, and attached the blood pressure cuff to the subject’s arm. Then, the Heart Spectrum Blood Pressure Monitor was connected to a computer for data collection. The 12-lead ECG and Heart Spectrum Blood Pressure Monitor were used simultaneously. The Heart Spectrum Blood Pressure Monitor calculated the heart spectrum results via FFT analysis for the diagnosis of AF. This analysis method was invented by OSTAR Meditech Corp. . Clinical trial results were judged by the examining physician.Human blood pressure and heart rate were measured using the oscillometric method. Each heartbeat causes the heart to emit blood, and then the sensor of the Heart Spectrum Blood Pressure Monitor on the arm detects the blood pressure and depicts the time-domain pressure wave. The time-domain pressure wave is converted to an energy-domain frequency wave via FFT Figs  and 3. TMeasurements were obtained from each subject consecutively three times using method 1 (M1), method 2 (M2), and method 3 (M3).M1 involved the following: standard blood pressure measurement was used to determine the heart index and was compared with the 12-lead ECG synchronously. M2 involved the following: from M1, the systolic and diastolic pressures were obtained and the mean arterial pressure (MAP) was calculated . MAP wasM3 involved the following: a constant pressure (60 mmHg) was used to analyze the heart index and to compare it with the simultaneous 12-lead ECG results.The sensitivity, specificity, PPV, and NPV of AF were analyzed via individual analysis and comprehensive analysis at the end of the trial.The heart index criteria for judging AF were as follows: AF, (I1 + I2 + I3) ≥ 5.0 and I1 ≥ 2.0; and non-AF, (I1 + I2 + I3) <5.0.Microsoft Excel statistical software  was used for the analysis. The statistical analysis programs for sensitivity, specificity, PPV, and NPV are noted in the following list:Sensitivity = A / (A + C),Specificity = D / (B + D),PPV = A / (A + B), andNPV = D / (C + D),where A, B, C, and D, represent true positive, false positive, false negative, and true negative of AF, respectively, based on 12-lead ECG.The detailed Statistical Analysis Plan is given in The clinical trial involved 63 subjects; subjects’ statistics are shown in Of the 29 patients with AF, a 73-year-old man was falsely judged as not having AF on heart spectrum analysis. Conversely, of the 33 patients without AF, a 67-year-old man was falsely judged as having AF on heart spectrum analysis.Ventricular premature complex (VPC) signal effects were also examined. A 48-year-old man with AF had two VPC signals, and a 92-year-old man with AF had one VPC signal that could be successfully identified as true positive on heart spectrum analysis. The test results were not affected by the VPC signals. Moreover, an 82-year-old man without AF had four VPC signals that were successfully identified as true negative on heart spectrum analysis. The test results were not affected by the VPC signals.From these test results, we calculated the sensitivity, specificity, PPV, and NPV were 97%, 97%, 97%, and 97%, respectively.Of the 29 patients with AF, an 81-year-old woman and a 92-year-old man with AF were falsely judged as not having AF on heart spectrum analysis. All 33 non-AF subjects were correctly identified as not having AF on heart spectrum analysis.Regarding VPC signal effects, a 48-year-old man with AF had four VPC signals; these were successfully identified as true positive on heart spectrum analysis. The test results were not affected by the VPC signals. Moreover, an 82-year-old man without AF had five VPC signals, and a 67-year-old man without AF had one VPC signal; these were correctly identified as true negative on heart spectrum analysis. The test results were not affected by the VPC signals.From the test results, we calculated that the sensitivity, specificity, PPV, and NPV were 90%, 100%, 100%, and 91%, respectively.All 29 patients with AF were correctly identified on heart spectrum analysis as true positives. Of the 33 patients without AF, a 67-year-old man was falsely judged to have AF on heart spectrum analysis.For the VPC signal effects, an 81-year-old woman with AF had one VPC signal, a 48-year-old man with AF had two VPC signals, and an 88-year-old woman with AF had one VPC signal, all of which were successfully identified as true positive on heart spectrum analysis. The test results were not affected by the VPC signals. Conversely, an 82-year-old man without AF had up to six VPC signals during approximately 10 s that were misjudged as AF on heart spectrum analysis; this was a false positive result.From the test results, we calculated that the sensitivity, specificity, PPV, and NPV were 100%, 94%, 94%, and 100%, respectively .The purpose of this clinical trial was to compare the Heart Spectrum Blood Pressure Monitor and 12-lead ECG in verifying the diagnosis of patients with AF. Sensitivity and specificity are used to determine the accuracy of diagnostic tools. According to the analysis of the M1, M2, and M3 results, M3 was superior to the other methods. The test results showed a sensitivity of 100%, specificity of 94%, PPV of 94%, and NPV of 100%.To confirm the diagnosis of AF, PPV is the most important measurement because PPV is the true positive ratio of the diagnosis. From this point of view, M2 is superior to other methods because the test results showed a sensitivity of 90%, specificity of 100%, PPV of 100%, and NPV of 91%.From the results of the clinical trial for VPC statistics , we deteThree measurement methods were used in this study: blood pressure (M1); MAP (M2), which was calculated from individual blood pressure as constant pressure; and a constant pressure of 60 mmHg (M3) to analyze the heart index and compare it with simultaneous 12-lead ECG.Atrial flutter was identified using 12-lead ECG in a 70-year-old man. Although atrial flutter is a type of arrhythmia, the focus of this clinical trial was AF; therefore, the patient with atrial flutter was included in the non-AF group for statistical analysis. In future trials, other types of arrhythmia patterns should be included with more waveform analyses.Users can determine and pre-diagnose the occurrence of AF using the Heart Spectrum Blood Pressure Monitor at home. Compared to using the general 12-lead ECG, which requires the users to visit the hospital for measurement and diagnosis by an examining physician, this application provides a more convenient and accurate tool for pre-diagnosis of AF. Patients can be treated with anticoagulants immediately after diagnosis to effectively reduce the risk of systemic embolization of non-valvular AF. Furthermore, justification for a home evaluation of AF includes the potential for decreased AF complications, such as strokes. However, AF is frequently asymptomatic; therefore, using the device during community screenings for AF is particularly beneficial to achieve early detection and treatment, especially for elderly individuals living alone. Further data collection will also facilitate future implementation of telecare. Using the devices could also prevent human error and help general practitioners and primary care physicians who have minimal experience reading an ECG.A previous study also tested the use of home blood pressure monitors for AF diagnosis , where tWe used three methods during this clinical trial, and the sensitivity, specificity, PPV, and NPV were all in the range of 90% to 100%. The results suggest that the Heart Spectrum Blood Pressure Monitor can be used for the diagnosis of AF. Through a simple measurement of blood pressure, users can detect the occurrence of AF at home and use this information as an early warning for further consultation with a physician. The device provides a convenient and effective filtering application compared to traditional methods that require visiting a physician for a 12-lead ECG.Through future clinical trials, we will be able to further analyze and explore big data, compare and analyze the different arrhythmia etiologies of various conditions, and further explore the conditions of patients with a heart index <5 (non-AF) for the differential diagnosis of diseases. In addition, telecare technology can be used by patients and healthy individuals to assess their heart function status, and maintain data for their own reference or for consultation with professional health care workers.S1 File(PDF)Click here for additional data file.S2 File(DOC)Click here for additional data file.S3 File(DOC)Click here for additional data file.


Background: Nasal congestion as the main symptom in patients with allergic rhinitis can impair nasal breathing. It causes hypoxia and concomitant sympathetic system activation, which may also lead to increased blood pressure levels in these patients. Objective: We postulated that appropriate therapy, including intranasal steroids, decreases blood pressure levels in patients with allergic rhinitis. Methods: In our study, we investigated the effect of intranasal steroid (4 weeks of mometasone furoate) on blood pressure changes in 45 patients with allergic rhinitis whose main complaint was nasal congestion. We used ambulatory monitoring for determining blood pressure levels before and after intranasal steroid therapy. None of the patients had any other systemic diseases. Results: We found a significant decrease of daytime systolic and diastolic blood pressures and mean blood pressure values . Although insignificant, we also found lower night-time systolic and mean blood pressure values . Conclusions: We found that post-treatment daytime average systolic, diastolic, and mean arterial blood pressure levels were significantly lower compared to values obtained during exacerbation of allergic rhinitis. Decrease in blood pressure with treatment of allergic rhinitis and nasal congestion suggests that nasal congestion and impaired nasal respiration may affect blood pressure and potentially cause serious problems in hypertensive patients with allergic rhinitis.  UnfortuThe positive effect of AR treatment on blood pressure levels in hypertensive patients was described in a controlled study . In thisWe hypothesized that treatment of AR may decrease blood pressure levels in normotensive patients with severe symptoms by improving of nasal congestion and consequent hypoxia. Study participants We enrolled 70 consecutive patients aged between 18 and 40 years who were diagnosed with seasonal AR by epidermal allergy tests between March and August, but had not received any medications to treat rhinitis. Skin prick test To confirm the allergy, all patients underwent skin prick tests (SPT), as previously reported, with aeroallergens common in Turkey   . Evaluation of patient symptoms Daytime sleepiness was evaluated using the Epworth Sleepiness Scale . It consThe VAS  was used to assess the subjective feeling of combined nasal symptoms ; it ranges from 0  to 10  . The patients were re-evaluated after the treatment period, and 24-hour blood pressure monitoring was repeated in patients with VAS score ≤ 3. The therapy was accepted as beneficial in patients whose pretreatment VAS score of ≥ 8 decreased to a post-treatment VAS score of ≤ 3. Post-treatment evaluations were performed on patients with VAS scores of 3 or below. Office blood pressure measurement Inhospital blood pressure was measured using a mercury sphygmomanometer following a 5-min. rest in a seated position. Ambulatory blood pressure measurement (ABPM) Ambulatory blood pressure was measured with Spacelabs 90207 ABPM device , which is an oscillometric device. The device was programmed to measure blood pressure once every 30 minutes beginning at 9:00 a.m. until 9:00 a.m. the day after [The patients were informed that they should not change their daily activity and that their arm should be in a comfortable position during the measurement. The procedure was considered successful if 85% of the measurements were read. Patient exclusion A detailed patient history, physical examination, and laboratory tests were deemed sufficient to confirm that patients did not have any concomitant disease. 2) were excluded. Twenty-five patients who had mechanical obstruction that affects nasal airflow , patients with perennial symptoms, sensitized to perennial allergens, history of hypertension, any pulmonary or cardiovascular system (CVS) diseases, OSAS, diabetes mellitus or hyper-hypothyroidism, or obesity  or ambulatory blood pressure measurements (> 135 – 85 mmHg) were accepted as valid exclusion criteria. The University Bioethics Committee approved the study protocol, and written informed consent was obtained from each patient. Causes for exclusion are presented in Treatment of allergic rhinitis In this 4-week study, patients with AR received mometasone furoate nasal spray (Nasonex™), 200 µg each morning. Statistical Evaluation The software SPSS 15.0  was used for statistical evaluation. Continuous variables were presented as mean ± standard deviation (SD) according to data distribution. Categorical variables were given as percent value. Data distribution was tested with Shapiro-Wilk test. Paired-samples Student’s t-test was used for continuous variables. c2-test was also used for categorical data. A p value < 0.05 was considered as statistically significant. We studied 45 subjects  = 29.6 ± 7.0 years) with AR. The mean time since onset of rhinitis was 7.16 years (SD ± 3.8). A history of atopic diseases in the family was reported by 22 patients (48.9%). A history of smoking was observed only in male patients . The mean values of ESS  score and VAS of the patients were decreased after treatment . After examining the ABPM of the patients before and after intranasal steroid treatment, a significant decrease in systolic and diastolic blood pressure and average blood pressure levels at daytime was detected  . On the other hand, no significant difference was detected in night blood pressure values  . We found a gender-specific blood pressure response to intranasal steroid therapy. Daytime blood pressure values were lower after the therapy only in male patients, while the values for female patients did not show any difference ,  . We found lower daytime systolic, diastolic, and mean blood pressure levels only in male normotensive patients with AR taking intranasal steroid treatment compared to pretreatment blood pressure measurements taken with ABPM. However, nighttime ambulatory blood pressure levels did not show any statistically significant decrease with intranasal steroid therapy in either male or female patients. In a previous study, significant reductions of systolic blood pressure were observed in hypertensive patients treated for AR . AlthougIt is known that nasal respiration is physiological and more effective than mouth respiration for effective alveolar ventilation in healthy people . In contWe selected patients with an Epworth score in the range of ‘sleepy’ (more than 10), which confirmed the presence of daytime sleepiness in our study. Sleep disturbances are very frequent in AR patients such that only 3.2% of patients have a good quality of sleep . SnoringWe were not able to detect any statistical difference in nighttime blood pressure levels. Indeed, intermittent hypoxia does not lead to nighttime blood pressure elevation. According to the findings of Tamisier et al. , there wWe found decreased blood pressure values with the therapy only in male patients . It is kNasal steroids are considered first-line treatment options when nasal congestion is the predominant symptom. A regular administration of intranasal corticosteroids for 2 – 4 weeks decreases nasal congestion, attenuates sleep disturbance, and thereby improving the quality of life in patients with AR , 27. TheWe confined our study population to patients having a relatively high symptom burden , which clearly introduced a selection bias. We thought that patients with more pronounced symptoms should have higher blood pressure values at baseline and also show a noticeable blood pressure response to the therapy. The absence of pulse oximetric data confirming presence of hypoxia is another major limitation of our study. However, previous data have already shown that nasal blockage due to allergic inflammation caused hypoxia as measured by pulse oximetry . Allergic rhinitis may cause an increase in daytime blood pressure values, especially in male patients. Although this increase may be less in magnitude in healthy normotensive AR patients, it may lead to unexpected clinical events, such as hypertensive crisis, in AR patients who already have hypertension. There was no financial support for the study. The authors have no conflict of interest to declare.


These inexpensive markers have become part of clinical routine and guideline recommendations. While their potential to replace parameters of macro-circulation such as cardiac output (CO) is limited, they facilitate the interpretation of the adequacy of CO and other macro-circulatory markers. Furthermore, they give additional hints on micro-circulatory impairment. In addition, a number of more sophisticated technical approaches to quantify and visualize micro-circulation including video-microscopy, laser flowmetry, near-infrared spectroscopy (NIRS), and partial oxygen pressure measurement have been introduced within the last 20 years. These technologies have been extensively used for scientific purposes. Moreover, they have been successfully used for educational purposes and to visualize micro-circulatory disturbances during sepsis and other causes of shock. Despite several studies demonstrating the association of these techniques and parameters with outcome, their practical application still is limited. However, future improvements in automated and “online” diagnosis will help to make these technologies more applicable in clinical routine. This approach is promising with regard to several studies which demonstrated the potential to guide therapy in different types of shock. Finally several organs have specific patterns of circulation related to their special anatomy (liver) or their auto-regulatory capacities . Therefore, this review also discusses specific issues of monitoring liver, brain, and kidney circulation and function.Sufficient organ perfusion essentially depends on preserved macro- and micro-circulation. The last two decades brought substantial progress in the development of less and non-invasive monitoring of macro-hemodynamics. However, several recent studies suggest a frequent incoherence of macro- and micro-circulation. Therefore, this review reports on interactions of macro- and micro-circulation as well as on specific regional and micro-circulation. Regarding global micro-circulation the last two decades brought advances in a more systematic approach of clinical examination including capillary refill time, a graded assessment of mottling of the skin and accurate measurement of body surface temperatures. As a kind of link between macro- and microcirculation, a number of biochemical markers can easily be obtained. Among those are central-venous oxygen saturation (S Organ function directly depends on appropriate supply of oxygen and energy. To maintain these prerequisites of cellular integrity and organ function, as well as to remove waste products and toxic metabolites, sufficient circulation, and perfusion are required.The main determinants of macro-circulation are pressure and flow. Both can be measured directly with a variety of techniques. Both flow and pressure are obviously connected in analogy to Ohm's law of electricity:Formula of Ohm's Law for Electricity and Its Analogy to CirculationU = Voltage; I = Electric flow; R = Resistance; MAP = mean arterial pressure; CVP = central venous pressure; CO = cardiac output.The electric flow (I) is driven by the difference of potential (voltage U) generated by the energy source, and it is modulated by the resistance within the circuit (R).Similarly, blood flow (cardiac output CO) is driven by a pressure gradient between mean arterial pressure and central venous pressure (CVP) which is provided by a generator (heart). Obviously CO is modulated by systemic vascular resistance (SVR).Under physiological conditions, macro- and micro-circulation are inter-dependent to a high degree. By contrast, for pathological conditions such as sepsis and other etiologies of shock, the loss of this “coherence” is almost pathognomonic , 2. UndeWhile CO and MAP are unquestioned cornerstones to provide appropriate perfusion, normal values of both parameters do neither preclude a misbalanced oxygen delivery and demand nor an impaired microcirculation.cvO2, plasma lactate and cv-a-pCO2-gap have been associated with poor outcome in a large number of studies vO2 in healthy subjects range from 70 to 75%.Necessarily, with constant SvO2 requires withdrawal of blood from a pulmonary arterial catheter (PAC) or oximetric measurement with a special PAC, ScvO2 can be obtained easily from a conventional central venous catheter (CVC) or continuously with a specific oximetric CVC. Although ScvO2 and SvO2 may differ due to the slightly different oxygen content of blood returning from the lower and upper half of the body, it is well accepted to replace SvO2 by ScvO2 for clinical purposes.While measurement of SAmong the bridges from macro- to micro-circulation plasma lactate is the parameter which is most “down-stream,” i.e., close to microcirculation and cellular metabolism . A varieAt least two trials associated decreasing lactate levels and lactate-guided early-goal directed therapy with improved outcome , 16. FinBased on these findings several recent guidelines recommend lactate measurement every 2 h within the first 8 h and every 8–12 h thereafter after admission with shock .vO2 by ScvO2 devices providing continuous measurement are available  When extended hemodynamic monitoring including CO is not available, they can be used as easily measurable indicators of the adequacy of blood flow.2) If CO is available, pathological values of these markers increase the likelihood of circulatory improvement by increasing CO.vO2: mixed venous oxygen saturationScvO2: central-venous oxygen saturationS2-gap: central-venous and arterial CO2 .cv-a-pCOWhile the macro-circulatory interconnections are transparent and easy to be determined, micro-circulation is much more challenging.Micro-circulation cannot be defined in a clear-cut formula such as Ohm's law. Consequently, assessment of micro-circulation is more complicated due to its dependency on macro-circulation, organ-specific auto-regulatory mechanisms and interactions between certain organs. Furthermore, the technical accessibility to quantify micro-circulation is much more complicated compared to macro-circulation.Therefore, micro-circulation is assessed based on a plethora of clinical, chemical, and physical surrogates which are frequently restricted to the individual micro-circulation of a single organ.The first approach to the assessment of micro-circulation is clinical examination aimed at detection of impaired general and specific circulation .The most “accessible” organ without any instrumental approach is the skin. Among all organs, skin has the largest weight and contributes about 16% of the body weight, i.e., about 10 kg in a normal weight adult.A structured assessment of the microcirculation of the skin starts with inspection and palpation aiming at estimation of the surface temperature. In patients with shock this allows for primary classification of “cold” shock and “warm” shock. “Warm shock” is caused by several etiologies of distributive shock including septic, anaphylactic and neurogenic shock.The etiology of “cold shock” can be hypovolaemic, cardiogenic, or obstructive . “Warm shock” is caused by endogenous or exogenous vasodilators. Most frequently it is due to sepsis. Cold shock typically is mediated by endogenous vasoconstrictors such as nor-adrenaline which is considered as a physiological compensatory mechanism in order to provide and stabilize the perfusion of the most vital organs such as brain, heart and lungs. Most of the other organs including the skin are summarized as “shock organs” that can tolerate markedly reduced perfusion for a certain time.Regarding the extent of the organ skin, its impaired perfusion is not a regional cosmetic side effect, but has systemic implications for the organism's thermal balance. Abnormal dermal vasoconstriction or vasodilatation results in reduced or increased thermal transfer from the body core to the surface and consecutive changes in the skin temperature . Due to The clinical assessment of the skin temperature should be performed with the investigator's back of the hand, since this part of the hand is most sensitive for temperature. Due to the moderate discriminatory power of this approach, a classification of the temperature as cold, slightly reduced, normal, and warm has been suggested.To improve the assessment of skin temperature, two approaches can be used:Instrumental measurement of skin temperatureSkin-core temperature gradients (SCTG).r = 0.71) was better for toe temperature compared to skin temperature on third finger, deltoid area of the arm, lateral portion of the thigh, and rectal temperature. It was slightly improved when the toe temperature was adjusted to ambient temperature. Furthermore, skin temperature on admission and in particular its changes over time excellently predicted survival. Henning and colleagues demonstrated in 71 patients with acute circulatory failure due to myocardial infarction, sepsis or hypovolaemia that the toe ambient temperature gradient better predicted mortality than cardiac index or arterial pressure  might fail in patients with colored skin, instrumental measurement of skin temperature is independent of its color.In addition to the assessment of surface temperature, clinical examination of skin perfusion includes structured static, and dynamic optical examination of the peripheral perfusion.Mottling of the skin has been defined as a patchy skin discoloration that frequently starts around the knees. It is caused by heterogenic constriction of micro-vessels . More reHigh inter-observer agreement with a kappa-value of 0.87 has been reported in this study. Baseline mottling-score as well as its changes over time were strongly associated to outcome, whereas mean arterial pressure, CVP, and CI failed to predict 14-days mortality . AnotherCapillary refill time (CRT) is defined as the time required for the skin to return to the baseline color after application of a blanching 15s pressure to the distal phalanx of the right and left index , 35, 36.Despite the appealing simplicity of CRT there are several limitations of this parameter: The inter-observer variability has been poorly investigated and resulted in contradictory findings –40. FurtA recent study demonstrated an association of visceral organ vascular tone with CRT and mottling score, but not with body surface temperature. However, skin temperature was determined in a dichotomous way (warm or cold) by subjective assessment of the examiner, but not with a thermometer or a probe .Normalization of the skin perfusion might be used as a goal for resuscitation, since it occurs earlier during resuscitation than normalization of lactate levels , 37, 41.Finally, a structured combination of clinical parameters of the skin perfusion might improve resuscitation compared to standard algorithms  Table 4Table 4.In addition to the above-mentioned structured clinical approaches to assess peripheral perfusion and body surface temperatures, a number of more sophisticated instrumental techniques have been introduced within the last two decades. Due to their technical properties they are frequently restricted to measurement of microcirculation in certain regions. Extrapolation of the findings in these specific areas to general peripheral perfusion has to be done cautiously. Finally, it has to be kept in mind that these techniques are not widely available and predominantly used for research purposes , 58.Based on pulse oximetry and the amount of absorbed infrared light, several commercially available devices provide a “perfusion index” (PI) which is calculated as the ratio of pulsatile blood-flow to non-pulsatile blood-flow . AbsorptBaseline values and changes of PI correlate to core-to-toe temperature difference . In thisVideo-microscopy is among the more generally known techniques , 59. It These alterations have been associated with hyperlactataemia, vasopressor dependency, organ dysfunction, and mortality . ResusciThe technique has been refined over time. Three generations of devices have been introduced within the last two decades: Orthogonal polarization spectral imaging (OPS), side-stream dark field , and incident dark field illumination . The 3rd generation technology provides better image resolution and visualization of more capillaries than OPS and SDF-devices . Video-mThe currently available technologies are time consuming, expensive and require a thorough training as well as a complex analysis of the measurements. Several pitfalls including artifacts induced by compression and saliva have to be considered .The normal ranges of PPV and MFI still are discussed and in part contradictory , 63, 64.To improve the quality of imaging and to standardize the description of the findings, several scores and consensus recommendations have been established , 65.Despite the use of standardized examination and supporting software the examination remains to be time-consuming  and limiThis might be improved by automated devices. However, at present there are still concerns regarding their reliability. Several studies demonstrated poor agreement of manual with automated measurements of sublingual micro-circulation , 67.If technical development will provide these techniques more readily available for clinical use at a reasonable price, this could be a major step forward to bring microcirculatory parameters into the first line of shock assessment and guidance of therapy , 69. HowLaser Doppler Flowmetry (LDF) is based on a confocal technique which analyses vascular density, diameters and flow in arterioles, capillaries and venules , 71. WhitcO2) and carbon dioxide concentrations in the tissue.This method uses transcutaneous electrodes for continuous measurement of oxygen  or their auto-regulatory capacities .Therefore, the following paragraphs will address specific issues of monitoring brain, liver, and kidney circulation and function.Although the brain accounts for only 2% of the total body weight in humans, it requires about 20% of the body's blood supply. Brain function depends on the continuous delivery of oxygen and nutrients. Even short interruptions of this supply may lead to decrease of neuronal function and subsequent brain cell death.2). Transcranial Doppler sonography (TCD) can be employed to assess CBF. With TCD, erythrocyte flow velocity is measured in large cerebral arteries using low-frequency ultrasound. Blood flow velocity depends not only on blood flow, but also on the diameter of the arterial vessel, and thus blood flow velocity only provides an estimate of CBF  is of critical importance for cerebral oxygen delivery  depends on the angle between probe and direction of blood flow. Therefore, the result significantly depends on probe position and user experience. This may in part be overcome by the use of transcranial duplex.Due to these limitations, specific skills and knowledge are a prerequisite in order to obtain reproducible and reliable results with TCD.2), can be estimated using principles of optical spectrometry. Usually, optodes containing sender and receiver are placed on the patients' forehead . Measured rScO2 values then resemble oxygen saturation in the frontal cortex, an area that is very sensitive to hypoxemia. Since the near-infrared light penetrates extra-cerebral  and intra-cerebral tissues, all of which absorb light, a low cerebral oxygen saturation may be masked by a high extra-cerebral oxygen saturation, which is called “extra-cerebral contamination”  may provide important therapeutic information. This technique was introduced into clinical practice in the 1980s for the assessment of cerebral oxygenation in preterm infants . Similar2 values may be measured as “relative” or “absolute” values. Although “absolute” values are sometimes claimed to be superior over “relative” values, there is no data yet available supporting this view.Depending on the algorithm and the number of photon emission wavelengths used, rScO2 was found to be around 70% in healthy volunteers  ultrasound and CT-(angiography). Direct angiography using arterial, portal-venous or venous access is less frequently required. Furthermore, hepatic hemodynamics can be assessed by catheterization of the liver vein. Use of a balloon catheter and measurement of the occlusion pressure may help to analyze the extent and etiology of portal hypertension.excretion, cellular integrity, and synthesis of the liver.Impaired hepatic perfusion and metabolism usually affect static, since these parameters except parameters of cellular integrity are slow-reacting and reflect liver function with substantial latency. This applies particularly to the parameters of liver synthesis: The most commonly measured biochemical parameters reflecting liver synthesis cholinesterase ChE and albumin have half-life times of 10 and 20 d, respectively. Fast-reacting parameters such as factor V  and factor VII  usually lack a 24/7-availability.To quantify these three qualities of liver function numerous parameters can be determined routinely. Most of them are considered as static parameters is that many of them are not specific for hepatic pathologies. This applies to elevations of bilirubin which can have pre-hepatic (hemolysis), intra-hepatic , and post-hepatic (biliary obstruction) origin. Similarly, increases in alkaline phosphatase may result from bone pathologies as well as from cholestasis. Furthermore, due to their specific properties and distribution, several enzymes reflect certain hepatic pathologies to a different degree: this applies to glutamate dehydrogenase GLDH and glutamate-oxalacetate-transaminase GOT (= ASAT aspartate-amino-transferase) which reflect particularly peri-central and peri-portal cellular damage, respectively. Both enzymes are not specific for the liver.Another draw-back of the Furthermore, the distribution of liver enzymes within the hepatocyte is different: While glutamate-pyruvate-transaminase  is restricted to the cytoplasm, GOT/ASAT is found in the cytoplasm and mitochondria, and GLDH is restricted to the mitochondria.To overcome some of these disadvantages, combined scores, and models of liver function have been introduced , 7. ThesAlthough these classifications and scores have been shown to better reflect severity and prognosis of severe liver impairment compared to single static markers, they can be influenced to a large extent by therapeutic measures such as substitution of plasma and coagulation factors, extracorporeal organ support such as dialysis and liver support, blood transfusion, plasma separation, and clinical interventions such as paracentesis with and without substitution of albumin. One early and important criticism regarding the MELD score was the potential misuse and manipulation of the score by therapeutic interventions influencing serum creatinine, bilirubin, and INR to increase LTX-likelihood. Indeed, it is a general weakness of MELD that all three components can be influenced with and without intent .By contrast, most of the dynamic tests of liver function are not directly influenced by the above-mentioned measures with a potential impact on the association of MELD with liver function.Interestingly, at least one study demonstrated an independent association of a dynamic liver function test  in addition to MELD with survival of patients on the transplantation list .dynamic tests have been suggested . To asses liver function, MEGX-concentrations before and in intervals of 15 min after application can be measured, and the MEGX-half-life time can be calculated. MEGX-testing has been used to some extent in clinical studies, and it has been clearly associated with morbidity and mortality . NeverthThe same applies to the caffeine test which is based on measurement of the serum concentrations of the caffeine metabolites paraxanthine, theobromine and theophylline and their ratio to caffeine 4, 8, and 12 h after the oral ingestion of 300 mg of caffeine.Similarly, the elimination of D-galactose by metabolization to galactose-1-phosphate and further degradation can be quantified  by repeated blood drawings after infusion of 0.5 g/kg 25% D-galactose solution. Also due to potentially life threatening side effects in case of galactose-intolerance, this test has lost its clinical use. Finally, the elimination of bromsulfopthaleine administered at a dosage of 5 mg/kg can be quantified by drawing blood samples after 30 and 45 min.While these biochemical metabolic tests all have a pathophysiological rationale and documented associations to morbidity and outcome, their practical use is low due to the need of elaborate non-routine biochemical analyses.oral application of the test-agent are the frequently impaired gastrointestinal motility and absorption in case of critically ill and patients with liver failure.Further limitations of tests based on As a consequence, in particular two tests with online and bedside availability remain to be more commonly used:The most widespread method is the indocyanine green (ICG) elimination.ICG is an infra-red absorbing and fluorescent dye which was originally introduced around WW-II as a dye in photography.in vivo measurement of ICG-concentrations over time. While the time to derive CO and EVLW is short (time for complete transit of the indicator to the site of detection), the prolonged measurement of the ICG elimination curve allows for assessment of the liver function. Double indicator TPTD technique and liver function were combined in at least one commercially available bedside device . While the main interest regarding this device might have been advanced hemodynamic monitoring, each measurement necessarily provided dynamic assessment of liver function.Due to its physical properties and overall low toxicity ICG became wide-spread in critical care in the 1990s. It was used for indicator dilution techniques to derive cardiac output (trans-pulmonary thermo-dilution TPTD) and extravascular lung water EVLW (double-indicator TPTD). Double-indicator TPTD used ice-cold ICG for indicator dilution with two different distribution volumes for the dye (remaining in the vasculature) and the thermal indicator . Concomitant measurement of the distribution volumes of the thermal indicator and the dye indicator allowed for exact calculation of EVLW. This technique required extra-corporeal or 13C or 14C-labeled test agent. To overcome the problem of potentially impaired resorption of an orally applied test agent, the LiMAX test quantifies the exhalation of 13CO2 derived from metabolism of intravenously applied 13C-methacetin. The test agent 13C-methacetin is metabolized by cytochrome-P450-isoenzyme 1A2 (CYP450 1A2) to acetaminophen (paracetamol) and 13CO2 which is measured by a breath-test. Similar as for ICG-PDR the results from the LiMAX-test have been associated to outcome and liver-resectability of patients with impaired liver function . As for other exhalation tests, the LiMAX test analyses the exhalation of a substrate of a function –99.Acute kidney injury (AKI) is one of the most common and life-threatening complications which significantly affects morbidity and mortality of intensive care unit patients . The mosHowever, these more clinical criteria have some limitations. Distinguishing transient AKI from persistent AKI is of clinical relevance, thus stressing the need for criteria to predict its reversibility , 103.One major problem in AKI is that the definition suffered for a long time from a lack of standardized system of identifying and classifying this syndrome. First, the RIFLE criteria  were proposed by the Acute Dialysis Quality Initiative. In the meanwhile, the Kidney Disease Improving Global Outcomes (KDIGO) group defined an unified version of all criteria which now present global consensus .Although urinary analysis and urinary biochemistry have limited clinical utility, the diagnosis of AKI is traditionally based on a rise in serum creatinine and/or fall in urine output (UO). UO is important not only for diagnosis, but also for risk prediction of AKI , 106.Typical causes of AKI in critically ill patients are sepsis, heart failure, hemodynamic instability, hypovolaemia, and exposure to nephrotoxic substances . The speglomerular filtration , glomerular integrity , tubular stress , tubular damage , and intra-renal inflammation   .The interest in biomarkers is combined with the desire to achieve early diagnosis and detection of renal stress or damage before functional change is evident.The tubular damage marker “Neutrophil gelatinase associated lipocalin” (NGAL) is one of the most investigated renal biomarker . NGAL isOther molecules such as the kidney injury molecule (KIM-1), tissue inhibitor of metalloproteinases-2 (TIMP-2), and  insulin-Beyond early diagnosis and risk stratification, these biomarkers may also help to change the definition of AKI in the future and contribute to a better understanding, diagnosis, prevention, and treatment of AKI .In certain circumstances, it may be necessary to use additional tools to diagnose AKI, especially in cases where creatinine and urine values change slowly, are misleading, or cannot be interpreted accurately. This is particularly relevant for critically ill patients where the presence of fluid overload, muscle wasting, sepsis, and reduced effective circulating volume may completely mask the diagnosis of AKI .Renal ultrasonography is useful for evaluating existing structural renal disease and diagnosing obstruction of the urinary collecting system. In detail, the presence of reduced corticomedullary differentiation and decreased kidney size is indicative of underlying CKD .Up to now, there are no good markers of medullary oxygenation as well on how to assess an improvement in medullary oxygenation in AKI , 112.Renal Doppler ultrasound and contrast-enhanced ultrasound are two techniques that may be used at the bedside to estimate renal perfusion and renal cortical microcirculation, respectively .Especially, Doppler-based renal resistive index (RRI) measurement is rapid, non-invasive, and repeatable and may therefore hold promise for monitoring renal function or renal perfusion in critically ill patients , 115.The renal resistive index [RRI = (peak systolic velocity–end diastolic velocity)/peak systolic velocity] consists of the measurement of renal arterial resistances to blood flow detected by echo-color-Doppler system. RRI is reliably correlated with kidney injuries and its severity. In several trials, RRI showed a direct correlation with cardiovascular damage, acute tubular necrosis, and—in septic shock patients—with the prediction of AKI occurrence , 115.Furthermore, depending on the clinical context, patients may require specific immunological tests, including anti-neutrophil cytoplasmic antibody (ANCA), anti-nuclear antibody (ANA), anti-glomerular basement membrane antibody (anti-GBM), and complement component 3 and 4 to rule out immune-mediated diseases  . These iRenal biopsies are rarely performed in critically ill patients, mainly due to the perceived risk of bleeding complications and general lack of therapeutic consequences . HoweverFuture techniques try to achieve the ability to rapidly and accurately measure and monitor GFR in real time . OpticalFurthermore, new imaging techniques such as cine phase-contrast magnetic resonance imaging or intra-vital multiphoton studies may be used in AKI detection. However, based on the complexity, financial costs and need for patient transport, it is likely that these methods will remain research tools .WH coordinated the review. WH, RZ, and TL drafted the manuscript. GS and RS also participated in the analysis of the data and helped to draft the manuscript.WH collaborates with Pulsion Medical Systems SE, Feldkirchen, Germany as member of the Medical Advisory Board. The remaining 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.


The KIT Score uncovers a burden of kidney injury that may yet be incompletely recognized, opening the door for earlier detection, intervention and preservation of renal function.The current standard of care measures for kidney function, proteinuria, and serum creatinine (SCr) are poor predictors of early-stage kidney disease. Measures that can detect chronic kidney disease in its earlier stages are needed to enable therapeutic intervention and reduce adverse outcomes of chronic kidney disease. We have developed the Kidney Injury Test (KIT) and a novel KIT Score based on the composite measurement and validation of multiple biomarkers across a unique set of 397 urine samples. The test is performed on urine samples that require no processing at the site of collection and without target sequencing or amplification. We sought to verify that the pre-defined KIT test, KIT Score, and clinical thresholds correlate with established chronic kidney disease (CKD) and may provide predictive information on early kidney injury status above and beyond proteinuria and renal function measurements alone. Statistical analyses across six DNA, protein, and metabolite markers were performed on a subset of residual spot urine samples with CKD that met assay performance quality controls from patients attending the clinical labs at the University of California, San Francisco (UCSF) as part of an ongoing IRB-approved prospective study. Inclusion criteria included selection of patients with confirmed CKD and normal healthy controls; exclusion criteria included incomplete or missing information for sample classification, logistical delays in transport/processing of urine samples or low sample volume, and acute kidney injury. Multivariate logistic regression of kidney injury status and likelihood ratio statistics were used to assess the contribution of the KIT Score for prediction of kidney injury status and stage of CKD as well as assess the potential contribution of the KIT Score for detection of early-stage CKD above and beyond traditional measures of renal function. Urine samples were processed by a proprietary immunoprobe for measuring cell-free DNA (cfDNA), methylated cfDNA, clusterin, CXCL10, total protein, and creatinine. The KIT Score and stratified KIT Score Risk Group (high versus low) had a sensitivity and specificity for detection of kidney injury status  of 97.3% (95% CI: 94.6–99.3%) and 94.1% (95% CI: 82.3–100%). In addition, in patients with normal renal function (estimated glomerular filtration rate (eGFR) ≥ 90), the KIT Score clearly identifies those with predisposing risk factors for CKD, which could not be detected by eGFR or proteinuria ( Chronic kidney disease (CKD) is a worldwide public health problem, with a global burden of 850 million people. CKD is now being recognized as a “hidden epidemic”, as most patients with early stages of CKD (~11% of the world’s adult population) go unrecognized, as they do not have symptoms and are unaware of their increased risk for heart problems, infections, hospitalization and kidney failure. Hence, CKD is often not considered as a major health issue, even though it affects twice the number of diabetics (422 million) and over 20 times the number of people with cancer (42 million) or HIV/AIDS (36.7 million).2 of body surface area). However, most cases of CKD 1–2 (CKD >60 mL/min/1.73 m2 of body surface area) go undetected. The eGFR has poor sensitivity for early CKD detection, as the inherent redundancy of renal reserve masks the early rise in SCr. Kidney biopsies, often triggered with more advanced stages of CKD, have value to assess pathology, but are invasive, expensive [CKD is defined as reduced renal reserve, persisting for ≥3 months and/or a prior diagnosis of a condition with known risk for kidney damage . CKD is xpensive , and canMultiple triggers and risk factors start the cascade of kidney damage in CKD, with progression to kidney failure CKD 5). There are over 10 million people worldwide in need of kidney salvage therapy with lifelong support from dialysis or kidney transplantation. Though dialysis and transplant provide kidney functional replacement, they are both still encumbered by varying adverse impacts on patient morbidity and mortality. There is also marked impact of CKD on other organ systems in the body; CKD patients have higher risks of infections, cardiovascular deaths and cancer [. There aEarly detection of kidney damage is crucial, as treatment in CKD 1–2 can result in renal preservation by either reversing or slowing the progression of kidney damage . CurrentThe primary aim of this study was to perform an assessment of multiple novel and known urine biomarker measurements to conduct an inexpensive, portable assay, called the Kidney Injury Test (KIT) in consecutive patients presenting with CKD at a large tertiary health care system, and develop and independently validate a quantitative KIT Score to reflect the different CKD stages. The KIT assay performance was also directly compared to the current standard of care tests (eGFR and proteinuria). A secondary aim was to explore the accuracy of the KIT assay to detect and quantitate kidney injury in CKD 1–2, i.e., subjects with normal eGFR (>60) but with predisposing risk factors for CKD. This report describes the process of biomarker selection, algorithm development and independent validation of the KIT Score as a novel diagnostic for the assessment and quantification of both early- and late- stage kidney damage. Residual, random spot urine was collected from 1169 sequential patients from the clinical labs at the University of California, San Francisco (UCSF), over 3 months, from October 2016 to January 2017, as part of routine clinical testing at the Parnassus and Mission Bay campus clinical labs. Sample selection for a diagnosis of CKD was enriched by selecting urine samples obtained from the nephrology, diabetes, or cardiology clinics at UCSF. To facilitate statistical power, the study was enriched for patients at increased risk with kidney disease, using the following criteria: the patient had a confirmed diagnosis of CKD (ICD10 code N18 ), no diaFor purposes of KIT Score development, the relevant cause of CKD or the predisposing risk factor for CKD was captured from electronic health records (EHR), together with demographic variables and SCr, to allow calculation of the eGFR . For eacTo avoid degradation of the biomarkers in the KIT assay, urine samples were either processed within an hour of collection or stored at 4 °C and processed within 24 h. Samples were discarded or not included for analysis in this study if the sample volume was less than 2 mL, there were insufficient data to confirm patient CKD diagnosis, or there was >24 h delay in sample processing due to logistical reasons. After the above filtering process, we had a final selection of 343 unique urine samples from 343 patients. We also obtained additional urine samples from 54 healthy controls selected from volunteers who had good health, with normal SCr, no proteinuria, and no identifiable CKD risk factors. The study adhered to the Declarations of Helsinki and Istanbul and was approved by the institutional review board of UCSF (IRB 16-21108), and the requirement for informed consent was waived by the IRB.g for 30 min at 4 °C. The supernatant was separated from the urine pellet containing cells and cell debris. The pH of the supernatant was adjusted to 7.0 using Tris–HCl and stored at −80 °C in the UCSF Biorepository until further analysis. Urine samples were collected in sterile containers , irrespective of micro- or macroscopic hematuria or proteinuria. Urine samples were centrifuged at 2000× KIT inputs normalized measurements of 6 primary urine biomarkers. The first biomarker was cell-free DNA (cfDNA): as a measure of the total apoptotic burden of kidney injury , measuren = 233, with 37 healthy controls) set, stratified by kidney injury status. Random forest modeling was used to identify relationships between the different markers for the detection of CKD with high sensitivity. Predictive models were trained using statistical and machine learning methods for development of the KIT Score algorithm, across all six selected DNA and protein biomarkers and multi-dimensional partition of these assay measurements were based on identified clinical thresholds by incorporating the SCr and additional known risk variables for CKD such as race, gender and age. Finally, a simple linear model incorporating the resulting partition was developed into the KIT Score with an additional threshold for the assessment of low and high risk of CKD.Random sampling was used to split the 397-patient cohort into a training  KIT Score Risk Groups. The sensitivity and specificity of the resulting quantitative and qualitative KIT Score, along with 95% confidence intervals, were calculated.An independent validation subset of 164 patients, with 17 healthy controls, was subsequently used to prospectively validate the pre-specified KIT assay and KIT Score. Logistic regression was used to compare the (full) model with the current standard of care tests, urine protein alone and eGFR. A T-test and logistic regression was used to compare the pre-defined KIT Score and model patient status , to assess its ability to distinguish subjects with early stages of CKD  and normal eGFR but with predisposing risk factors for developing kidney damage , from healthy volunteers (eGFR > 90) who have no known predisposing risk factors. A p-value < 0.01 was considered significant. R2 = 0.0087) and, as shown by other investigators [Of the 1169 patients recruited and urine samples collected, 201 samples met the exclusion criteria of low urine volume and were triaged from further analysis, leaving 968 patients , and outperforms the current standard of care tests .The primary aim of this study was to develop a composite KIT Score scaling from 0 (low risk) to 100 (high risk) and prospectively assess the capability of a quantitative KIT Score for the detection of kidney injury with a high degree of sensitivity and specificity. We show that, though the current measures of renal function (eGFR and proteinuria) are predictive of tage CKD , the quare tests . Urine cp-value < 0.0001). We also developed a qualitative KIT Score, an approach that can have important implications for population kidney risk assessment. A pre-defined risk threshold of 18.5 was established in the training data, allowing the separation of the KIT Scores into low (≤18.5) and high risk (>18.5) groups of kidney injury. This was confirmed in the test-set to provide predictive information on kidney injury status above and beyond proteinuria and eGFR  and 94.1% , respectively. In contrast, the sensitivity and specificity of proteinuria was 46.9%  and 88.2% , respectively, for the same samples. Similarly, the sensitivity of SCr was 65.6% . The estimation of negative and positive predictive values of the KIT Score is dependent on the prevalence rate of the disease, thus the prevalence rate of hypertension can be used as an example. The prevalence of hypertension in the general US population is approximately 33%. Consequently, the estimated positive and negative predictive value of the quantitative KIT Score for hypertension would be ~89.1% and 98.2%, respectively.R2 = 0.14 was between eGFR and protein), suggesting that each of the biomarkers is providing independent information towards the prediction of kidney injury status. Principal component analyses (PCA) . These factors highlight that, despite published data on correlations between the abundance of blood cfDNA and kidney dysfunction [We show the contribution of individual biomarkers to the KIT Score below . The abues (PCA) B elucidafunction ,28, urinCXCL10 is a key inflammatory cytokine dysregulated in immune-mediated renal injury ,49,50,512 like in CKD 1, without proteinuria or identified risk for kidney injury. It is important to note that ~15% of the healthy controls tested here have a mild elevation in their KIT Score (just above the high-risk threshold of 18.5). At this stage of the study, we cannot identify if these healthy controls with higher KIT Scores have undetected risk factors for kidney injury, as all subjects were de-identified. p-value < 0.00001). When compared to healthy controls, there is a strong association between the KIT Score and predisposition to kidney injury, even in subjects with normal renal function in CKD 1 (eGFR > 90), with a likelihood ratio of p-value < 0.0001) and an assay threshold of 18.5 had a sensitivity and specificity of 92.9  and 94.4% , respectively. This same effect was further amplified for the KIT assays ability to detect both CKD 1 and 2, with a likelihood ratio p-value < 0.0001), with the >18.5 KIT Score threshold having a sensitivity of 95.8%  for early CKD detection. A total of 60% of patients in CKD 1 have elevated KIT Scores >18.5, even though they have “normal” renal function, and no proteinuria. These are exactly the target patients we want to capture with the KIT assay as their early-stage CKD would be undetected by the current standard of care tests. In fact, the KIT Score identifies 92% of patients in CKD 1 who have no proteinuria as having early kidney injury. In CKD 2–3, though approximately 60% of patients have no proteinuria, the KIT Score detects all patients as high risk and provides different quantitative measures for each patient’s CKD injury burden. In CKD 4–5, proteinuria and the KIT Scores are more concordant as kidney damage is advanced and proteinuria is recognized as a late marker of renal injury. Thus, these collective results clearly demonstrate that the assay achieves its primary and secondary objectives of predicting kidney injury with greater sensitivity than the current standard of care tests , and, unlike our current clinical assays, the KIT Score can accurately identify very early stages of CKD in population screens.The driving force behind the development of the KIT assay and KIT Score was a recognition of the massive, and increasing, burden of unrecognized kidney injury , compounThis comprehensive search led us to six biomarkers: cfDNA, methylated cfDNA, clusterin, CXCL10, creatinine, and urinary protein. Cell-free DNA has been recognized as a sensitive marker of disease burden in the plasma of patients with autoimmune diseases ,66 and tCXCL10 has been well established as a marker of immune-mediated injury in a variety of contexts due to its role as a ligand for the CXCR3 receptor ,45,51,71Urine total protein and clusterin are well-established markers of kidney dysfunction ,40,41 anEarly detection of kidney injury has very important ramifications on limiting the rate of CKD progression and positively impacting health care worldwide. As renal hemodynamic changes are acutely sensitive to systemic perturbations, improved management of the main underlying causes of CKD would be an immediate benefit, especially the improved and tight control of blood pressure , stabiliDelays in kidney injury detection and consequently patient referral is a significant obstacle to getting new patients into effective treatment regimens while they still have a chance to maximize the benefits of renal preserving therapies. To emphasize how many patients “miss” the opportunity for diagnosis of CKD in earlier stages of their disease, patients with ESRD use the emergency department at a rate six times higher than the national mean rate for US adults—half of which result in hospital admission . Thus, iOngoing studies are planned and underway whereby serial assessment of the pre-defined KIT Score with the pre-defined KIT assay will allow us to assess the value of individual biomarkers in the assay during renal injury and renal recovery. In addition, we are setting up collaborations with pharmaceutical partners where serial assessment of the KIT assay can be used as a means to non-invasively and accurately track for early kidney injury from drug nephrotoxicity, inherent to many immune-modulators, such as calcineurin inhibitors  and antiAs the assay biomarkers were chosen and the assay was developed with the specific intent to detect very early kidney injury, we also observed that the KIT assay can detect that a small percentage of “normal” controls display urine KIT Scores that hover at the high-risk threshold of 18.5. Though not confirmed, it is possible that this is not assay noise and these cases are true positives with very early identification of kidney injury risk in the pre-CKD 1 or CKD 0 stage. As 96% of people with CKD do not realize they have it , one sigA limitation of the current study design is the use of a population enriched for CKD subjects from a tertiary care site. Subjects obtained from more screening and community settings may be more representative of the general population, particularly for the detection of early-stage CKD. Additionally, the study was cross-sectional and may not have fully represented early- and late-stage CKD. Longitudinal studies monitoring patients with signs of early-stage CKD are planned for the improved assessment of the early detection capabilities of the KIT Score and for the impact of early detection on CKD progression. Finally, it may be possible to further augment the KIT Score with additional biomarkers to allow improved differential diagnosis of CKD and minimize the need for serum creatinine and proteinuria measurement.The positive economic impact of early kidney injury detection and its treatment cannot be underscored. Almost a third of the Medicare budget is devoted to the management of kidney injury and disease in the US. The loss of kidney function in CKD 5 adds an additional fiscal burden of ~$80,000 per year due to dialysis support. Although renal transplantation enables patients to come off dialysis, the shortage of renal donors, both living and cadaveric, renal transplantation, with an initial procedure cost of ~$100,000, followed by maintenance medication costs of ~$20,000/year, results in only a small dent in the dialysis Medicare budget . The traIn conclusion, this study provides the blueprint for the KIT assay biomarkers, the KIT assay algorithm development process, the KIT Score definition and its performance for the early detection of kidney injury, and its direct comparison with the current standard of care tests. This study proposes that the KIT test could be used (1) as a screening test when there is a concern of co-morbidities that are known to increase the risk of CKD, such as cardiovascular morbidity, obesity, diabetes, without documentation of abnormal kidney function by current assays; (2) as an adjunctive test to monitor the burden and accurate progression of CKD in patients where the current standard of care tests have already detected renal injury, i.e., patients with known pre-existing CKD at different stages of kidney disease; (3) to allow for the sensitive assessment of recovery from kidney injury when exposed to different reno-protective therapies and management options. Further studies are needed, and planned, for the longitudinal screening of patients over time to better understand the natural history of the progression of CKD, the benefits of early detection, intervention and monitoring, and the infection points where CKD injury becomes fixed and progressive.