Our previous cross-sectional study has demonstrated the independently non-linear relationship between fasting C-peptide with renal dysfunction odds in patients with type 2 diabetes (T2D) in China. This longitudinal observational study aims to explore the role of serum C-peptide in risk prediction of new-onset renal dysfunction, then construct a predictive model based on serum C-peptide and other clinical parameters.The patients with T2D and normal renal function at baseline were recruited in this study. The LASSO algorithm was performed to filter potential predictors from the baseline variables. Logistic regression (LR) was performed to construct the predictive model for new-onset renal dysfunction risk. Power analysis was performed to assess the statistical power of the model.During a 2-year follow-up period, 21.08% (35/166) of subjects with T2D and normal renal function at baseline progressed to renal dysfunction. Six predictors were determined using LASSO regression, including baseline albumin-to-creatinine ratio, glycated hemoglobin, hypertension, retinol-binding protein-to-creatinine ratio, quartiles of fasting C-peptide, and quartiles of fasting C-peptide to 2h postprandial C-peptide ratio. These 6 predictors were incorporated to develop model for renal dysfunction risk prediction using LR. Finally, the LR model achieved a high efficiency, with an AUC of 0.83 (0.76 - 0.91), an accuracy of 75.80%, a sensitivity of 88.60%, and a specificity of 70.80%. According to the power analysis, the statistical power of the LR model was found to be 0.81, which was at a relatively high level. Finally, a nomogram was developed to make the model more available for individualized prediction in clinical practice.Our results indicated that the baseline level of serum C-peptide had the potential role in the risk prediction of new-onset renal dysfunction. The LR model demonstrated high efficiency and had the potential to guide individualized risk assessments for renal dysfunction in clinical practice. Seve22.12 and ACR <30 mg/g at baseline, and they were advised to return for follow-up appointments every 3-6 months. Finally, the patients underwent a mean 2-year follow-up. The participants were excluded from the present study due to the following exclusion criteria: (1) age < 18 years old at initial phase; (2) patients with renal dysfunction at baseline; (3) patients with serious autoimmune diseases, such as systemic lupus erythematosus; (4) patients with serious infectious diseases, liver diseases and/or tumor; (5) patients who had a rapid renal function decline within 3 months during the follow-up period; (6) patients who lost to follow up; (7) patients with absence of important clinical parameters at baseline, especially the levels of serum C-peptide, 2h postprandial C-peptide. Finally, 166 subjects with type 2 diabetes and normal renal function at baseline were enrolled in the present study. This study was approved by the Ethics Committee of Affiliated Jinhua Hospital, Zhejiang University School of Medicine.This was a longitudinal observational study, the subjects of this study were randomly selected from patients with type 2 diabetes who had visited at the Endocrinology Department of the Affiliated Jinhua Hospital, Zhejiang University School of Medicine, between January 2017 and December 2017 , systolic blood pressure (SBP), diastolic blood pressure (DBP), and the use of ACEI/ARB, diabetic duration, serum creatinine, uric acid, fasting C-peptide, 2h postprandial C-peptide, total protein, albumin, total bilirubin, total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), triglycerides, alanine aminotransferase, aspartate aminotransferase (AST) and HbA1c. During the follow-up period, the first or second urine samples of all these participant at their first and last visits were collected and stored at -80°C, respectively. All the samples were thawed and recentrifuged before measurement. The levels of urinary creatinine, ACR, A1MCR, NGAL/Cr, UTRF/Cr, URBP/Cr and UORM/Cr were detected and calculated by using Beckman Coulter biochemical Analyzer and Byron Diagnostics reagents .2 were defined as renal dysfunction.Additionally, the height and weight of the subjects were used to calculate BMI. The serum fasting C-peptide to 2h postprandial C-peptide ratio was defined as C0/C2. The levels of eGFR were obtained using the algorithm of Xiangya equation . In the 2.3https://dxonline.deepwise.com/) and R software (4.2.3 version). The normal distribution variables were presented as mean ± standard deviation (SD); the continuous variables with skewed distribution were presented as median (Q1 - Q3); the categorical variables were presented as frequencies with percentages. Pearson’s chi-squared test was used to compare the differences of the categorical variables between subjects with and without new onset renal dysfunction during follow-up period. Unpaired t-test and Mann-Whitney test were performed to conduct the between-group comparisons of continuous variables, as appropriate. Spearman correlation analyses were executed to evaluate the linear relationships between the continuous variables. By the principle of avoiding multicollinearity and over-fitting of the model, the least absolute shrinkage and selection operator (LASSO) regression was performed to filtrate the potential predictors (seed = 1). In the present study, predictors were chosen according to the lambda value with the minimum mean square error. Of note, according to the findings of the previous study, fasting C-peptide and UA were non-linearly associated with the odds of renal dysfunction, therefore, the quartiles of fasting C-peptide, C0/C2 and UA were also analyzed as the potential variables in LASSO regression, respectively.All the statistical analyses in this study were conducted by using the Deepwise and Beckman Coulter DxAI platform (Logistic regression (LR) was used to establish the predictive model. 5-fold cross-validation was used to validate the stability of the models. The area under the receiver operating characteristic curve (AUC), accuracy, sensitivity and specificity were used to assess the performance of the model. The Shapley additive explanations (SHAP) values were also analyzed to evaluate the importance of every potential predictor. Power analysis was performed to assess the statistical power of the model. A two-tailed p-value < 0.05 was considered statistically significant.33.1At the initial phase of this study, 166 subject with type 2 diabetes and normal renal function were included, 61.45% (102) of them were male, 38.55% (64) were female, 39.76% (66) had hypertension, the average age was 57.11 ± 12.31 years old, and the median follow-up time was 22.35 months. During the 2-year follow-up, 21.08% (35/166) of participants progressed to renal dysfunction. 3.2Before the construction of the predictive models, in order to evaluate the multicollinearity, the linear correlations between the potential continuous variables for the univariate analysis (p ≤ 0.1) in 3.3Based on non-zero coefficients corresponding to the lambda value with the minimum mean square error in the LASSO regression analysis (seed = 1), six predictors were determined from 34 basal clinical parameters, including ACR, HbA1c, hypertension (yes or no), URBP/Cr, fasting C-peptide quartiles, and C0/C2 quartiles (3.4These six predictors selected out by LASSO regression were combined to establish the prediction model for new onset renal dysfunction risk using LR algorithm. 3.5After conducting power analysis, the power of the LR model for predicting the risk of renal impairment was found to be 0.81, which was considered a relatively high level of statistical power. A nomogram graph was developed based on the LR model to make the model more available for individualized prediction of new onset renal impairment risk in clinical practice. For each individual, the values of various covariates corresponded to the Points, respectively; and the total points accumulated by the points of various covariates corresponded to the risk of new onset renal dysfunction (4In the present study, in order to avoid multicollinearity and the over-fitting of the model, LASSO regression was performed to screen out six potential predictors from 34 clinical variables, including ACR, HbA1c, URBP/Cr, fasting C-peptide quartiles, C0/C2 quartiles and hypertension. Using these predictors, we developed and validated LR algorithm to predict the new-onset risk of renal dysfunction in patients with type 2 diabetes. Generally, the LR model provided a high performance. Furthermore, based on power analysis, the statistical power of the LR model used to predict the risk of kidney injury was calculated to be 0.81, which corresponded to a relatively high level of statistical power. This suggested that this model had a strong ability to detect true relationships between the predictor variables and the outcome of interest, therefore, we concluded that this model had reliable and valid statistical efficacy. We further constructed a nomogram graph to make the model more available for individualized prediction of new onset renal impairment risk. It is noteworthy that serum C-peptide in the forms of fasting C-peptide quartiles and C0/C2 quartiles played an important role in the model. To our knowledge, this is the first study which clarified the potential role of serum C-peptide in predicting the occurrence risk of renal dysfunction in patients with type 2 diabetes.Chronic kidney disease is one of the most common complication of diabetes. Due to the high prevalence of diabetes all over the world, the population with type 2 diabetes and chronic kidney disease is increasing rapidly every year, and this has become a global healthcare burden , 20. IdeIn the present study, six predictive features were determined by LASSO regression, and LR algorithms was performed to establish the prediction model for the occurrence of renal dysfunction. The study by Hosseini Sarkhosh et al.  determinThe highlight of this study included that in order to avoid the multicollinearity and the over-fitting of the models, LASSO regression was performed to filter the potential predictors; and the power analysis validated the statistical power and reliability of this model, suggested that it had a strong ability to detect true relationships between the predictor variables and the outcome of interest. Moreover, to our knowledge, we firstly clarified the potential role of serum C-peptide in predicting the occurrence risk of renal dysfunction in patients with type 2 diabetes. However, several limitations of the present study were worth noting. First, due to lack of complete information of fasting C-peptide, 2h postprandial C-peptide levels in many patients, the sample size of the longitudinal observational study was relatively small, and the participants were recruited from a single center, so the findings might be lack of generalizability, potentially limiting its application. Second, an external validation was needed to validate the prediction performance of the LR model. Thus, more prospective, multicenter and larger sample-size studies were needed to elucidate these findings.In conclusion, we demonstrated that serum C-peptide had a potential role in predicting the new onset renal dysfunction in patients with type 2 diabetes. The LR model had a high performance for renal dysfunction risk prediction. The nomogram graph based on the LR model might provide an available tool for individualized prediction of new onset renal impairment risk. Generally, this study is a continuation of our previous cross-sectional study , and it The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of Affiliated Jinhua Hospital, Zhejiang University School of Medicine. The patients/participants provided their written informed consent to participate in this study.Study design: DS, YM, HW. Statistical analysis: HW, YH,YM. Manuscript writing: DS, HW. Data collection: DS, YH. All authors contributed to the article and approved the submitted version.


This systematic review and meta-analysis included all clinical trials that compared the efficacy of mobile app-based educational programs to that of more conventional educational treatment for the patients. Eleven papers were included in the current analysis, representing 759 CKD patients. 381 patients were randomly assigned to use the mobile apps, while 378 individuals were assigned to the control group. The mean systolic blood pressure was considerably lower in the mobile app group . Meanwhile, the mean level of satisfaction among patients who used the mobile app was considerably greater . Additionally, the mean self-management scores in the mobile app groups were significantly higher . Mobile health applications are potentially valuable interventions for patients. This technology improved the self-management of the disease, reducing the mean levels of systolic blood pressure with a high degree of patient satisfaction.Chronic kidney disease is one of the main causes of mortality worldwide. It affects more than 800 million patients globally, accounting for approximately 10% of the general population. The significant burden of the disease prompts healthcare systems to implement adequate preventive and therapeutic measures. This systematic review and meta-analysis aimed to provide a concise summary of the findings published in the existing body of research about the influence that mobile health technology has on the outcomes of patients with the disease. A comprehensive systematic literature review was conducted from inception until March 1 Chronic kidney disease, often known as CKD, is one of the main causes of mortality worldwide. It affects approximately 800 million patients globally, accounting for approximately 10% of the general population. The increase in the incidence of CKD can be linked to the rise in the prevalence of health conditions related to CKD, including being overweight or obese, getting older, developing diabetes, or having high blood pressure , 3. The Mobile health technology is an evolving approach to caring for patients with chronic disorders. Tablets, cell phones, and web-based portals are all examples of mobile devices that can be used to access this technology. Mobile health technologies promote communication between patients and their healthcare professionals, making it easier for patients to monitor their health at home and allowing for earlier diagnosis of any deterioration in their condition , 9. HealThis meta-analysis was conducted in accordance with the PRISMA   and CochSupplementary Table 1A comprehensive systematic literature review was conducted from the beginning of the study until its completion on March 1, 2023, using the following databases: PubMed, Google Scholar, Web of Science (ISI), Scopus, System for Information on Grey Literature in Europe (SIGLE), Virtual Health Library (VHL), New York Academy of Medicine (NYAM), Clinical trials, Controlled Trials (mRCT), EMBASE, Cochrane Collaboration, and WHO International Clinical Trials Registry Platform (ICTRP). This review covered the period from the study. No limitations were placed on the patients regarding their age, gender, ethnicity, language, race, or location.The search methodology employed controlled vocabulary terms within the parameters of the searched databases. Medical subject headings in conjunction with text words were employed to ensure that a comprehensive selection of articles was examined. A manual search was conducted, including all relevant references from the retrieved articles. The approach of cross-referencing was utilized until it was determined that there was no other pertinent research. The following phrases served as inspiration for each possible combination: “Chronic”, “Kidney”, “renal”, “CKD”, “Dialysis”, “Mobile”, “m-health”, “mhealth”, “smartphone”, “smartphone”, “tablet”.This systematic review and meta-analysis included all clinical studies that compared the efficacy of educational programs delivered via mobile applications to conventional educational treatments for patients with chronic renal disease. We excluded research for which data extraction was not feasible, studies conducted on animals, reviews, case reports, guidelines, letters, editorials, posters, comments, or book chapters. Articles without a comparison group were disregarded. Two independent reviewers conducted the initial screenings, and any discrepancies were resolved through discussion. The PRISMA Flowchart illustrates the reasons for study exclusions and the screening processes.Information regarding the characteristics of the included studies, such as titles, authors, publication years, registration numbers, study designs, time frames, and locations, was extracted from the relevant articles. Patients' age, gender, race, marital status, level of education, annual income, and number of comorbidities were among the demographic information collected at baseline. Data related to CKD included stage, duration of illness, and results of renal function tests. In addition, data related to mobile applications were extracted, including the operating system, duration of sessions, type of mobile app use, and features. Variables associated with the outcomes of interest were also reviewed, including the burden of kidney disease, renal function test results, medication adherence, patient satisfaction, self-management of CKD, body weight, and blood pressure.The risk of bias in the included randomized controlled trials (RCTs) was assessed using the methodology developed by the Cochrane Collaboration . For obset al. [In studies involving continuous variables, researchers commonly employ either the weighted mean difference (WMD) or the standardized mean difference (SMD). To convert data originally presented as a median and range into a mean and standard deviation (SD), the formulas developed by Hozo et al.  were appet al. . Data anet al. , 24, andA comprehensive search of the available literature turned up a total of 324 different papers. Following the title and abstract screening process, 300 research papers were identified as eligible, and 24 were excluded. The preliminary review identified thirty publications that should proceed to the full-text screening phase. There were 14 publications considered for inclusion in the data extraction process, but only 12 were used. Throughout the manual search, one article was located, which led to the discovery of eleven publications suitable for systematic review and meta-analysis. The search strategies employed for the databases are outlined in Supplementary Table 2The present meta-analysis included eleven articles, encompassing 759 patients with CKD -35. Of tThere were 315 patients with hypertension. Diabetes mellitus was encountered among 136 patients, whereas cardiovascular diseases and dyslipidemia were revealed among 50 and 12 patients. The average baseline glumerular filtration rate (GFR) ranged from 64.27 to 76.2 ml/min/1.73m2 .et al., 2015 [et al. [The potential for bias in the included RCTs was assessed. All of the included investigations, except for Diamantidis l., 2015 , demonstl., 2015 , 32, 34.l., 2015 , 32, 34 l., 2015 , 32, 34 l., 2015 , 31, 34 l., 2015 , 31. Thel., 2015 , 33, 35, [et al. , which oThree articles included 399 patients with CKD and evaluated the impact of mobile health applications on the mean values of glomerular filtration rate. Using the random-effects model , the study found that there was no significant difference between the groups that used the mobile application and those that did not  .Three studies included 207 patients and assessed the mean serum phosphate levels difference between the mobile application and control groups , 33, 34.The difference in mean serum calcium levels between the mobile application and control groups was revealed in two articles following 62 patients with CKD , 34. WheThe difference in body weight between the mobile application and control group among patients with CKD was reported in two articles, including 81 patients , 31. TheThe influence of mobile applications on the average levels of systolic blood pressure (SBP) and diastolic blood pressure (DBP) in 155 patients with chronic kidney disease was evaluated in three articles , 32, 33.The difference in medication adherence between the mobile application and the control groups was evaluated in three studies involving a total of 342 patients diagnosed with CKD , 28, 35.The effects of mobile applications on the burden of chronic renal disease were investigated in two trials with 67 patients diagnosed with CKD , 31. TheThree studies included 87 patients with CKD and evaluated the mean levels of patients’ satisfaction between mobile applications and control groups , 29, 31.In two separate studies , 34, 144Over the past century, there has been a significant transformation in the delivery of care for individuals with CKD. The traditional provider-centered approach has been replaced by a patient-centered framework, leading to increased patient engagement in the decision-making process and the evolution of technologies to support the self-management of CKD . The advet al., 2022, revealed that smartphone applications improve the understanding of chronic disorders with significant enhancement of self-management [et al., revealed limited effectiveness of mhealth apps for managing adults with chronic disorders [Mobile applications offer an effective means of providing care to patients with CKD. In line with this finding, Stahr nagement . Mobile nagement . Contrarisorders . The effisorders , 44, 45.et al. revealed the efficacy of mobile health applications for controlling blood pressure. This was accomplished with significant improvement in self-management and medication adherence [et al. (2021) revealed the effectiveness of mobile technology in managing elevated blood pressure among the vulnerable population [In the present meta-analysis, mobile health applications had a significant impact on SBP. In this respect, Li dherence . Khoong pulation .et al. [et al. [Dietary mobile health applications can be used as a complement to nutrition screening practice. This technology can help dietitians mitigate nutritional problems in patients with chronic diseases. This reduces the reliance on traditional dietary control methods . Paradoxet al. . They re [et al.  reported [et al. , 52. NewThis meta-analysis collected contentious information addressing the influence that mobile health applications have on the outcomes of CKD patients. On the other hand, while evaluating the results of the investigation, some caveats need to be taken into account. Although five randomized controlled trials were included in this meta-analysis, most of the studies used observational methods. This demonstrated that there was a potential danger of selection bias. Furthermore, there was noticeable heterogeneity among the studies, likely due to variations in study design, mobile applications used, demographic factors, and research outcomes. To address these shortcomings, future research should involve more RCTs with larger sample sizes and longer follow-up periods.Mobile health applications are potentially valuable interventions for patients with chronic kidney disease. This technology improved the self-management of the disease, reducing the mean levels of systolic blood pressure with a high degree of patient satisfaction. Implementing mobile health applications improves healthcare quality for patients with chronic kidney disease by providing an accessible, feasible, and effective self-management intervention.


Hydralazine, doxazosin, and verapamil are currently recommended by the Endocrine Society as acceptable bridging treatment in those in whom full cessation of antihypertensive medication is infeasible during screening for primary aldosteronism (PA). This is under the assumption that they cause minimal to no effect on the aldosterone-to-renin ratio, the most widely used screening test for PA. However, limited evidence is available regarding the effects of these particular drugs on said ratio.n = 26) or doxazosin (n = 20) or verapamil (n = 15). All samples were taken under highly standardized conditions.In the present study, we retrospectively assessed the changes in aldosterone, renin, and aldosterone-to-renin values in essential hypertensive participants before and after treatment with either hydralazine (p = 0.067) and a significant fall in the aldosterone-to-renin ratio . Doxazosin caused declines in both plasma aldosterone concentration  and the aldosterone-to-renin ratio . With respect to verapamil, we found no statistically significant effect on any of these outcome variables.Hydralazine resulted in a borderline significant rise in active plasma renin concentration (19 vs 25 mIU/L, We conclude that the assumption that these drugs can be used with little consequence to the aldosterone-to-renin cannot be substantiated. While it is possible that they are indeed the best option when full antihypertensive drug cessation is infeasible, the potential effects of these drugs must still be taken into account when interpreting the aldosterone-to-renin ratio. The aldosterone-to-renin ratio (ARR) is the most widely used screening test for primary aldosteronism (PA) and is recommended by current guidelines . HoweverA total of 61 Caucasian Dutch patients who had been referred to our hypertension clinic for evaluation of their hypertension participated in the three studies. Of these, 26, 20, and 15 had been treated with hydralazine, doxazosin, and verapamil, respectively. Except for being hypertensive, none of the patients had any concomitant disease, such as diabetes or reduced renal function. Nevertheless, slightly over half of them were overweight.All active treatment phases were preceded by a placebo run-in period.All participants gave informed consent to partake in this study which was approved by the Institutional Review Board.Secondary causes of hypertension were ruled out after appropriate diagnostic procedures. These included measurements of active plasma renin concentration (APRC), plasma aldosterone concentration (PAC), calculation of the ARR, and additional tests such as saline loading if indicated. In case secondary hypertension was diagnosed, patients were excluded from this study.As part of our routine diagnostic work-up for secondary hypertension, we discontinued any antihypertensive medication for 3 weeks when this could be safely withheld. All measurements took place within this time window. After the initial assessment, during which participants were given a placebo tablet, they were treated with the respective drugs for at least 2 weeks prior to repeat testing. Doses were up-titrated until blood pressure was 140/90 mmHg or below.All investigations took place in a metabolic ward to which patients had been admitted prior to the investigations. On the day of testing, after an overnight fast and complete bed rest for 10 h, participants stayed in the laboratory from 08:00 a.m. until noon. After we had inserted an indwelling needle into the right antecubital vein, patients were allowed to rest for another 45 min. Thereafter, we took the first blood sample for determination of untreated plasma active renin and untreated plasma aldosterone concentrations (U-APRC and U-PAC respectively). All blood samples were taken in the supine position. Blood was collected in chilled tubes and spun immediately under cooled conditions and the plasma was stored at − 80 °C until assay. This process was repeated after participants had been placed on their respective drug regimens to determine their treated APRC and PAC values (T-APRC and T-PAC respectively).Throughout the entire period, blood pressure was measured at 5-min intervals with an automatic, oscillometric device , while patients remained in the supine position until the end of the study.APRC was measured by a direct immunoradiometric assay that detects active renin. Its characteristics are as follows: sensitivity 2.5 mIU/L, intra-assay variability 2.6%, and inter-assay variability 4.3%. PAC was measured by solid-phase radioimmunoassay (antibody-coated tubes) with a sensitivity of 55 pmol/L, an intra-assay variability of 4.3%, and an inter-assay variability of 6.7%. Untreated and treated ARR  were calculated from the respective PAC and APRC results.Using IBM SPSS Statistics Version 26 for Windows for all analyses, we first confirmed the normality of distribution of all data. The ones from the verapamil and doxazosin populations (VP and DP respectively) were both normally distributed, but those from the hydralazine population (HP) required log transformations before analysis. We performed paired t-tests on all groups comparing U-APRC and T-APRC, U-PAC and T-PAC, and U-ARR and T-ARR. Multiple regression analyses were performed to assess possible confounding by age, sex, and BMI on changes in APRC, PAC, and ARR during treatment.p value of < 0.05 was considered statistically significant.For all analyses, a Unless stated otherwise, data are expressed as means with standard error of the mean (SEM).The demographic characteristics of all participants are summarized in Table p = 0.067). PAC, on the other hand, did not change significantly . The ARR fell significantly from 38 ± 10 to 24 ± 4 (p = 0.017). Multiple regression analysis did not reveal age, sex, BMI, baseline blood pressure, or drug dosage to be significant predictors for the percentage change in APRC, PAC, and ARR values.Hydralazine was administered at a median dosage of 150 mg per day (interquartile range (IQR) 75–150 mg). During treatment with hydralazine, APRC rose from 19 ± 3 to 25 ± 4 mIU/L, which was of borderline statistical significance (p = 0.639). However, declines in PAC (470 ± 49 vs 330 ± 28 pmol/L) and ARR (30 ± 5 vs 20 ± 3) were both statistically significant . Multiple regression analysis did not reveal age, sex, BMI, baseline blood pressure, or drug dosage to be significant predictors for the percentage change in APRC, PAC, and ARR values.Doxazosin was administered at a median dosage of 10 mg per day (IQR 3–20 mg). Doxazosin did not significantly affect APRC levels post-treatment .Verapamil was administered at a median dosage of 240 mg per day (IQR 240–480 mg). The mean values for pre- and post-treatment levels of APRC (21 ± 3 vs 21 ± 4 mlU/L) did not significantly differ. PAC (420 ± 58 vs 326 ± 35 pmol/L) and the ARR (27 ± 8 vs 18 ± 3) fell after administration of verapamil, but changes were very variable and not statistically significant (Individual patient data of the ARR before and after the three forms of treatment are presented in Fig. p value obtained in our statistical analysis.The primary findings of our study are that both hydralazine and doxazosin resulted in significant falls in the ARR, an outcome not in keeping with conventional wisdom on the topic. Hydralazine’s changes seem to have been primarily driven by changes in the APRC while doxazosin’s effect seemed to have conversely been the result of changes in PAC. In addition, while the changes in PAC and ARR values after verapamil administration were not statistically significant, the magnitude of their declines was nonetheless rather large in our opinion. Given that verapamil was our smallest study population, comprising only 15 participants, it is possible that a larger population would garner a clearer picture regarding verapamil’s potential effects on the RAAS. Regardless, we feel that it would be negligent to conclude that verapamil has no effect on the ARR based on the non-significant 1-adrenoceptor-mediated renin activation could be the driving factor in our findings regarding hydralazine.The effect of hydralazine on aldosterone levels has been largely overlooked in scientific research, with no studies regarding its effect on the ARR published. A number of studies could be found regarding the effect of hydralazine on renin levels. In all studies, hydralazine administration resulted in rises in renin levels, with the rise being statistically significant in all but one study –9. HydraThe most notable study concerning the effect of doxazosin on aldosterone, renin, and the ARR was performed by Mulatero et al. in a population with primary aldosteronism . The finl-type calcium channel blockade resulting in higher intracellular calcium levels and consequently lower renin uptake in blood cells and, therefore, higher renin concentrations in plasma. Zacharieva and coworkers, as well as Frishman and colleagues, also noted a rise in PRA upon verapamil administration [Unlike hydralazine and doxazosin, verapamil has had a fair amount of scientific investigation regarding its effects on renin and, to a lesser extent, aldosterone. While the vast majority of studies found that renin and aldosterone were unaffected by verapamil –31, thisstration , 34. Constration . Concernstration –40. ThisThe primary clinical implication of our findings is a warning against complacency with regard to the usage of the abovementioned drugs when screening for PA. The level of research regarding these drugs and their effect on the ARR is simply far from authoritative. While it is true that these drugs have far less direct interaction with the RAAS in their primary mechanisms of action than many other antihypertensives and thus theoretically are less likely to affect the ARR values of patients undergoing PA screening, it is unwise to assume that they are inert when screening for PA. Such a lack of prudence would in all likelihood result in a significant number of missed diagnoses.We hope that these findings demonstrate the clear and pressing need for greater research on this topic. Almost no research regarding these drugs and their effect on the ARR have been performed, and inasmuch as data are available, the majority of these are now roughly 40 years old.The main weakness of our study was that our patients had blood samples taken from the supine position, despite current guidelines advising that patients be in the seated position for blood samples when screening for PA. However, we deliberately wanted to avoid posture-related variations in renin and aldosterone levels as the upright position may have variable effects on plasma aldosterone. Previous research has indicated that the ARR is less variable when measured in the supine position . An addiOur data show that hydralazine resulted in a borderline significant rise in active plasma renin concentration and a significant fall in the aldosterone-to-renin ratio. Doxazosin caused declines in both plasma aldosterone concentration and the aldosterone-to-renin ratio. Verapamil did not significantly affect any of our outcome variables though it did result in a large but non-significant decline in both PAC and ARR. Based on our findings, we conclude that using these drugs when screening for PA with no regard for their potential effects on the ARR to be unadvisable. While it is possible that they are indeed the best option when full antihypertensive drug cessation is infeasible, the potential effects of these agents must still be taken into account when interpreting the aldosterone-to-renin ratio. Additionally, we see a clear and pressing need for further studies on this topic in larger patient groups with or without evidence of primary aldosteronism. We believe that our findings emphasize the importance of standardized test conditions when measuring the ARR in order to make accurate interpretation feasible. Clinicians should weigh up the risks and benefits of drug cessation when performing ARR testing, and when cessation isn’t viable, clinicians should be aware of the potentially unpredictable changes to the ARR that can result even by drugs deemed relatively inconsequential to the ARR. In patients using medication at the time of ARR testing, the increased likelihood of both type I and II errors should be kept in mind.


Adherence to antihypertensive drugs (AHDs) is crucial for controlling blood pressure (BP). We aimed to determine the effectiveness of measuring AHD concentrations using a dried blood spot (DBS) sampling method to identify nonadherence, combined with personalized feedback, in reducing resistant hypertension.We conducted a multicenter, randomized, controlled trial  in patients with established resistant hypertension. Patients were randomized to receive either an intervention with standard of care (SoC) or SoC alone. SoC consisted of BP measurement and DBS sampling at baseline, 3 months (t3), 6 months (t6), and 12 months (t12); AHD concentrations were measured but not reported in this arm. In the intervention arm, results on AHD concentrations were discussed during a personalized feedback conversation at baseline and t3. Study endpoints included the proportion of patients with RH and AHD adherence at t12.P = 0.008, n = 40) and remained the same in the SoC arm . The difference in adherence between the arms was statistically significant (P = 0.014). The prevalence of resistant hypertension decreased to 75.0% in the intervention+SoC arm  and 59.5% in the SoC arm  at t12; the difference between the arms was statistically nonsignificant (P = 0.14).Forty-nine patients were randomized to receive the intervention+SoC, and 51 were randomized to receive SoC alone. The proportion of adherent patients improved from 70.0 to 92.5% in the intervention+SoC arm (Personalized feedback conversations based on DBS-derived AHD concentrations improved AHD adherence but did not reduce the prevalence of RH.  Nonadherence to antihypertensive drugs (AHDs) is one of the most important barriers to achieve blood pressure control ,2. UnconOnly a few randomized clinical trials have been performed that investigate interventions improving adherence in patients with resistant hypertension –10. The In this unique randomized, controlled trial RHYME-RCT (Resistant HYpertension: MEasure to ReaCh Targets), we compared an intervention with DBS sampling at the moment of blood pressure measurement combined with feedback using our communication tool on top of standard of care (SoC) compared with SoC alone. The primary aim of our trial was to determine whether this intervention leads to a decrease in resistant hypertension. Our second aim was to determine whether this decrease in resistant hypertension was due to an improvement in adherence.https://trialsearch.who.int/Trial2.aspx?TrialID=NTR6914) is a randomized, multicenter, single-blinded, controlled trial to improve adherence to AHDs and thereby improve blood pressure and resistant hypertension. Reporting is based on the ESPACOMP Medication Adherence Reporting Guidelines (EMERGE) and CONSORT reporting guidelines : enalapril and [enalaprilate], perindopril and [perindoprilate], irbesartan, valsartan, losartan and [losartan-carboxylic acid (losartan-CA)], hydrochlorothiazide, bumetanide, spironolactone and [canrenone], amlodipine, barnidipine, nifedipine, metoprolol, and doxazosin ,16.2 or less, possible secundary causes of hypertension that were not excluded yet, unwillingness to do a 24-h ambulatory blood pressure measurement (24-h ABPM) or insufficient understanding of the Dutch or Turkish language to read the patient information leaflet. It was not allowed to make any changes in AHD therapy between the selection of patients and the eligibility visit.Exclusion criteria were an estimated GFR of 15 ml/min per mBefore participation patients had to provide written informed consent. This study was approved by the local medical ethical committee of the Erasmus Medical Center, Rotterdam, the Netherlands (MEC-2018–027).After signing informed consent, patients went to an eligibility visit where blood was drawn using DBS sampling and simultaneously a 24-h ABPM was started to measure blood pressure in the following 24 h. The 24-h ABPM was obliged to minimize white-coat hypertension.If daytime blood pressure measured with ABPM was at least 135 and/or 85 mmHg, patients were randomized in a 1 : 1 ratio to either a SoC arm or intervention+SoC arm using a digital randomization tool (ALEA) .SoC consisted of visits at 3 (t3), 6 (t6), and 12 (t12) months after the eligibility visit and included a blood pressure measurement, DBS sampling, and a visit to an internist or nurse specialist. All blood pressure measurements were performed as indicated in the current American and European hypertension guidelines ,17,18. RDirectly after randomization, before any results on adherence were available, the treating physician or nurse was asked to estimate the adherence rate of included patients, to determine if there was any bias in selecting patients.The intervention consisted of a comprehensive feedback conversation at baseline and t3 where adherence results were discussed with the help of a communication tool  independAdherence was measured using drug concentrations in blood sampled with a DBS and measured with UHPLC-MS/MS. Sampling of blood was always combined with a blood pressure measurement at the same time. Measured drug concentrations were either reported as positive, present in blood, or negative, absent in blood. To minimize false-negative outcomes, only undetected AHDs were reported as negative. The intra-patient variability of AHD concentrations in blood is high, and therefore, trough levels could not be used as a cut-off for nonadherence ,20. FurtPatients were categorized as nonadherent if all measured AHDs were reported as negative, partially nonadherent if one or more AHDs were reported as negative but at least one AHD was reported as positive, and adherent if all measured AHDs were reported as positive. The adherence data were converted into a binary variable by combining total nonadherent and partially nonadherent together.Due to COVID-19 and a temporary reduction of physical visits at the outpatient clinics, some changes had to be made with regard to the visit schedule of randomized patients to maintain a total of three and preferable four visits. When the closing visit at t12 was missed, this was rescheduled at the first convenient moment in time to stay as close as possible to a 12 months follow-up. Because of this change in schedule, data were analyzed in accordance with their visit number: visit 1 = t0, visit 2 = t3, visit 3 = t6, and visit 4 = t12.The sample size calculation is based on the expected improvements in the prevalence of resistant hypertension due to improvements in adherence . It was expected that the prevalence of resistant hypertension at t12 improved (i.e. reduced) from 100 to 80% in the intervention+SoC arm due to the intervention and participation in a study and from 100 to 90% in the SoC alone due to participation in the study. The extent of the improvements was based on several previously conducted adherence trials ,22. A to2-test to study differences in adherence and resistant hypertension between patients randomized to the intervention+SoC versus SoC alone. For this, we tested the arms both separate from each other by selecting patients based on their randomization arm and as a whole group.Continuous variables with a normal distribution are described as mean value ± one standard deviation (SD), and otherwise as median value (25th to 75th percentile). Normality was tested by the Shapiro--Wilk test. Categorical variables are described as numbers and percentages. Within-group changes in percentage adherence and resistant hypertension from t0 to t12 were evaluated by McNemar tests. We used a chit-test and differences between patients randomized to the intervention+SoC versus SoC alone with an independent samples t-test.Differences in mean blood pressure over time, t0 versus t12, within the same arm were tested using a paired sample We performed an intention-to-treat analysis, including all randomized patients, as well as a per-protocol analysis, including the patients with available measurements at t0 and t12, and one of t3 and t6. The per-protocol analysis is preferred while all steps  of the intervention are included.To determine the influence of adherence on resistant hypertension (dependent variable) generalized estimating equations (GEEs) were used, which could account for the clustering of data within individuals due to multiple visits. The calculated defined daily dose (DDD) at t0 and t12 as well as the randomization arm were included as covariates in this binary regression model.P values were two-sided, and a value of less than 0.05 was considered statistically significant.All We used the SPSS version 24.0 for Windows , and GraphPad Prism 9.3 software  for analysis.An interim analysis was performed with data from the trial to check the assumptions made in the sample size calculation. For this, at least 25 patients had to be included in both arms that had reached three months follow-up. We expected to find a larger difference between the arms in the proportion of patients with resistant hypertension at this time point due to the shorter follow-up time, as compared to results after 12 months of follow-up. At the time of the interim analysis, 27 patients in the intervention+SoC arm and 28 patients in the SoC arm were analyzed. In the intervention+SoC arm, the proportion of patients with resistant hypertension decreased to 75% and in the SoC arm to 59%. This decrease in resistant hypertension was higher than expected. However, there was a reversed improvement in resistant hypertension, with a difference between the two arms of 16% in the proportion of patients with resistant hypertension with a lower proportion of resistant hypertension in the SoC arm as compared to the intervention+SoC arm. Given these interim findings and difficulties with the inclusion and visits of patients due to COVID-19 restrictions, the inclusion of patients was stopped by the researchers before reaching the required number of patients to determine the efficacy of the intervention. However, because of ethical considerations, the complete protocol was carried out for patients already included in the trial.Patients were recruited from August 2018 till January 2021.A flowchart of the 168 patients that intended to participate in the trial is presented in Fig. P < 0.001], and DBP 5.5 mmHg . Note that there is a slight discrepancy in blood pressure averages between Table Blood pressure in both arms decreased over time  . When combining patients from both arms, a significant decrease in resistant hypertension (Δ −34.8%) was found between t0 and t12 .At 12 months follow-up, no statistically significant difference in the proportion of patients with resistant hypertension was observed between the arms .No differences were found in outcomes for the per-protocol and intention-to-treat analysis. Therefore, only the results of the per-protocol analysis are shown (P = 0.014)  and randomization arm  as covariates.There was a significant difference in adherence between the SoC and intervention+SoC arm after 12 months of follow-up . We also explored the influence of the method of blood pressure measurement throughout the study, as 24-h ABPMs were only obliged at t0, but preferred at t3, t6, and t12. This resulted in a decrease in 24-h ABPM use in both arms, which were substituted with AOBPs. At t12, 83% of the patients in the intervention+SoC arm had a 24-h ABPM and in the SoC alone arm 75% (P = 0.452). The DDD of AHDs decreased in the intervention+SoC arm with an average of −0.1 and increased in the SoC arm with 0.7. This difference was not statistically significant (P = 0.059).To explain our findings on the difference in adherence but lack of difference in resistant hypertension at t12 between the arms, additional post hoc analyses were performed. Using a higher cut-off value (140 mmHg SBP and/or 90 mmHg DBP) to define resistant hypertension, the proportion of patients with resistant hypertension in the intervention+SoC arm decreased to 50.0% and in the SoC arm to 48.8%. When using this cut-off at baseline the proportion of patients with resistant hypertension differed between the intervention+SoC arm (85% resistant hypertension) and the SoC alone arm (79% resistant hypertension) (n = 90). In 31% (n = 28) of the patients, the estimations of the physicians were incorrect  of which 36% consisted of nonadherence that was not recognized by the physician.Adherence estimations of physicians at t0 (adherent or nonadherent) were compared with the actual nonadherence determined from the measured drug concentrations (n = 423) and intervention (n = 460) arm  following a 12 months embargo from the date of publication to publish additional results from the study .L.E.J.P. has received lecture fees from Astellas Pharma. D.A.H. has received lecture fees and consulting fees from Astellas Pharma, Astra-Zeneca, Chiesi Pharma, Medincell, Novartis Pharma, Sangamo Therapeutics, and Vifor Pharma. He has received grant support from Astellas Pharma, Bristol-Myers Squibb, and Chiesi Pharma (paid to his institution). D.A.H. does not have employment or stock ownership at any of these companies, and neither does he have patents or patent applications. In the last 3 years, T.vG. has received lecture fees and study grants from Chiesi and Astellas, in addition to consulting fees from Roche Diagnostics, Thermo Fisher, Vitaeris, CSL Behring, Astellas, and Aurinia Pharma. In the last 3 years, L.vD. has received a research grant from Teva for a study not related to this one. The other authors declare no conflicts of interest.


Proteinuria significantly increased during the following years, reaching a nephrotic range (>5 g/day). A kidney biopsy revealed a tubule-interstitial involvement compatible with type 2 diabetes. Leptin replacement therapy, started in 2018, improved glycaemic control and lipid profile, also determining a reduction in insulin total daily dose. In 2019, after the publication of the CREDENCE study, canagliflozin was started on top of losartan and ramipril. After an initial, expected eGFR drop, kidney function stabilized, and albuminuria significantly reduced (from 4120 to 984 mg/24h), while serum potassium showed only minimal increase. At last follow-up (2022) total proteinuria was still reducing (510 mg/24h), while kidney function was substantially unchanged (eGFR 40 ml/min/1.73 m2). This case report suggests that, despite not recommended in international guidelines, the use of SGLT2i in combination with dual renin angiotensin system blockade should be considered in specific conditions and under close clinical monitoring.Sodium glucose cotransporter 2 inhibitors have proven strong efficacy in reducing end-stage renal disease in patients with type 2 diabetes. We are presenting here the case of a 40-year-old woman with acquired partial lipodystrophy, type 2 diabetes and essential hypertension complicated by chronic kidney disease and proteinuria in the nephrotic range. She first came to our attention in 2012; estimated glomerular filtration rate (eGFR) was 41.5 ml/min/1.73 m Several clinical trials have documented as SGLT2i are able to slow eGFR decline and reduce albuminuria . The CRE disease . These d disease .Lipodystrophic syndromes are a heterogeneous group of rare acquired or congenital disorders characterised by either generalized (GLD) or partial (PLD) lack of subcutaneous adipose tissue (SAT) , 7. Thes22 and proteinuria was 375 mg/24h; the microscopic urinary sediment also showed 10 red blood cells, and 31 white cells/high power field and hyaline casts. At physical examination, her body mass index (BMI) was 19.8 kg/m2 and BP 126/80 mmHg. Chest and heart inspection, palpation and auscultation revealed no pathologic findings. Peripheral pulses were valid.A 40-year-old woman came to our attention in 2012 with new-onset T2D and poor metabolic control (HbA1c 82 mmol/mol). She had a medical history of arterial hypertension and, 7 years before, a pregnancy complicated by gravidic gestosis and HELLP syndrome. She also had hypercholesterolemia and severe hypertriglyceridemia requiring pharmacologic treatment. After delivery, blood pressure (BP) progressively increased and renal function started to decline, with rapid onset and persistence of moderate proteinuria. At the first visit, eGFR was 41.5 ml/min/1.73 mThe routine analysis showed mild anaemia , likely due to folate deficiency , normal liver enzymes and electrolytes balance. She was treated with losartan 50 mg + ramipril 10 mg, metformin 500 mg BID, glimepiride 2 mg, fenofibrate 145 mg, atorvastatin 40 mg and PUFA. Such RAAS double blockade had been started years before for the recurrency of a relevant proteinuria (up to 3 g/24h) documented several times after the pregnancy. Measures of BUN, creatinine and electrolytes had been performed every six months. No side effects were reported. Blood pressure control was adequate and serum potassium was 5.14 mEq/l, allowing us to confirm a reduced dose of losartan as add-on to ramipril.The anti-hyperglycaemic treatment was initially intensified by introducing insulin glargine at bedtime, repaglinide and sitagliptin, while glimepiride was withdrawn. A nutritional counselling recommended to limit protein and salt intake according to international guidelines for management of CKD.2), and proteinuria (798 mg/24h) worsened, with a normal urine sediment. No other alterations emerged at routine analysis, including complete blood count (CBC) and haemoglobin level . An abdominal ultrasound reported hepatic steatosis, kidneys of longitudinal length (LL) of 101 and 92 mm with hyperechoic cortical parenchyma and renal sinus cysts, aorta with atheromatic plaques. The doppler ultrasonography of renal arteries (RA) showed absence of stenosis, with renal/aorta ratio (RAR) within normal limits and normal renal resistive index (RRI 0.60 and 0.64). She was advised to continue dual RAS blockade with stabilization of eGFR and albuminuria until 2014, when, in face of an eGFR of 45 ml/min/1.73 m2, an albumin to creatinine ratio (ACR) of 91 mg/g, mean BP values of 135/80 mmHg and K+ 5.2 mEq/L, we tried to withdraw losartan.In 2013, her glucose control further deteriorated (HbA1c 101 mmol/mol), and the patient was admitted in hospital, undergoing a therapeutical intensification to a basal-bolus insulin regimen plus DPP4-inhibitor (linagliptin 5 mg). eGFR (35.0 ml/min/1.73 m2), ACR raised up to 358 mg/g, inducing us to reintroduce losartan. Moreover, her BMI was 20.2 kg/m2, and she showed a peculiar pattern of subcutaneous adipose tissue distribution characterised by extreme reduction of the adipose tissue in the limbs while it was preserved in the face, confirmed by plicometry and Dual Energy X-ray Analysis, which allowed us to diagnose partial lipodystrophy. To better define the subtype of lipodystrophy, screening for PPARG and LMNA genes pathogenic mutations, responsible of most frequent congenital forms of partial lipodystrophy, was performed and no mutations were found. A complete hormonal profile was then performed, revealing low-normal leptin levels (7.5 ng/ml) without abnormalities in the hypothalamus-hypophysis-axis, thyroid, ovarian and adrenal gland function  while kidney function was stable (eGFR 50 ml/min/1.73 m2 and K+ 4.28 mEq/L). The doppler ultrasound revealed a proximal moderate stenosis of the right RA (peak systolic velocity (PSV) of 350 cm/s, end diastolic velocity of 107 cm/s and RAR of 4.0) without signs of renal hypoperfusion (RRI of 0.64-0.69 and 0.57-0.64). Both kidneys presented normal LL (100 mm and 98 mm) and normal parenchymal thickness  with loss of corticomedullary differentiation. Kidney biopsy was then indicated to distinguish between a diabetic kidney disease (DKD), a kidney involvement secondary to lipodystrophy or a primary glomerular disease, like membranoproliferative glomerulonephritis. At microscopic analysis, a tubular atrophy emerged with interstitial fibrosis, lymphomonocytes infiltrates and vascular hyalinosis, all suggestive of DKD . and the decision to start leptin replacement therapy (LRT) under a compassionate use program was taken, with a brilliant response (triglycerides 113 mg/dl and HbA1c 56 mmol/mol after six months). Treatment was well tolerated and consented to rapidly halve insulin total daily dose (from 2 to 0.9 UI/kg in just one year).In 2019, the results of the CREDENCE trial were published, demonstrating relevant nephroprotection of canagliflozin in T2D patients with advanced CKD and macroalbuminuria. Given that the patient’s eGFR and electrolyte balance had been quite stable during the last 4 years, we decided to introduce canagliflozin 100 mg on top of losartan ad ramipril, strictly monitoring kidney function. The patient was completely involved in this choice: we shared the decision with the medical team and explained to her the clinical rationale and the expected benefits. Renal ultrasound and doppler examination were repeated before starting treatment. The stenosis of right RA was unchanged  while both kidneys showed slight LL reduction (85 mm and 86 mm), parenchymal thickness still in the normal range , and no sign of hypoperfusion (RRI 0.63-0.65 and 0.59-0.68).2 after 6 months of treatment, from 38 to 27 ml/min/1.73 m2), eGFR gradually improved: after one year it was 32 ml/min/1.73 m2, and then further improved to 38 ml/min/1.73 m2 later on  double RAS blockade: pros and con; ii) antiproteinuric effect of SGLT2i; iii) leptin, metabolic control and proteinuria; iv) anaemia and competitive effects of SGLT2i and RAS blockers; v) status of the renal arteries.In the real life, the clinical scenario is often very different from what is shown in RCTs. This case report is a bright example, raising relevant points for discussion: ACEi and ARBs are well established drugs largely used for treating hypertension and reducing the progression of CKD in subjects with and without T2D , but thepost-hoc analysis of the CREDENCE Trial (vs. 31% and 29% respectively) but an absolute reduction of 341 mg/g. Although the effect on eGFR decline is consistent across all class of UACR, the results of DIAMOND Trial , showed a statistically significant reduction in proteinuria only in those with baseline eGFR >60 ml/min/1.73 m2, thus suggesting that proteinuria reduction may differ according to baseline eGFR (In patients with CKD, albuminuria is a well-known determinant of further progression of kidney function decline . SGLT2i CE Trial  reportedine eGFR .Other factors may have contributed to slow the progression of kidney failure in this patient; among these, the improved metabolic control obtained with LRT. It should be also mentioned that LRT itself may reduce proteinuria in patients with lipodystrophy: in a recent open-label study, treatment with metreleptin for 24 months significantly reduced albuminuria and proteinuria in patients with GLD but not PLD . Of noteAnother aspect that should be considered, and frequently assessed when adding SGLT2i to a full-dose RAS blockade regimen, is red blood count and haemoglobin. Anaemia is largely prevalent in patients with T2D especially when CKD coexists . Many meLastly, the role of renal artery stenosis deserves consideration. Renovascular disease is a rare cause of CKD, whose prevalence increases in specific population of hypertensive patients and can be responsible of progressive end-stage renal disease. More often it is due to atherosclerotic changes in proximal renal artery . The kid4In conclusion, SGLT2i are effective and safe in treating CKD and proteinuria of different aetiology. Their use in combination with RAS dual blocking, although requiring strict clinical monitoring for risk of hypotension and hyperkalaemia, can be considered a valid option in rare and complex disorders with massive protein loss and risk for a rapid progression to ESKD.The original contributions presented in the study are included in the article/Ethical approval was not provided for this study on human participants because single case report. Informed consent obtained. Written informed consent was obtained from the relevant individual for the publication of any potentially identifiable images or data included in this article.All Authors contributed to this work. EB: data acquisition, visualization, and writing – original draft. GC: data acquisition, visualization, and critical revision. SM: data acquisition and visualization. VO: evaluation of kidney biopsy. DG: data acquisition and execution of kidney biopsy. FS: data acquisition, visualization, and supervision. AS: data acquisition, visualization, supervision, and critical revision. All Authors approved the final version of the manuscript.


The triglyceride–glucose (TyG) index has been proposed as a potential predictor of adverse prognosis of cardiovascular diseases (CVDs). However, its prognostic value in patients with coronary heart disease (CHD) and hypertension remains unclear.A total of 1467 hospitalized patients with CHD and hypertension from January 2021 to December 2021 were included in this prospective and observational clinical study. The TyG index was calculated as Ln [fasting triglyceride level (mg/dL) × fasting plasma glucose level (mg/dL)/2]. Patients were divided into tertiles according to TyG index values. The primary endpoint was a compound endpoint, defined as the first occurrence of all-cause mortality or total nonfatal CVDs events within one-year follow up. The secondary endpoint was atherosclerotic CVD (ASCVD) events, including non-fatal stroke/transient ischemic attack (TIA) and recurrent CHD events. We used restricted cubic spline analysis and multivariate adjusted Cox proportional hazard models to investigate the associations of the TyG index with primary endpoint events.P for trend = 0.018). Similar results were observed in ASCVD events. Restricted cubic spline analysis also showed that the cumulative risk of primary endpoint events increased as TyG index increased.During the one-year follow-up period, 154 (10.5%) primary endpoint events were recorded, including 129 (8.8%) ASCVD events. After adjusting for confounding variables, for per standard deviation (SD) increase in the TyG index, the risk of incident primary endpoint events increased by 28% . Compared with subjects in the lowest tertile (T1), the fully adjusted HR for primary endpoint events was 1.43 (95% CI 0.90–2.26) in the middle (T2) and 1.73 (95% CI 1.06–2.82) in highest tertile (T3) (The elevated TyG index was a potential marker of adverse prognosis in patients with CHD and hypertension.The online version contains supplementary material available at 10.1186/s12933-023-01866-9. With the rapid development of the global economy and the increasingly serious aging, about 31.1% of adults in the world are affected by hypertension . As a maMore and more evidence show that insulin resistance (IR) and its related diseases are not only a sign of diabetic patients, but also a risk factor for CVDs in non-diabetic patients. In recent years, TyG index has been favored by many researchers because it is a very easy to obtain value to evaluate the degree of IR . The resThis trial was a single-center, prospective observational, hospital-based clinical trial approved by the Ethics Committee of Zhengzhou University Central China Fuwai Hospital  . This study was in accordance with the principles of the Declaration of Helsinki and all patients completed the signing of informed consent form before being enrolled.From January 2021 to December 2021, a total of 1778 subjects aged 18 to 75 years old with CHD and hypertension who had a previous history or were first diagnosed in the inpatient department were enrolled in accordance with the trial procedure ], baseline blood pressure, age, gender, smoking history and drinking history; the clinical history included established history of CVDs [including myocardial infarction (MI) or heart failure (HF) or stroke)], diabetes, chronic kidney disease (CKD), peripheral artery disease (PAD); the laboratory indicators of blood samples were fasting venous blood collected by professional medical staff from all participants in the early morning, including fasting blood glucose (FBG), glycated hemoglobin A1c (HbA1c), total cholesterol (TC), triglyceride (TG), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), estimated glomerular filtration rate (eGFR) and uric acid (UA); imaging medical data included the location and extent of coronary artery disease. The units of FBG and TG were first converted from mmol/L to mg/dL, and the calculation basis was multiplied by 18.02 and 88.54, respectively. Then, the TyG index was calculated as Ln [fasting TG (mg/dL) × FBG (mg/dL)/2].CHD was defined as having at least one of the following conditions : (1) perThe WHO hypertension guidelines were used to define the initial diagnosis of hypertension defined as systolic blood pressure (SBP) was greater than 140 mmHg or their diastolic blood pressure (DBP) was no less than 90 mmHg . All patClinical follow-up was carried out by skilled clinicians in outpatient or telephone contact at the time points of 1 month, 6 months, and 12 months, and standard computerized case report forms were filled out at each of these intervals. When there was more than one endpoint event occurred during the follow-up period, the first event data were statistically analyzed. The endpoint events were independently categorized by three cardiovascular specialists who were not aware of the baseline information. When there were disagreements regarding event identification, the three experts came to a decision together after talking.The primary endpoint of this clinical trial was defined as a compound endpoint of all-cause mortality or the first occurrence of total nonfatal CVDs events within one-year follow up. The total CVDs was defined as follows: (1) nonfatal stroke/TIA, defined as the sudden onset of a neurological deficit persisting for ≥ 24 h in the absence of any other disease that could account for the symptoms, with the findings of brain computed tomography or magnetic resonance imaging; (2) nonfatal CHD, defined as acute MI, unstable angina requiring coronary revascularization [percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)]; (3) HF, defined as requiring hospitalization and treatment due to clinical manifestations of HF. The secondary endpoint was ASCVD events, defined as the occurrence of stroke/TIA and CHD events.2 test  was used to compare the demographic variables and clinical characteristics and the results were Bonferroni’s corrected (for multiple comparisons). The cumulative incidence of endpoint events in groups were analyzed using the Kaplan–Meier curve.All statistical analyses were performed using SPSS version 27.0  and R version 4.2.3. The subjects were classified according to the occurrence of primary endpoint events during follow-up and the tertiles of TyG index. Continuous data that met the normality test was expressed as mean ± SD or median (interquartile range), and categorical variables were expressed as percentages (%). The continuous variables included age, BMI, TC, TG, HDL-C, LDL-C, FBG, HbA1c, eGFR and UA; categorical variables included gender, smoking, drinking, past medical history and usage of medications. One-way analysis of variance (for continuous data) or Fisher’s exact test or χP < 0.05) variables with primary endpoint events in univariate Cox analysis and clinically important variables: Cox Model 1 was unadjusted model; Model 2 was adjusted by confounding factors including age, sex; Model 3 was further adjusted for current smoking, BMI, diabetes, established CVDs , stains, antiplatelet drugs, fibrates drugs, antidiabetic agents, SBP, DBP, UA, eGFR, TC, LDL-C. The TyG index was input into the model as a continuous variable and a categorical variable (the tertile of the TyG index). The dose–response relationship between the TyG index and the risk of the primary endpoint events was analyzed by performing the restricted cubic spline analysis. We also performed subgroup analysis based on gender, age (< 65 years or ≥ 65 years), BMI (< 28.0 kg/m2 or ≥ 28.0 kg/m2), diabetes status (yes or no), established CVDs (yes or no), blood pressure control status (controlled or uncontrolled) and LDL-C level (< 1.80 mmol/L or ≥ 1.80 mmol/L) to determine whether the correlation between TyG index and primary endpoint events in different subgroups was different, and the P value of the interaction was calculated. P value of less than 0.05 was defined as statistically significant.In order to evaluate whether the TyG index affects the occurrence of endpoint events, we constructed three Cox proportional hazard regression models. The selection of confounding factors was based on statistically significant (P < 0.05). However, there was no significant difference in gender distribution, CVDs and CKD prevalence, target vessel territory, usage of stains and antiplatelet medication, SBP and eGFR level among the three groups  patients were male. All patients were grouped according to the tertile level of TyG index   and CKD prevalence (P < 0.001), or to have multivessel disease (P = 0.020) and LCX vessel territory (P = 0.006). Significant differences could also be found for TC level (P = 0.030), UA level (P = 0.020), eGFR level (P < 0.001), usage of metformin (P = 0.005) and sulfonylurea agents (P = 0.003).Baseline characteristics of participants with and without primary endpoint events were shown in Table P < 0.05). There was no significant correlation between TyG index and SBP and eGFR   Table .Table 3TP = 0.632). All patients were followed up for one year after discharge. During the follow-up period, 154 (10.5%) primary endpoint events were recorded, including 129 (8.8%) ASCVD events. To show the outcomes of patients with different levels of the TyG index, we generated unadjusted Kaplan–Meier survival plots .The results of the restricted cubic splines were presented in Fig. P for trend < 0.001). A similar pattern was observed in fully adjusted model   . Moreover, the sensitivity analysis that excluded patients with a history of antidiabetic agents and SGLT2i agent usage showed results were consistent with the primary analysis  in the fully adjusted regression model. Compared with subjects in the lowest tertile (T1), the fully adjusted HR for ASCVD was 1.37 (95% CI 0.83–2.25) in the middle (T2) and 1.77 (95% CI 1.05–3.00) in the highest tertile (T3), respectively (Table 2), diabetes states (yes or no), CVDs (yes or no), blood pressure control status (controlled or uncontrolled) and LDL-C (≥ 1.80 or < 1.80 mmol/L). There was no statistically significant interaction between gender, age, BMI, diabetes states, CVDs, LDL-C level and TyG index . The statistical significance was observed only among females, patients without diabetes, patients without established CVDs, patients with BMI ≥ 28.0 kg/m2 and patients with LDL-C ≥ 1.80 mmol/L  , age (> 65 or ≤ 65 years), BMI  in controlled hypertension and HR 1.13 (95% CI 0.84–1.52) in uncontrolled hypertension, 2 or LDL-C ≥ 1.80 mmol/L.Recently, a large number of studies have provided strong statistical evidence for the correlation between TyG index and the development and prognosis of CVDs . HoweverIn addition to diabetes, IR is also an important marker of metabolic syndrome such as obesity, hypertension and dyslipidemia, which have been fully proved to be closely related to CVDs , 16, 17.As a convenient and easy-to-obtain measure of IR, TyG index can not only predict the occurrence of diabetes , hyperteTyG level was a more significant factor in controlled hypertension than in uncontrolled hypertension. The possible explanation for this inconsistency is considered as follows: Firstly, previous data have shown that about 50% of hypertensive patients are considered to have IR and hyperinsulinemia . IR and Gender differences in IR-related CVDs risk have previously been reported , 41. In The mechanism of TyG index related to CVDs and adverse cardiovascular outcomes has not been clearly elucidated. TyG is an index composed of two risk factors for CVD, both lipid-related and glucose-related factors reflect IR in the human body, which may be one of the explanations for this association , 16, 44.Several limitations of this trial should be considered. Firstly, this was a single-center study, so potential bias may be introduced. Secondly, the sample size was relatively small, and the incidence of all-cause death was relatively low, which may limit reliable statistical analysis and make it difficult to specify the association between the TyG index and a single component of primary endpoint events. Thirdly, insulin levels were not measured in most patients in this study, and HOMA-IR values could not be calculated. Fourthly, laboratory parameters were only detected once on admission, and changes during the one-year follow-up period may cause deviations in the analysis results. Finally, although most of the patients with CHD enrolled in the study were diagnosed by coronary angiography, some were still diagnosed by coronary CTA. Further multicenter, more rigorous studies with larger sample sizes may make our conclusions more reliable.In conclusion, the TyG index was significantly associated with adverse prognosis in patients with CHD and hypertension, and this relationship remained significant after adjustment for other confounders. Thus, in clinical work, for patients with CHD and hypertension, TyG index should be paid attention and closely monitored while strengthening the control of traditional cardiovascular risk factors including hypertension.Additional file 1:Table S1. Univariate Cox proportional hazard analysis between variables and primary endpoint. Table S2. Sensitivity analysis for the association between the TyG index and outcomes. Table S3. Multivariable Cox regression analysis for the association between the TyG index and outcomes.Additional file 2: Figure S1. Kaplan–Meier curves for endpoint events according to quartiles of TyG index. A: Kaplan–Meier curves for primary endpoint events; B: Kaplan–Meier curves for ASCVD events.


The target peak inspiratory pressure (PIP) was 30 cmH2O and the PEEP was 15 cmH2O. The following hemodynamic variables were monitored using the PICCO® system: mean arterial pressure (MAP), central venous pressure (CVP), and cardiac output (CO). The cerebral hemodynamics variables monitored were intracranial pressure (ICP)  and cerebral oxygen saturation (rSO2) (with the oximetry monitor INVOS 5100® system). The following respiratory parameters were monitored: oxygen saturation, fraction of inspired oxygen, partial pressure of oxygen, end-tidal carbon dioxide pressure, Pmean, PEEP, static compliance (Cstat), and dynamic compliance (Cdyn). Results: All LRMs were safely performed as scheduled without any interruptions. Systemic hemodynamic stability was maintained during the lung recruitment maneuver. No changes in ICP occurred. We observed an improvement in rSO2 after the maneuver (+5.8%). Conclusions: Stepwise LRMs are a safe tool to avoid atelectasis. We did not observe an impairment in cerebral hemodynamics but an improvement in cerebral oxygenation.Background: Lung recruitment maneuvers (LRMs) have been demonstrated to be effective in avoiding atelectasis during general anesthesia in the pediatric population. Performing these maneuvers is safe at the systemic hemodynamic and respiratory levels. Aims: We aimed to evaluate the impact of a stepwise LRM and individualized positive end-expiratory pressure (PEEP) on cerebral hemodynamics in an experimental neonatal model. Methods: Eleven newborn pigs  were included in the study. The LRM was performed under pressure-controlled ventilation with a constant driving pressure (15 cmH Mechanical ventilation is a lifesaving approach that carries inherent risks including brain damage and cognitive impairment ,2,3. TheExperimental studies have demonstrated the efficacy of LRMs in achieving optimal alveolar opening during mechanical ventilation in neonatal models.Evidence supports the safety of employing recruitment maneuvers in neonatal models . LRMs haThis study was designed to evaluate the impact of a stepwise LRM and individualized PEEP on cerebral hemodynamics  in an experimental neonatal model.This study has been approved by the Institutional Animal Care and Use Committee of the Puerta de Hierro-Segovia Arana Health Research Institute, Madrid, Spain . This study was conducted in accordance with the ARRIVE guidelines for experimentation in animal research . The animals were handled according to the European and national regulations for the protection of experimental animals (2010/63/UE and RD 53/2013). This study included Landrace–Large White newborn pigs, less than 72 h old and 2.56 ± 0.18 kg in weight. All were examined by a veterinarian prior to experimentation.2 possible to maintain peripheral O2 saturation (SpO2) ≥ 92%. A 24G peripheral line was cannulated. A bolus of morphic chloride (0.2 mg/kg) and a bolus of cisatracurium (0.15 mg/kg) were administered. Once an adequate anesthetic depth was reached  [Anesthesia was delivered using the approach previously described . Generaline MAC) , the pig2 (EtCO2) between 40 and 45 mmHg, without generating auto PEEP . Basal PEEP was set to 3 cmH2O, and an I:E ratio of 1:1. The starting FiO2 was 30%. A convective warming device (Equator®) was used to maintain the piglet in normothermia (37–39 °C) with measurement of central temperature taken with an esophageal thermometer. Anesthesia maintenance was accomplished with sevoflurane at 2.5%, morphine chloride boluses at 0.2 mg/kg/h, and a continuous perfusion of cisatracurium at 0.12 mg/kg/h. Maintenance fluid therapy was maintained with Ringer’s lactate at 4 mL/kg/hour.The animals were connected to a Flow-i C20 anesthesia machine  under volume-controlled ventilation (VCV) for a TV of 6 mL/kg and a respiratory rate (RR) that maintained normocapnia: an end tidal CO-10 mL/kg of physiological saline at 36 °C was administered when the mean arterial pressure (MAP) was under 45 mmHg.-An extra dose of morphine (0.1 mg/kg) was administered when the piglet had a heart rate greater than 180 bpm.No volume loading or other drugs were routinely administered prior to the experiments. According to the protocol, we proceeded as follows:®. The right jugular vein was cannulated with a Seldiflex®  5.5F and 8 cm long three-lumen central venous catheter. This vascular access was used for the administration of fluids and medication, as well as for central venous pressure (CVP) monitoring and thermodilution.Electrocardiography and pulse oximetry were monitored in all animals with the Infinity Delta monitor, Dräger® .For invasive hemodynamic monitoring, the right femoral artery was cannulated with a PULSIOCATH 3F arterial thermodilution catheter, 7 cm in length (PV2013L07-A) from the PiCCO monitor® Model 1104B. This catheter was placed by performing a trephine at the right frontal level with a drill nº 36 (2.71 mm) in prone position. The pressure transducer was placed through a compressor plug, leaving it at the intraparenchymal level.ICP monitoring was achieved with the placement of an ICP monitoring catheter Camino2 monitoring, we used the INVOS 5100® system  by placing a unilateral neonatal sensor at the left frontal level because ICP monitoring at the right frontal level prevented bilateral sensor placement.For regional rSOAt the end of all monitoring techniques, we left the newborn pigs in the supine position.® . Other settings: RR 35 rpm, target peak pressure: 30 cmH2O, and target PEEP: 15 cmH2O. The I:E ratio during the LRM was 1:1. Five breaths were set at each pressure step and ten breaths at the maximum pressure step. Pressure reductions were made in the VCV mode with a TV of 6 mL/kg. We descended from a PEEP of 8 cmH2O with PEEP decreases of 2 cmH2O, providing 30 s in each step to calculate the alveolar collapse point (first step in which Cdyn drops) and individualized PEEP . Subsequently, the opening maneuver was repeated (up to a peak pressure of 30 cmH2O and PEEP of 15 cmH2O) to end the LRM with the calculated individualized PEEP . LRMs should be stopped at any moment if desaturation (SpO2 < 91%) or hypotension occur (MAP < 30 mmHg or <20% of baseline).The LRMs were run using the Flow-i 4.3 anesthesia system’s lung recruitment-specific software® . Paramet2, FiO2, and SpO2.Respiratory monitoring: inspiratory peak pressure, mean airway pressure (Pmean), inspiratory and expiratory TV (ICV and ECV), PEEP, dynamic compliance (Cdyn), static compliance (Cstat), EtCO2 and pCO2 were analyzed.Arterial blood gases were drawn prior to each LRM , and 10 min after the end of the LRM, pOSystemic hemodynamic monitoring: heart rate (HR); blood pressure (BP): SBP (systolic blood pressure), DBP (diastolic blood pressure), and MAP; CVP; and cardiac output (CO) measurements were obtained using thermodilution and arterial pulse wave analysis.2.Cerebral hemodynamic monitoring: CPP was calculated with the formula (CPP = MAP − ICP), ICP, and rSOEvery parameter was continuously monitored. The aforementioned data were compared at these times: at the start of the maneuver, during the maximum opening pressure step, at each step of PEEP descent, and 10 min after the end of the LRM.We decided to evaluate the baseline data (start of the LRM) following the induction of general anesthesia and intubation, as these procedures may contribute to partial lung collapse. The selection of maximum opening pressure steps allowed us to evaluate the effects of increased intrathoracic pressure on systemic hemodynamics and cerebral parameters. It also allowed us to examine the response and potential adverse effects of the maneuver at the maximum pressure level. The last selected time point data comparison was 10 min after completing the LRM, aiming to capture values when alveoli are maximally expanded. This specific temporal point allowed us to evaluate the immediate effects of the LRM and any associated changes in lung function, systemic hemodynamics, and cerebral parameters.Sample size and power calculations were based on previous data from similar studies and determined using the GRANMO 7.12 software program . Eleven animals per group were deemed adequate to accept an alpha risk of 0.05 and a beta risk of 0.05 in a two-sided test to obtain a statistically significant difference > 1 unit in Cdyn and a standard deviation assumed to be 0.9.2, MAP, CPP, CVP, CO, and EtCO2. The time variable was introduced as a fixed independent variable, and the marginal effects were obtained for each time with their respective 95% confidence intervals, as well as a graphical representation of them. To evaluate the effectiveness of the LRM, a comparison was made between parameters before and after the maneuver , using the nonparametric Wilcoxon signed-ranks test. The significance level was set to 0.05 for all comparisons. The statistical package used is Stata/IC v.15.1 .A descriptive analysis was performed for categorical variables using absolute and relative frequencies, and for numerical variables using the median, 25th and 75th percentiles, and minimum and maximum values. To evaluate the evolution over time of the different parameters, generalized estimating equation (GEE) models were used, which consider that each animal was evaluated at different points in time. The “identity” function was used as the link function and a Gaussian distribution was used for the dependent variables. The dependent variables were ICP, rSOA total of 12 newborn pigs were studied, but one of them was excluded due to hemodynamic collapse after induction of anesthesia. The LRM was performed according to protocol in all experimental animals and a complete set of data was recorded. No additional boluses of saline or morphine chloride were necessary.2, Cdyn, and Cstat. However, it is worth noting that only the parameter Cstat demonstrated statistical significance (p = 0.042).Comparing the respiratory data obtained at the baseline with those obtained after the application of individualized PEEP shows that improvements were noted in all measured parameters, including PaOp = 0.038)  vs. PEEP 6  (= 0.038) . Analyzi changes .The mean baseline MAP was 53.2 mmHg (±6.8), the mean baseline CVP was 6.2 mmHg (±2.29), and the mean baseline CO was 1 l/min (±0.24). All three systemic hemodynamic parameters remained constant throughout the different phases of the LRM .p = 0.226). The lowest ICP value was with PEEP 3 at 9.1 , which was also not statistically significant (p = 0.941) (The baseline CPP was 44 mmHg (±7.43). It remained constant throughout the different phases of the LRM . The bas= 0.941) .2 with a baseline value of 49% (±4.34). No statistically significant variations were observed in the moments of maximum alveolar pressure, but a statistically significant improvement was observed at the end of the LRM; the level at the individualized PEEP was +5.8% over baseline rSO2  (p = 0.04)  .p = 0.640) on the behavior of ICP throughout the LRM. Instead, a relationship between CPP and ICP was observed in our study. When CPP increased by 1 mmHg, ICP decreased by 0.09 mmHg  (p = 0.006). Furthermore, a relationship between CVP and ICP was also observed, with an increase in ICP of 0.92 mmHg  (p < 0.001) for each mmHg of CVP. CO had no statistically significant effect (p = 0.399) on ICP during the LRM . By contrast, EtCO2 turned out to have an impact on ICP significantly, since for every 1 mmHg increase in exhaled CO2, ICP increased by 0.2 mmHg  (p < 0.001)  .2 increased by 0.39%  (p < 0.001). With respect to CPP, rSO2 increased by 0.35%  (p < 0.001) for each mmHg that CPP increased. In contrast to ICP, there was an effect of CO on rSO2, since for each l/min increase in CO, rSO2 improved by 7.22%  (p = 0.011). CVP also influenced the behavior of rSO2, since for each mmHg increase in CVP, rSO2 also increased by 1.2% (95% CI 0.63–1.77) (p < 0.001)  .2 as a function of Pmean did not show statistical significance (p = 0.119). We observed instead an increase in rSO2 in relation to the increase in EtCO2; for each mmHg that EtCO2 increased, rSO2 also increased by 0.21%  (p = 0.03)  .2, and CPP remained stable throughout the entire LRM sequence.In this experimental study, we evaluated the impact of LRMs on ventilation and systemic and cerebral hemodynamics. The recorded data confirm, with the protocol used in the present study, the efficacy of LRMs in achieving optimal alveolar opening with an improved Cstat. The data also confirm that LRMs do not impact the ventilation and systemic hemodynamics as previously reported . The preOur model is a neonatal piglet with intact brain function. We chose an experimental model because invasive neurological and hemodynamic monitoring in healthy neonates cannot be performed for ethical reasons. However, we believe it is very important to have data and scientific evidence on the behavior of the brain in neonatal patients where alterations in ICP and cerebral hemodynamics can have devastating consequences on neurological development.The implications of an LRM and PEEP on ICP can be explained with the Monro–Kellie theory. ICP tends to remain constant up to certain limits. ICP depends on the volume of three components . When the volume of one of these compartments increases, the volume of the other two is reduced as a compensatory mechanism to maintain a constant ICP. There is a point in the ICP/intracranial volume ratio at which these protective mechanisms cease to be effective and ICP increases exponentially with low volume increases . In ventAlthough the generalized knowledge is that LRMs and PEEP alter ICP, there are other studies that support our findings. Feldman studied in an experimental model how PEEP affected rabbits with an intracranial mass. He did not find an increase in ICP, but he found that these compensatory mechanisms were less effective, and the point of decompensation was reached earlier. In our case, we did not observe an increase in ICP because our patients have an intact central nervous system with intact protective mechanisms .Therefore, we can say that an LRM with an opening pressure between 15 and 30 mmHg during fewer than 25 breaths (43 s), and in a stepwise manner with individualized PEEP, did not seem to have cerebral repercussions.Regarding hemodynamic effects, neither MAP nor CPP decreased in our study. CO remained constant throughout the entire LRM, which justifies the hemodynamic stability at BP levels. This lack of impact on CO can be explained by the fact that the newborn pigs were normovolemic (baseline CVP of 6.2 mmHg), which would explain why no serum boluses were required during the LRM.Sevoflurane was the anesthetic agent chosen for our study. This inhalational anesthetic has been the subject of numerous studies investigating its impact on systemic hemodynamics. Our decision was based on its ability to maintain adequate hemodynamic stability with minimal effects on blood pressure and systemic resistance. Additionally, sevoflurane has demonstrated the ability to maintain stable cardiac outputs during anesthesia, making it a safe choice .2), several studies have examined these aspects in patients undergoing intracranial surgery. Sevoflurane has been found to exert neuroprotective effects, as it can reduce ICP and improve rSO2 compared to other anesthetic agents. Furthermore, studies have shown that sevoflurane decreases the cerebral metabolic rate of oxygen (CMRO2) while maintaining a proportional reduction in cerebral blood flow (CBF) [2 supports its utility in neuroanesthesia, indicating its potential to preserve cerebral perfusion and mitigate neuronal damage.Regarding its relationship with intracranial pressure (ICP) and regional cerebral oxygen saturation (rSOow (CBF) ,23. This2O in the absence of falling CO or BP [Studies in different populations with brain pathology support our observations. Frost observed that, in adults with brain damage, ICP did not increase even with PEEP levels of 40 cmHCO or BP . PulitanCO or BP .2O) in patients with altered brain function (traumatic brain injury or subarachnoid hemorrhage). No significant changes in ICP or cerebral compliance were observed in any case, but they determined an increase in CVP and a decrease in MAP and CPP in patients with normal pulmonary compliance [Caricato et al. studied the effects of pressurization  ,26. OtheIn most of the studies, an increase in CVP was observed. We observed that CVP directly increased proportionally to the Pmean. The rise in intrathoracic pressure favors the increase in pressure in the right atrium and in turn, retrogradely, in the right jugular vein. This generates a decrease in venous drainage of the sagittal sinus, thus increasing ICP .There are protective mechanisms to attenuate the increase in ICP: distensibility and the presence of valves in the jugular veins, and drainage in the vertebral venous plexus. An increase of 20 mmHg in the right atrium is necessary to overcome the protection generated from collapsed jugular veins .In our study, there were no changes in CVP and ICP. This is possibly because our LRMs have a very limited duration in time (less than 43 s). In addition, most studies do not consider either Pmean or DP ,29.2. The increase in arterial CO2 pressure generates vasodilation that conditions a rise in cerebral perfusion with increased ICP and increased jugular venous saturation. Mascia and Robba found that increased PEEP only had an effect on ICP in patients who did not respond to alveolar recruitment. An excessive increase in PEEP produces hyperinflation with alveolar overdistension, leading to an increase in dead space [Regarding lung–brain interactions, there is a relationship between ICP and COad space ,31,32,332 improves by almost 6% at the step where individualized PEEP is established. There are few studies in the literature on the effects of protective ventilation on cerebral hemodynamics. Nemer observed an improvement in SpO2 and in the cerebral tissue pressure of O2 in patients with TBI (with an associated ARDS) by increasing PEEP to 15 cmH2O without ICP elevation [Our final objective was to determine if LRMs improved cerebral oxygenation despite the hemodynamic changes it could produce. In our study, rSOlevation .2 and PEEP with rSO2 and optic nerve sheath diameter. There is a direct relationship between this diameter and ICP and it is a non-invasive way of assessing it. It was observed that rSO2 increased with PEEP. The optic nerve sheath diameter increased as well , but it never exceeded physiological values. Hyperventilation of the patients improved ICP but decreased rSO2, as we observed [Other studies aimed to assess the relationship between PaCOobserved ,35.The main limitations of our study are that it was performed in a neonatal animal model and therefore cannot be directly extrapolated to humans, although the study of newborn pigs is the most commonly used for neonatal studies and the one that most closely resembles humans.Another consideration is that our patients have an integrated blood–brain barrier, so we cannot extrapolate the results to patients with brain damage. Regarding the number of newborn pigs, eleven may seem a small sample size, but the reason we used this size is because of ethical constraints. It is important to include the minimum number of animals to obtain significant results. Additionally, in experimental animal research, the usual number per group to obtain significant results is between six and ten in most of the studies.2 since it is a tool that provides great informative value with few complications associated with its use. The results obtained indicate that these maneuvers enhance cerebral oxygen supply and are regarded as safe interventions from a hemodynamic, respiratory, and cerebral perspective in neonatal patients without neurological impairments. Consequently, they can be employed in different clinical settings (operating rooms or intensive care units). In the future it would be important to study these effects in damaged model brains as well.There is scarce evidence in the literature on the behavior of ICP during RMs in healthy newborns. We decided to develop this study in an experimental animal model since it is not ethically justified to perform invasive procedures in healthy neonates. We thought it would be interesting to evaluate rSOIn our study, we have observed that LRMs in a healthy neonatal model are safe and well tolerated hemodynamically at the systemic and cerebral levels. The LRM does not produce a significant increase in ICP but does improve final cerebral oxygenation. We consider that it is important to confirm that the patient is in a state of euvolemia before performing an RM to avoid hemodynamic alterations. Clinical studies in humans are needed to verify these findings. As our study uses an experimental animal design, it is limited to a small sample size due to the ethical limitations of the ARRIVE guidelines. However, we calculated the sample size to be sufficient to obtain statistically significant results. It would be interesting to conduct clinical studies with an increased number of patients to verify whether our results are confirmed in studies with larger sample sizes.