In non-hypertension, as compared with quartile 1, the β (95% CI) of systolic blood pressure for quartiles 2, 3, and 4 was −0.92 (−2.07–0.23), −0.05 (−1.30–1.20), and −0.48 (−1.83–0.88), respectively, in multivariable analysis . As compared to quartile 1, the ORs for treated hypertension in quartiles 2, 3, and 4 were 1.36 (0.88–2.10), 1.35 (0.87–2.09), and 1.56 (0.98–2.47), respectively, upon multivariable analysis including antihypertensive medication use as a covariate . Furthermore, 1SD increase in serum copper was non-significantly associated with 1.16 (0.97–1.37)-fold increased risk of hypertension in multivariable analysis (p = 0.096). (4) Conclusion: In the present study, we discovered that the serum copper concentration was not related with hypertension or blood pressure levels. Antihypertensive drug use may distort the correlation between copper and blood pressure levels. Information on antihypertensive drug use may be taken into account when identifying new risk factors for hypertension.(1) Background: Epidemiological studies on the relationship between serum copper and hypertension are contradictory. We assessed the relationship between serum copper and blood pressure among adults in the United States. (2) Methods: We divided hypertension into two categories: treated hypertension and untreated hypertension. Linear or logistic regression analysis was applied to investigate the association between serum copper concentrations and blood pressure levels. (3) Results: As compared to quartile 1, the odds ratios (ORs) for untreated hypertension in quartiles 2, 3, and 4 were 1.02 (0.74–1.42), 1.23 (0.88–1.72), and 1.08 (0.74–1.58), respectively, in multivariable analysis (all  Hypertension, a global public health issue, is the principal reversible risk factor for cardiovascular disease (CVD) and the leading cause of mortality worldwide ,2. The cRecently, trace elements and their associations with hypertension have come into our view, although these associations are conflicting. Two prior studies reported significant associations of serum copper with hypertension, in which one study was in fact a univariate analysis without considering confounding factors . In the n = 15082) were excluded. Adolescents younger than or 20 years of age (n = 1439) and pregnant women (n = 34) were also removed. Thus, 3376 eligible subjects were included for final analysis. The study population included non-hypertension (n = 2380) and hypertension (n = 996). We further classified hypertensive participants into treated hypertension (n = 611) and untreated hypertension (n = 385). The flowchart of patient selection is shown in Our analyses were based on the National Health and Nutrition Examination Survey (NHANES), which was a research project designed to assess the health and nutritional status of the US population . For thihttps://www.cdc.gov/nchs/nhanes/index.htm (accessed on 5 July 2023).All participants’ blood was collected in corresponding tubes and was gently inverted five to six times as soon as possible. After clotting for 30–45 min and centrifugation at 2900 rpm for 15 min both at room temperature, serum was stored in frozen conditions and transported to the Division of Laboratory Sciences, National Center for Environmental Health, Centers for Disease Control and Prevention, for analysis. The serum copper concentration was quantified using inductively coupled plasma dynamic reaction cell mass spectrometry (ICP-DRC-MS), a powerful multielement analytical technique with the ability to detect even trace levels of elements. All the data exceeded the lower limit of detection (LLOD) for the tests. The LLOD of serum copper was 2.5 μg/dL. More comprehensive information on laboratory procedures and methods is accessible through the official website: Blood pressure was measured by trained and qualified staff according to standardized protocol and procedure at the mobile examination center. In simple terms, after the subjects were asked to sit quietly for 5 min, certified examiners measured their blood pressure and obtained three or sometimes four consecutive blood pressure readings. The average of all acquired measurements was calculated and recorded. Participants were defined as having hypertension if they satisfied one or more of the following conditions: (1) mean systolic blood pressure ≥140 mmHg, (2) mean diastolic blood pressure ≥ 90 mmHg, (3) subjects who were diagnosed to have high blood pressure, and (4) individuals with currently taking prescribed medicine for hypertension. Hypertension was further classified into 2 categories: hypertension under or not under treatment.Antihypertensive medications were determined according to the drugs reported by the patients to have been taken during the previous 30 days. According to the 2017 ACC/AHA hypertension guidelines, we categorized antihypertensive drugs as angiotensin-converting enzyme inhibitors (ACE-Is), angiotensin receptor blockers (ARBs), beta-blockers (BBs), calcium channel blockers (CCBs), thiazide and thiazide-like diuretics (thiazides), as well as others .2). eGFR was computed employing the Chronic Kidney Disease Epidemiology (CKD-EPI) formula [Potential covariates associated with hypertension were determined according to previously published studies ,10. We e formula . Diabete formula .For descriptive analysis, continuous variables are shown as the mean ± standard deviation, and categorical variables are shown as a percentage (numbers). In particular, age is presented as the median  for its non-normal distribution. Differences in variables between quartiles of serum copper were analyzed using chi-square , ANOVA (continuous variables), and Kruskal–Wallis tests only for age. Alongside that, standardized serum copper was adopted in order to unify data and facilitate analysis.First, logistic regression models were utilized to compute the odds ratios (ORs) and their respective 95% confidence intervals (CIs) to furnish a quantitative assessment of the association between serum copper and hypertension prevalence. We regarded subjects with untreated hypertension as cases, and those without hypertension were the controls. Then, linear regression models were employed to investigate the correlation between serum copper and systolic BP and diastolic BP in a non-hypertensive population. Testing for trends in event rates across the quartiles was performed using the STATA procedures Opartchi. We fitted 2 statistical models: the crude model was not adjusted and the adjusted model was adjusted for education, smoking status, drinking status, BMI, eGFR, HDL-C, diabetes status, and CAD. We performed multiple imputation for missing values of systolic and diastolic blood pressure, as well as all covariates under the assumption of missing at random, with 25 imputations .2), diabetes . The product terms between serum copper and stratification variables were introduced into the same regression model as covariables to perform interaction analysis. Moreover, we conducted a few sensitivity analyses to evaluate the soundness of the results. On the one hand, the models were reconstructed with excluding participants with impaired eGFR (<60 mL/min/1.73 m2) to account for the effect of renal function injury on blood pressure. On the other, we refitted our models after keeping serum samples in the range of the 1st to 99th percentiles of the serum copper distribution to eliminate the influence of outliers. Data analysis was conducted using STATA version 17.0 and R software version 4.2.0. All tests were two-sided, and a p-value < 0.05 was deemed to be significant.Moreover, we carried out several tentative analyses. To assess the effect of different antihypertensive drugs on the relationship between serum copper and hypertension, a three-stage analysis was performed. First, we took participants with treated hypertension as cases and those with non-hypertension as controls. Second, the setting of cases and controls in the first stage was unchanged, and the multivariate model was further adjusted for antihypertensive medications. Third, we set hypertensive patients treated with single antihypertensive drugs as the case group, and the non-hypertensive subjects as the control group. Stratified analyses were implemented by sex , age , BMI , smoking status , drinking status , education level , eGFR . In contrast, the prevalence of untreated hypertension varied weakly across serum copper quartiles.The characteristics of the study individuals according to quartiles of serum copper are depicted in The association between serum copper and untreated hypertension prevalence is depicted in In multivariable regression analysis, as compared with quartile 1, β (95% CI) of systolic blood pressure for quartiles 2, 3, and 4 was −0.92 (−2.07–0.23), −0.05 (−1.30–1.20), and −0.48 (−1.83–0.88), respectively . On a cop = 0.096). As shown in In crude analysis, on a categorical or continuous scale, serum copper levels were notably associated with hypertension in individuals receiving antihypertensives. In partially adjusted analysis without including antihypertensives as a covariate, this association remained. However, this association disappeared after further adjustment for antihypertensive drugs. As compared to quartile 1, the ORs for hypertension in quartiles 2, 3, and 4 were 1.36 (0.88–2.10), 1.35 (0.87–2.09), and 1.56 (0.98–2.47), respectively . The P fTo explore the interactive effects on the association, we conducted subgroup analysis through a series of strata variables in To the best of our knowledge, this is the first study to highlight the possible effects of antihypertensive drug use on the correlation between the serum copper and blood pressure. The main findings of the present study are as follows: serum copper levels were not significantly related to high blood pressure on either a categorical or continuous scale. The apparent-looking association of serum copper with hypertension could be attributed to antihypertensive drugs use.In the untreated hypertension group, we did not find serum copper–hypertension associations in the multivariable analysis on a continuous or categorical scale. Since these patients were less likely to be prescribed antihypertensive drugs, our results could be deemed more reliable without the confounding effects of these medications. A small, matched, case-control study enrolling only 58 individuals found no statistical correlation between serum copper concentration and the risk of untreated hypertension. Similarly, another study with a large sample size enrolled only male populations and also discovered no significant difference in serum copper between untreated and non-hypertensive people . These sIn non-hypertension individuals, there was most likelihood to observe the association of serum copper with blood pressure levels (as a continuous variable) if present. However, we also did not reveal the serum copper–blood pressure association on a continuous or categorical scale either in the univariate or multivariable analysis. It has been reported that in univariate analysis, serum copper concentration was not correlated with systolic and diastolic blood pressure levels after the exclusion of antihypertensive drug users . A recenFor the treated hypertension, we first observed the relationship of serum copper with hypertension in univariate analysis or in multivariable analysis without including antihypertensive drug use as a covariate. Very interestingly, this association finally disappeared after further adjusting the covariate of antihypertensive drug use in the multivariable analysis. Therefore, serum copper–hypertension association was greatly affected by the antihypertensive medications. Prior studies reporting significant associations of serum copper with hypertension largely did not include antihypertensive medications as a covariate ,5,18. OnThis study had several limitations. First, this study is cross-sectional in design, and the confounding was unable to be avoided. Thus, this finding should be hypothesis-generating. Second, the antihypertensive drug-specific group is small in sample size, although this study includes 3376 subjects, a large sample size powered enough to indicate the absent associations of serum copper with blood pressures. Thus, more participants should be enrolled to study the serum copper–hypertension association in the antihypertensive drug-specific group so as to replicate our findings in the current study. Third, a reverse causality could bias our results, which are, thus, needed to be confirmed in randomized trials.In the present study, we discovered that serum copper concentration was not related with hypertension or blood pressure. Antihypertensive drug use had a great impact on the serum copper levels and distorted its association with blood pressure levels. Identification of a novel risk factor for hypertension should be cautious in the absence of information on antihypertensive drug use.


Patients were further stratified by the type of iron deficiency [absolute iron deficiency (AID) versus functional iron deficiency (FID)]. The key outcome was change in hemoglobin (∆Hb) between pre- and post-infusion haemoglobin (Hb) values. Parenteral iron response was assessed using propensity-score matching and multivariate linear regression. The impact of kidney impairment versus the nature of iron deficiency (AID vs. FID) in response was explored. Results: 732 subjects  were evaluated. No significant differences were observed in the time to repeat Hb among CKD stages and FID/AID patients. The Hb rise was significantly lower with lower kidney function . When groups with different degrees of renal impairment were propensity-score matched according to whether iron deficiency was due to AID or FID, the level of CKD was found not to be relevant to Hb responses . However, a comparison of patients with AID and FID, while controlling for the degree of CKD, indicated that patients with FID exhibited a diminished Hb response regardless of their level of kidney impairment. Conclusion: The nature of iron deficiency rather than the severity of CKD has a stronger impact on Hb response to intravenous iron with an attenuated response seen in functional iron deficiency irrespective of the degree of renal impairment.Background: Limited knowledge exists about factors affecting parenteral iron response. A study was conducted to determine the factors influencing the erythropoietic response to parenteral iron in iron-deficient anaemic patients whose kidney function ranged from normal through all stages of chronic kidney disease (CKD) severity. Methods: This retrospective cohort study included parenteral iron recipients who did not receive erythropoiesis-stimulating agents (ESA) between 2017 and 2019. The study cohort was derived from two groups of patients: those managed by the CKD team and patients being optimised for surgery in the pre-operative clinic. Patients were categorized based on their kidney function: Patients with normal kidney function [estimated glomerular filtration rate (eGFR) ≥ 60 mL/min/1.73 m Iron deficiency anaemia (IDA) can be the result of reduced iron intake, reduced intestinal absorption or chronic blood loss resulting in absolute iron deficiency (AID). In addition to this, a state of functional iron deficiency (FID) occurs when there is inadequate iron available for erythropoiesis in the presence of adequate iron stores . This stIn chronic kidney disease (CKD), apart from being an independent risk factor for death, IDA is associated with reduced quality of life, cardiovascular disease (CVD), hospitalizations, and cognitive impairment ,5,6. PreIron supplementation in IDA reduces the need for blood transfusion, length of hospital stays and the costs to healthcare providers . In CKD,2) and 2 (eGFR 60–89 mL/min/1.73 m2) represent preserved kidney function but require the presence of albuminuria or other evidence of kidney damage for CKD diagnosis. CKD Stages 3–5 encompass a range of impaired kidney function levels, graded by progressively reduced filtration capacity . CKD is classified into five stages based on the estimated glomerular filtration rate (eGFR) and the presence of kidney damage. CKD Stages 1  response to parenteral iron from those likely to have a sub-optimal response. .2). Determining the validity of and explanation for this observation underpinned the rationale for the current study. This retrospective observational study was therefore conducted to evaluate the response to parenteral iron in patients with differing degrees of kidney function and to identify reasons for differential response.The pre-operative anaesthetic department at our institution noticed that surgical patients with lower eGFR exhibited a less favorable response to parenteral iron compared to those with well-preserved eGFR  at a large hospital that included a tertiary nephrology centre in northwest England between 2017 and 2019. The study cohort was derived from two patient groups merged into a single cohort. A total of 81% of the iron infusions were delivered to patients in the CKD clinics, whereas the remaining 19% were in pre-operative patients who received parenteral iron for IDA. Subjects were excluded if they were receiving ESA or had no post-infusion Hb recorded within 90 days of infusion. This was a retrospective cohort study of subjects who received parenteral iron in the form of ferric derisomaltose . The underlying kidney disease was recorded for the CKD patients, and the nature of planned surgery was recorded for the surgical patients. The severity of CKD based on the stages of CKD was also recorded. Data on baseline and post infusion Hb parameters, iron indices and red-cell indices as well as the parenteral iron dose were also recorded. All data were fully anonymized.Anaemia was defined as Hb < 130 g/L for men and <120 g/L for women according to World Health Organisation definitions .Based on their iron parameters, patients were categorized into those with FID or AID. Two different definitions of FID and AID were used in this study. This was because the FID definition differs between CKD and non-CKD populations due to the influence of CKD and chronic inflammation on iron metabolism . Since oAccording to the international consensus statement on the perioperative management of anaemia and iron deficiency, AID was defined as ferritin < 30 µg/L, whereas FID was defined as ferritin ≥ 30 µg/L and Tsat < 20%.In the CKD3–5 population, AID was defined as ferritin ≤ 100 µg/L and Tsat < 20%, whereas FID was defined as ferritin > 100 µg/L with Tsat < 20%.The total dose of iron (TDI) infused for each infusion episode was also recorded. A simplified dosing regime, based upon Hb and weight and differing between the pre-operative and CKD clinics, was used as shown in Mild reactions: defined as localized infusion site reactions that did not result in discontinuation of infusions.Moderate reactions; defined as systemic symptoms leading to discontinuation of infusions but not to hospitalization.A severe reaction; defined as systemic symptoms requiring hospitalization for ≥ 24 h.Iron infusion-associated reactions were categorized into mild, moderate, and severe reactions: The study procedure was compliant with the principles of the declaration of Helsinki and was approved by the local institutional review board—the Northern Care Alliance NHS Group (Ref: S21HIP50). As this was a retrospective observational study using routinely collected and fully anonymized data, the need for individual patient consent was not considered necessary.The primary outcome was the change in Hb (∆Hb) post-parenteral iron, defined as the difference between the pre-infusion Hb and the post-infusion Hb. This was first compared across the various stages of CKD. Then we compared the response between subjects with FID and those who had AID. To address potential sources of bias, a propensity-score matching (PSM) method was used to balance out the effect of CKD severity and other baseline variables recognized for their impact on hemoglobin response. This enabled us to disentangle and evaluate the influence of the type of iron deficiency on the observed response isolating it from the influence of CKD on response and vice versa. A multivariate linear regression analysis was also conducted to determine the wider predictors of Hb response.Descriptive statistics of categorical data were summarized as frequencies and percentages. Continuous variables were summarized as the mean ± standard deviation (SD) or median and interquartile range (IQR). Inter-group comparisons were made using a one-way ANOVA or the Kruskal–Wallis rank test. The Chi-square or Fisher’s exact test was used to compare categorical variables. 2 (as the treated group) vs. eGFR < 60 mL/min/1.73 m2 eGFR ≥ 60 mL/min/1.73 m2 (treated) vs. eGFR < 30 mL/min/1.73 m2 (control group)eGFR ≥ 60 mL/min/1.73 m2 (treated) vs. eGFR < 30 mL/min/1.73 m2 (control group).eGFR = 30–59 mL/min/1.73 mSeparate PSM analyses were undertaken to provide clearer insights into the effects of kidney function, FID and AID on the response to parenteral iron. In the initial set of PSM analyses, separate propensity scores (PS) were generated for matching subjects within the following groups:PS were calculated using the following variables: age, gender, diabetes, baseline Hb, baseline ferritin, baseline Tsat, presence or absence of FID and time from iron infusion to repeat Hb. In the second PSM analysis, separate PS models were used to assess the effect of the two types of IDA AID (treated group) vs. FID (control group). To ensure that subjects met the definitions of FID, those with both normal ferritin and Tsat (>20%) were excluded from the inferential analysis. The PS were estimated using the following variables: age, gender, diabetes, baseline Hb, baseline eGFR and time to repeat Hb. To assess the effect of kidney impairment on ∆Hb, the type of iron deficiency was included in the covariates used to generate PS. Conversely, to evaluate the impact of the nature of iron deficiency on ∆Hb, the degree of kidney impairment (baseline eGFR) was one of the covariates used to generate PS. This minimised the confounding effect of kidney impairment while evaluating the effect of FID on response and vice versa. PSM was conducted with radius matching see . The wider predictors of response to parenteral iron were assessed using multivariate linear regression. Predictor covariates were chosen based on previous knowledge of their effect on anaemia, iron metabolism and erythropoiesis. They included age, gender, ethnicity, body mass index (BMI), diabetes, CVD, TDI tertile, baseline eGFR, baseline mean corpuscular volume (MCV) and the nature of iron deficiency (FID vs. AID). The time from infusion to Hb recheck was also included in the multivariate linear regression model. This addition aimed to mitigate potential bias stemming from variations in the duration before Hb recheck post-infusion. Furthermore, to avoid the potential confounding of Hb response by inadequate total parenteral iron dose, the total iron deficit for each subject was calculated using the Ganzoni formula . We thenn = 673) of infusions originated from CKD iron clinics, while 19% (n = 161) were from pre-operative iron clinics.The baseline characteristics of the subjects are presented in The median total iron dose per kilogram of body weight was 18.0 mg/kg (interquartile range: 15–21 mg/kg). Most subjects (88%) received their complete iron dose as a single infusion, while 12% required two infusions spaced one week apart.n = 398), followed by those with well-preserved eGFR (eGFR > 60 mL/min/1.73 m2 either without CKD or CKD stages 1–2) accounting for 25% (n = 191). A small subset of patients (n = 6) was receiving renal replacement therapy. Baseline median Hb was 107.0 g/L (interquartile range: 99.0–116.0 g/L) with higher baseline Hb associated with higher kidney function. Conversely, baseline median ferritin was 92.0 µg/L (interquartile range: 33.0–211.5 µg/L), and higher ferritin was associated with worse CKD stage.Regarding the distribution of subjects based on kidney function, the largest proportion (47%) fell into CKD stage 4  and functional iron deficiency (FID), a total of 252 infusions (33.7%) were administered to patients with AID (defined as ferritin < 30 µg/L), while 496 infusions (66.3%) were given to patients with FID (defined as ferritin ≥ 30 µg/L with Tsat < 20%)n = 202). Polycystic kidney disease was present in 6.1% (n = 41) of subjects, while glomerulonephritis, hypertensive and ischemic nephropathy, obstruction and reflux nephropathy, unknown CKD aetiology, and CKD of miscellaneous other causes contributed the remaining cases . Among subjects with CKD, the leading cause of renal impairment was diabetic nephropathy  had lower GI diseases, 23.1% (n = 30) had upper GI conditions, 19.2% (n = 25) had genitourinary pathology, 17.7% (n = 23) had orthopedic conditions, 9.2% (n = 12) had gynecological indications, and 6.2% (n = 8) had other reasons for undergoing surgery.Among the 130 subjects with iron-deficiency anemia (IDA) requiring surgery, gastrointestinal (GI) indications were predominant. Specifically, the distribution was as follows: 24.6%  received 444 (60%) infusions whereas those with FID (ferritin > 100μg/L with Tsat < 20%) received 290 (40%) infusions. It is important to note that patients with ferritin levels exceeding 100μg/L together with Tsat levels above 20% were excluded from this specific analysis, as detailed in As shown in 2 were matched to 523 subjects with eGFR < 60 mL/min/1.73 m2. The groups were matched by age, gender, diabetes, baseline ferritin, baseline Hb, baseline Tsat, FID and time to repeat Hb. The PSM analysis was conducted in two phases . First, 2 compared to those with eGFR < 60 mL/min/1.73 m2 (12.1 g/L vs. 8.7 g/L). However, after PSM and adjustment for AID or FID, the difference in ∆Hb between the two groups was no longer apparent (12.4 g/L vs. 12.3 g/L). A similar result was observed when subjects with eGFR ≥ 60 mL/min (n = 127) were compared to those with eGFR < 30 mL/min (n = 362) . The result was no different in subjects with eGFR 30–59 mL/min (n = 156) vs. eGFR < 30 mL/min (n = 362) (∆Hb before PSM = 10.2 g/L vs. 7.9 g/L after PSM = 9.9 g/L vs. 10.0 g/L). Before PSM, the mean ∆Hb was significantly higher in those with eGFR ≥ 60 mL/min/1.73 mThe second PSM analysis was focused on evaluating the change in hemoglobin (∆Hb) between individuals with FID and those with AID. The analysis was conducted after ensuring that the two groups were closely matched in terms of age, gender, diabetes, baseline Hb and eGFR. n = 218) compared to subjects with FID (n = 465) (15.0 g/L vs. 6.8 g/L). This difference persisted after matching, which notably included matching for eGFR (14.6 g/L vs. 7.4 g/L). A similar pattern was noted with the CKD-aligned definition of FID (ferritin > 100 µg/L and Tsat < 20%) .PSM analyses were conducted with two different definitions of FID, the traditional definition and the CKD-related definition. With the traditional definition (Ferritin ≥ 30 µg/L and Tsat < 20%), the average rise in Hb before PSM was more than 8 g/L higher in those with AID , p = 0.021. Other predictors of poor response included diabetes, ∆Hbβ = −2.66 (−4.81–−0.51), p = 0.015; total iron infusion dose per kg in the 3rd tertile (>20 mg/kg) ∆Hbβ = −3.04 (−5.49–−0.59), p = 0.015; higher baseline Hb, ∆Hbβ = −3.22 (−3.94–−2.5), p < 0.001; higher baseline MCV, ∆Hbβ = −0.21 (−0.34–−0.08), p = 0.002; and the presence of FID ∆Hbβ = −7.61 (−9.94–−5.29), p < 0.001 (compared to AID). It is worth noting that FID had the greatest negative impact on response to iron infusion amongst all the predictors that were tested.Infusion-associated reactions occurred in 7 of the 834 infusion episodes (0.8%) . Of thesAlthough anaemia in CKD patients has been attributed to the effects of erythropoietin deficiency and uremia, both of which are dependent on the severity of CKD, the impact of FID alone on Hb response has not been studied. In this study, we used PSM analyses to isolate the effect of FID from that of kidney impairment on Hb response. First, we compared responses among patients with different CKD stages while adjusting for FID. Then we compared the responses between patients with FID vs. AID while adjusting for the degree of renal impairment. Furthermore, combining data from pre-operative and CKD cohorts allowed us to assess Hb responses across a wider range of patients representing all levels of kidney function, including patients without CKD.Our study revealed a mean ∆Hb of 8 g/L following a mean iron infusion dose of 18.5 mg/kg. This result was significantly higher than that reported by Sivakumar et al. (3.5–4.5 g/L)  but loweIn our study, subjects with normal or well-preserved eGFR (no CKD and CKD1–2), showed a better response than those with CKD3–5 (∆Hb = 14.0 g/L vs. 8.3 g/L), which was in keeping with the observations of the pre-surgical anaemia clinic team that stimulated the rationale for this study. However, this difference was no longer apparent after PSM corrected for the effect of FID. Crucially, this pattern held true across the various levels of CKD a–c. On tFID, for which a key component of the pathogenesis is due to hepcidin upregulation in chronic inflammatory states (including CKD), is a key factor reducing iron availability for erythropoiesis and inducing erythropoietin resistance . This isThe pre-operative intravenous iron used to treat anaemia before major abdominal surgery (PREVENTT) trial found that parenteral iron administered 10–42 days before elective major abdominal surgery was not superior to placebo in preventing death or reducing transfusions in anemic patients . HoweverRegarding the wider risk predictors of Hb response to parenteral iron, Black ethnicity, lower BMI, diabetes, total iron dose above 20 mg/kg, higher baseline MCV, and presence of FID were independently associated with poor response . It was interesting to observe that the dose response to iron infusion appeared to diminish at total doses above 20 mg/kg . The reaOur study highlighted the safety of modern parenteral iron preparations. As shown in recent studies, available preparations have been associated with a much lower risk of serious adverse events (SAE) compared to more historic IV iron preparations ,29. Our findings carry important implications for the management of iron deficient patients. First, patients with pre-operative anaemia and FID are less likely to respond adequately to parenteral iron. These patients should be investigated and treated for reversible causes of FID. Conversely, patients with AID can be anticipated to have a better ∆Hb after parenteral iron, irrespective of their kidney function. Therefore, it is key that the causes of anaemia and the nature of iron deficiency are determined. This should be incorporated into pre- and peri-operative pathways, allowing time for investigation, diagnosis, and treatment. When considering CKD patients, the degree of kidney impairment has less impact on response than the nature of iron deficiency. However, it should be remembered that, although parenteral iron may have a reduced effect on ∆Hb in patients with FID, its effect on other parameters such as cardiac function and exercise tolerance was not addressed in this study and will require further exploration with prospective studies. The strength of our study stems from the relatively large number of patients evaluated and the application of PSM to analyse the effect of FID and AID on ∆Hb independent of kidney function and vice-versa. Nevertheless, it is imperative to acknowledge certain limitations inherent to our study. First, the retrospective observational nature of the study inherently exposes the study to potential sampling bias. Although this was mitigated through the meticulous employment of PSM, residual bias cannot be entirely dismissed. Second, a significant limitation arises from the absence of data pertaining to intra-operative blood loss among pre-operative patients who went on to have surgery. This is noteworthy given its potential impact on the post-treatment rise in hemoglobin levels. Thirdly, there is a likelihood that several pre-operative patients with anaemia experienced the resolution of the underlying causes of their anaemia only after surgery; Consequently, a more robust hemoglobin response might have been tempered by ongoing blood loss prior to surgery. Fourth, the variable duration between iron infusion and subsequent hemoglobin reassessment among recipients introduces a potential source of bias. Nonetheless, it is imperative to underline that our analysis addresses this concern through both PSM and multivariate techniques. Further limitations encompass the utilization of the MDRD formula for estimating the glomerular filtration rate (eGFR), which might be less precise than the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula, particularly at well-preserved kidney function levels. Additionally, the absence of inflammatory markers such as C-reactive protein underscores the real-world nature of our study, which contrasts with prospective designs that could offer a more comprehensive parameter assessment.In conclusion, AID and FID are better predictors of Hb response to parenteral iron than kidney function, with the best responses seen in AID patients with lower ferritin and Hb. The presence of FID rather than the level of kidney function per se attenuates the response to parenteral iron. In this study, we found that the intravenous iron used, ferric derisomaltose, was safe and associated with minimal risk of serious adverse reactions, with adequate doses increasing the chance of optimal response.


Periodontal diseases is considered the most important global oral health burden according to the world health organization (WHO) . Accessed 21 Sep 2023). It is a common local inflammatory disease associated with hypertension, this study aims to explore the relationship between periodontitis and uncontrolled hypertension and whether inflammation indication such as white blood cell (WBC) count or neutrophil count is a mediator of this relationship.One thousand four hundred eighty-eight elders attending annual physical and oral examinations in Zhejiang province were included in this study. The staging of Periodontitis was classified as none, mild-moderate and severe. Participants are categorized into two groups based on blood pressure: hypertensive( positive high blood pressure( HBP) history or underwent HBP medication or blood pressure( BP) ≥ 140/90 mmHg) and uncontrolled hypertensive (systolic blood pressure( SBP) ≥ 140 mmHg or distolic blood pressure( DBP) ≥ 90 mmHg). Peripheral blood samples were collected, information on hypertension history and potential confounders  was collected in questionnaires. The correlation between periodontitis and hypertension was investigated using logistics regression analyses, mediation analysis was assessed for the effect of inflammation on hypertension.The study population includes 1,488 participants aged 55–90 years. Odds of uncontrolled hypertension increased significantly along with periodontitis in the regression models both in unadjusted model (odds ratio( OR): 1.407, 95% confidence intervals( CI): 1.037 ~ 1.910) and fully adjusted model . Mediation analysis confirmed that WBC and neutrophic count function as a full mediator of the association between periodontitis and uncontrolled hypertension either in the unadjusted or the adjusted model.In a study of urban elderly population in southeast China, periodontitis is found to be significantly associated with uncontrolled hypertension, such relation is mediated by WBC and neutrophil count. Periodontitis can increase the difficulty of controlling hypertension. Promotion of periodontal health strategies in the dental setting could help reduce the burden of hypertension and its complications. Periodontal disease is one of the most frequent diseases with a prevalence of 45–50% of the world population , almost Systemic arterial hypertension is the most prevalent chronic NCD in the world. Numerous epidemiological studies have demonstrated a strong association between hypertension and the development of various cardiovascular diseases, including coronary artery disease, heart failure, stroke, and peripheral vascular disease. The population attributable fraction of high blood pressure for cardiovascular disease mortality is 40.6%  –13. MorePrevious epidemiological studies and meta-analyses have reported the relation between oral health and cardiovascular diseases, suggesting periodontal disease is associated with hypertension –20. HoweWe used data on urban elderly population (aged from 55–90 years) from a routine physical examination from 6 community hospitals in Hangzhou, capital city of Zhejiang province which has a high economic level according to the national gross domestic product in mainland China. This study was conducted following the Declaration of Helsinki and approved by the Ethics Committee of Stomatology Hospital Affiliated to Zhejiang University School of Medicine .Exclusion criteria for study participants were as follows: (1) data for blood test or questionnaires were missing, (2) did not complete oral and periodontal examinations. (3) presence of systemic infections, (4) systemic antibiotic treatment in the past 3 months, (5) undergoing periodontal treatment in the past three months.Five thousand eight hundred nineteen participants were attending the routine physical examination in 2021, of which 4014 received oral examinations and blood pressure values were available for 3668 participants. After excluding those who did not perform oral and systemic examinations, 1488 participants remained.A post hoc power analysis was carried out using the G-POWER 3.1 programme at the end of the study. At an effect size of 0.02 and α of 0.05, a sample size of 1400 can achieve a power of 0.97.All the periodontal examinations were finished by well-trained and calibrated periodontists. Periodontal examinations were conducted on two-diagonal quadrants randomly, one in the maxilla and the other in the mandible, excluding third molars and implants. Measurements were taken at four sites per tooth , mesiobuccal (MB), mesiolingual (ML), and distolingual (DL)). Probing depth (PD) and clinical attachment loss (CAL) were assessed by a manual UNC-15 probe . Tooth loss was also recorded at the same time. Periodontitis status was classified into three categories, namely, severe periodontitis, mild-moderate periodontitis, and no periodontitis. Periodontitis classification was based on a modified half-reduced CDC/AAP definition  , 22. SevThe diagnosis of arterial hypertension was based on a medical history, with focus on antihypertensive drugs, a blood pressure measurement, and patients’ self-report. Blood pressure was measured on both arms each for 2 times after the initial rest of 5 min and a one-minute interval between each. Resting BP was recorded and calculated as the average of 4 readings. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure defined that the diagnosis of hypertension is made when the average of 2 or more diastolic BP measurements on at least 2 subsequent visits is ≥ 90 mm Hg or when the average of multiple systolic BP readings on 2 or more subsequent visits is consistently ≥ 140 mm Hg . HyperteQuestionnaires were distributed to all participants, including sex, age, height, weight, alcohol consumption, exercise frequency, and smoking habits. sex was categorized as female and male. Body mass index (BMI) was calculated from weight /height2 (kg/m2). Alcohol consumption was classified into 3 groups: (1) never, (2) often, and (3) daily. Exercise frequency was categorized into 3 groups: (1) never, (2) 1–3 times per week, (3) 4–7 times per week . SmokingData analysis was performed using IBM SPSS Statistics version 25.0 for Windows . Continuous variables were reported as means ± standard deviation (SD). Categorical variables were reported as number of cases (n) and percentage (%). Comparisons between different periodontal status were conducted using chi-squared test for categorical variables and ANOVA for continuous ones.We employed logistic regression models to evaluate the multivariable association between periodontal disease and hypertension. Independent variables were selected among clinical and demographic characteristics, age, sex, systolic blood pressure, diastolic blood pressure, fasting plasma glucose, cholesterol, triglycerides, high-density lipoprotein, white blood cells, neutrophil count, lymphocyte count, body mass index, smoking and alcohol consumption were included. Following the initial crude model , 4 extended models were generated with adjustment for age and sex (model 2), additional inclusion of BMI and waist circumference (model 3), an additional inclusion of inflammation indexes including white blood cell, neutrophil count, and lymphocyte count (model 4), lifestyle habits including smoking, exercising and alcohol consumption were added in model 5. Odds ratios and 95% CI were reported.Finally, we used 2 mediation models to identify and explain the pathways or processes underlying the relationship between periodontitis and uncontrolled hypertension, via the hypothetical mediator of inflammation factors.Baseline characteristics of the study are presented in Table p < 0.05. After adjusted for sex and age (model2), OR and 95% CI is 1.367(1.005 ~ 1.861), p < 0.05. Model3 introduced serum lipids indexes, OR and 95% CI is 1.405(1.024 ~ 1.928), p < 0.05. Model4 introduced inflammation indexes, OR and 95% CI is 1.421(1.034 ~ 1.953), p < 0.05. Model5 adjusted for lifestyle habits, OR and 95% CI gets to 1.950(1.127 ~ 3.373), p < 0.05. The result of the regression models confirmed that the parameter selection of the periodontitis models does not affect the result of the study that odds of uncontrolled hypertension increased significantly along with periodontitis in the regression models.Of the hypertensive participants (with both hypertension history and a tested high blood pressure), after adjusting for all potential confounders, we did not observe any association between periodontitis and hypertension. When we categorized our study population into periodontally healthy and periodontitis and restrict our analysis to UNCONTROLLED high blood pressure only, we found a significant effect of periodontitis on the odds of hypertension Table . In the Because both a (the regression coefficient of periodontitis on mediators) and b (the regression coefficient of mediators on uncontrolled hypertension) are significant, and c' (the regression coefficient of periodontitis on uncontrolled hypertension) is not significant, it is considered that WBC and neutrophil count function as a full mediator of the association between periodontitis and uncontrolled hypertension either in the unadjusted or the fully adjusted model. While lymphocyte count did not function as a mediator. Results of the mediation analysis are summarized in Table Currently, there is a lack of standardized diagnostic criteria for periodontitis in epidemiological surveys, making Full mouth periodontal examinations (FMPE) the “gold standard” for evaluating periodontal health. In our study, we implemented a protocol for partial mouth periodontal examinations (PMPE). Since PMPE protocols involve examining fewer probing sites compared to FMPE, applying a case definition designed for FMPE may result in underestimating the prevalence of the disease. Among various protocols for PMPE, such as Ramfjord teeth (RT) and community periodontal index (CPI), the two random diagonal quadrants protocol demonstrates the highest level of accuracy . For ourAccording to our study findings, the presence of periodontitis was associated with elevated blood pressure. However, there was no statistically significant difference between the severity of periodontitis and either SBP or DBP, nor with the prevalence of hypertension. Similar findings have been observed in other observational studies conducted among various populations, including Korean female adults , the PueThere are some limitations in the study. As our oral epldemiological study was carried out on a community level, the x-ray were not taken and radiographic bone loss could not be assesed. Secondly, the study categorized hypertensive patients into two groups: hypertension vs. uncontrolled hypertension. It could be more accurate if reclassified as controlled hypertension  vs. uncontrolled hypertension. However, due to medical history being based on self-reported questionnaires, its accuracy is insufficient. Also, lack of case–control studies is a limitation of cross-sectional research, and blood pressure outcomes following periodontal treatment were not provided. Further research is needed to enhance the evidence supporting this correlation and to elucidate the mechanisms through which periodontal pathogens or the subsequent inflammation contribute to elevated blood pressure.China has become an aging society due to improvement in living standards and the extension of life expectancy. Our study took place in Hangzhou, capital city of Zhejiang province. It’s holding the 19th Asian Games in Sep. 2023, which represents the economically developed regions of China, thus the data reflects a general trend for the impact periodontal status puts on general health. The National Healthcare Security Administration of China is reducing oral medical cost though centralized procurement, considering oral health is an important factor that affects the quality of life, policymakers need to address oral health needs and consider adding coverage for comprehensive oral health benefits.The study found the significant association between periodontitis and uncontrolled hypertension is mediated by WBC and neutrophil count. Periodontitis can increase the difficulty of controlling hypertension. Promotion of periodontal health strategies in the dental setting could help reduce the burden of hypertension and its complications.


Hypouricemia is defined as a level of serum uric acid below 2 mg/dl. Renal hypouricemia is related to genetic defects of the uric acid tubular transporters urate transporter 1 and glucose transporter 9. Patients with renal hypouricemia can be completely asymptomatic or can develop uric acid kidney stones or acute kidney injury, particularly after exercise. Renal hypouricemia is especially challenging to diagnose in patients with acute kidney injury, due to the nonspecific clinical, hematochemical and histological features. No common features are reported in the literature that could help clinicians identify renal hypouricemia-acute kidney injury. Currently available guidelines on diagnosis and management of renal hypouricemia provide limited support in defining clues for the differential diagnosis of renal hypouricemia, which is usually suspected when hypouricemia is found in asymptomatic patients. In this paper we report a case of renal hypouricemia-acute kidney injury developing after exercise. We carried out a review of the literature spanning from the first clinical description of renal hypouricemia in 1974 until 2022. We selected a series of clinical features suggesting a diagnosis of renal hypouricemia-acute kidney injury. This may help clinicians to suspect renal hypouricemia in patients with acute kidney injury and to avoid invasive, costly and inconclusive exams such as renal biopsy. Considering the excellent outcome of the patients reported in the literature, we suggest a “wait-and-see” approach with supportive therapy and confirmation of the disease via genetic testing.The online version contains supplementary material available at 10.1007/s40620-022-01494-8. SLC22A12, encoding for the apical urate transporter 1 , or SLC2A9, encoding the basolateral glucose transporter 9 . They are rare diseases with an autosomal recessive pattern of inheritance [Primary renal hypouricemia (RHUC) is caused by pathogenic variants in eritance . RHUC maeritance , 5.We report the case of a young man affected by RHUC who developed AKI as the first disease manifestation, and we provide a review of currently available literature looking for clinical features suggestive of this diagnosis in patients with AKI.SLC2A9 gene, thus confirming the clinical suspicion of RHUC. The patient was discharged without sequelae. In the following three years, kidney function remained normal and serum UA was persistently undetectable.A 17-year-old Asian male was admitted to the Emergency Department because of vomiting, fever and bilateral flank pain lasting four days after playing basketball. Familial and previous medical history was unremarkable. Blood pressure and vital parameters were normal. Laboratory tests showed severe kidney function impairment (serum creatinine 8.49 mg/dl), in the absence of acid–base and electrolyte imbalance, and normal UA levels (serum UA 4.6 mg/dl) Table . Of noteSCL22A12 or SCL2A9. Demographic, clinical and laboratory data did not differ between patients with clinical and genetic diagnosis, except for the evidence of disease relapses during follow-up , the clinical management of patients with RHUC-AKI could consist in a “wait-and-see” monitoring approach, supportive therapy and rapid detection of AKI complications. Follow-up data are reported in only 37.5% of patients, who relapsed in 40% of cases. Interestingly, all relapses occurred in patients with a genetically confirmed diagnosis, while the majority of patients who received a clinical diagnosis of RHUC did not have follow-up data, resulting in a lower number of disease relapses. These data could possibly be explained by the nephrologist’s awareness of the disease resulting from positive genetic testing and the consequent follow-up, rather than to a more aggressive phenotype. This observation suggests that genetic confirmation of RHUC can help to set up an appropriate long-term follow-up in these patients, preventing further relapses and avoiding additional kidney injury.Pathomechanisms responsible for AKI in RHUC are not fully elucidated. Intratubular precipitation of UA causing urate nephropathy was one of the first suggested hypotheses , 12. KidPrevious studies reported on a direct action of high intratubular uric acid concentrations on the activation of the toll-like receptor 4 (TLR4) pathway and the nucleotide binding oligomerization domain-like receptor family pyrin domain-containing 3 (NLRP3) inflammasome, leading to an increased release of interleukin-1β (IL-1β) . IL-1β cFinally, a recent paper suggested that RHUC-AKI is caused by an abnormal salvage pathway of purines during anaerobic exercise . RHUC-AKSLC2A9 or SLC22A12, while carriers were not identified. Isolated hypouricemia is also described in heterozygous patients [Interestingly, all patients with a clinical picture of RHUC-AKI who underwent genetic testing showed biallelic pathogenic variants in patients , albeit patients . These oLong-term data on kidney prognosis in patients with RHUC are lacking. As a matter of fact, RHUC-AKI can relapse and indeed, in our cohort, 60% of patients with available follow-up data showed at least one relapse. Interestingly, previous studies reported that hypouricemic patients have a ninefold higher rate of prior kidney disease  compared to those without hypouricemia . As wideIn conclusion, our study on RHUC-AKI suggests that: (1) Clinical  and laboratory findings  should lead us to suspect RHUC in patients with AKI; (2) Clinical evaluation is reliable in assessing the diagnosis of RHUC and can help avoid kidney biopsy in favor of genetic testing, which is pivotal for assessing genotype–phenotype correlations; (3) RHUC is a risk factor for AKI only in patents with biallelic genetic variants in disease-causing genes; (4) Hypouricemia is not a risk factor for kidney injury per se, and the combination of multiple pathomechanisms such as gender, genetic background and triggers are probably needed to determine AKI and CKD. Supplementary file1 (DOCX 20 KB)Below is the link to the electronic supplementary material.


Rheumatoid arthritis (RA) is characterised by increased rates of cardiovascular disease (CVD), which represents the leading cause of death. Patients with RA presents increased prevalence of hypertension, which substantially contributes to the increased CVD burden associated with the disease. A solid pathophysiological background supports the presence of microvascular dysfunction in RA even in the absence of established CVD, while macrovascular dysfunction in the form of large artery stiffening has been further described. Janus kinase (JAK) inhibitors constitute a novel class of disease-modifying anti-rheumatic drugs (DMARDs) for the management of rheumatoid arthritis (RA). However, the vascular effects of JAK inhibitors in RA patients remain largely understudied. More recent evidence suggests higher risk of major adverse cardiovascular events with JAK inhibition compared to treatment with a TNF inhibitor, and calls for more careful consideration of potential negative effects on the cardiovascular system. The present prospective observational cohort study aims to investigate the impact of JAK inhibitors on ambulatory blood pressure and haemodynamic profile, as well as markers of micro- and macrovasculopathy among patients with RA. A solid pathophysiological background supports the presence of vascular dysfunction in RA, which is detected even in the absence of established CVDs.5 Dysregulation of autoimmunity and cumulative inflammatory load in RA leads to overexpression of adhesion molecules, pro-thrombotic, and pro-inflammatory factors, which in turn increase vascular smooth muscle cell proliferation and tone and promote the development of atherosclerosis.6 Indeed, patients with RA show impaired vascular biomarkers such as flow-mediated dilation (FMD) of the brachial artery.7 Furthermore, elevated levels of circulating biomarkers of thromboinflammation and endothelial dysfunction in patients with autoimmune inflammatory diseases suggest that an ongoing vasculodestructive process is already underway despite the absence of clinical evidence of CVD.8Rheumatoid arthritis (RA) is the most prevalent autoimmune rheumatic disorder characterised by increased rates of cardiovascular complications, which represent the leading cause of death in these patients.9 Among these patients, hypertension represents the most prevalent CVD risk factor and significantly aggravates cardiovascular prognosis.10 Despite major implications in terms of CVD development and progression, hypertension remains largely underdiagnosed and undertreated in patients with RA.11 Furthermore, the impact of anti-rheumatic treatment is often neglected and needs to be further taken into consideration. Antirheumatic treatment modalities exert divergent effects on the vasculature, with positive, neutral, or even negative effects which further contribute to the CVD complications associated with RA. While these effects have been well-described or are being intensively investigated for cornerstone treatments such as corticosteroids or biologics, the vascular effects of novel antirheumatic treatments, such Janus kinase (JAK) inhibitors, remain in comparison understudied.13 Ultimately, chronic inflammation, traditional CVD risk factors and, to a different extent, specific antirheumatic treatment modalities act synergistically to form a prothrombotic microenvironment and trigger the degeneration and remodelling of the vascular architecture.While microvascular endothelial dysfunction is considered inherent to the disease, patients with RA present increased prevalence of traditional CVD risk factors.14 In the 2019 updated European League Against Rheumatism (EULAR) recommendations for the management of RA with synthetic and biological disease-modifying antirheumatic drugs (DMARDs), it is recommended to add any biological DMARD or JAK inhibitor on top of conventional synthetic DMARDs upon presence of poor prognostic factors . Potential safety concerns secondary to JAK inhibition include a higher risk of herpes zoster infections and venous thromboembolic events .15 With regard to the latter, the effects of JAK inhibitors on the cardiovascular system are being thoroughly investigated and have not yet been specified in detail. A systematic review and meta-analysis of randomised controlled trials indicated no significant change in cardiovascular risk for patients with RA treated with JAK inhibitors at least in a short-term perspective.16 Nevertheless, the recent ORAL Surveillance trial comparing the combined tofacitinib doses with a TNF inhibitor in a cardiovascular risk–enriched population with RA showed higher risks of major adverse cardiovascular events and cancer with the JAK inhibitor than with a TNF inhibitor.17 No apparent mechanism of action has been proposed or proven currently for this safety signal.18 Despite their efficacy in the suppression of RA-related inflammation, treatment with JAK inhibitors may negatively affect CVD risk factors, such as platelet count and lipidemic profile.19 By contrast, data remain scarce regarding the impact of JAK inhibitors on blood pressure, especially ambulatory blood pressure, haemodynamic profile, and markers of micro- and macrovasculopathy among patients with RA. Notably, both the macrovasculature and the microvascular network in RA can be easily assessed by use of non-invasive techniques that are being widely applied in the field of CVDs, such as assessment of arterial stiffness and nailfold videocapillaroscopy (NVC), respectively.JAK inhibitors are the newest drug class of disease-modifying medication that have been approved for the treatment of RA. Their mechanism of action is based on the modification of the signal transducer and activator of transcription (STAT) constituents in cytokine signalling, which is implicated in the pathogenesis of RA. As a targeted low molecular mass drug that can pass the lipid bilayer of the cellular membrane, they offer the first long-term oral biologic option in RA.20 Its predictive value in terms of cardiovascular health is superior to the conventional office blood pressure measurements, as stated in current hypertension guidelines.21 Patients with RA present increased prevalence of hypertension, which along with smoking confers the highest CVD risk of all traditional CVD risk factors in this specific group of patients.9 They additionally present disturbed abnormal blood pressure rhythm, with increased prevalence of nocturnal hypertension and disturbed nocturnal blood pressure drop (non-dipping).22 Remarkably, the newest devices for ambulatory blood pressure monitoring can simultaneously record haemodynamic parameters throughout the whole 24h period, including central (aortic) blood pressure, wave reflection, total vascular resistance, as well as markers of arterial stiffness such as augmentation index (AIx) and pulse wave velocity (PWV).24h ambulatory blood pressure is a powerful predictor of CVD morbidity and mortality in the general population and in high CVD risk populations.23 Other markers of arterial stiffness include the assessment of AIx from the analysis of the wave reflections, and pulse pressure calculated by subtracting diastolic blood pressure from systolic blood pressure.24 Data from tenths of thousands of individuals have established the prognostic value of arterial stiffness in terms of CVD risk prediction.25 Arterial stiffness is closely associated with traditional CVD risk factors, predominantly age and hypertension.24 Increased PWV is an independent predictor of CVD morbidity and mortality in the general population and high risk patients such as those with hypertension, type 2 diabetes mellitus, end-stage renal disease, and elderly individuals.26 Its predictive value not only remains significant even after adjustment for Framingham risk score,27 but also enhances the utility of current risk prediction models when added on top of classical CVD risk factors.28 Arterial stiffness in RA has been addressed in several studies, with the majority concluding that markers of arterial stiffness are increased in RA individuals. However, whether and to which extent increased arterial stiffness in RA reflects the increased prevalence of traditional CVD risk factors or the consequences of chronic inflammation remain under investigation.29 Furthermore, the impact of novel antirheumatic treatments including JAK inhibitors on arterial stiffness remains unclear.Arterial stiffness is defined as the loss of arterial elasticity and compliance subsequent to mechanical and structural changes of the vascular wall. The gold-standard marker of arterial stiffness is measurement of PWV, which corresponds to the rate at which pressure waves travel downstream through the arterial wall.30 and correlate with the presence of pulmonary arterial hypertension31 and as markers of CVD risk, such as arterial stiffness33 and increased levels of uric acid.34 Capillaroscopic microvascular abnormalities are also common in patients with CVDs. Evaluation of NVC in autoimmune rheumatic diseases has been proposed as a potential tool for the prediction of microvascular heart involvement,35 while preliminary data have shown that capillary abnormalities correlate with CVD risk, either as an individual marker in high-risk patients36 or in combination with other microvascular indices in low-to-moderate risk hypertensive patients.37 Several patterns of capillaroscopic abnormalities have been previously described with NVC in patients with diabetes mellitus including capillary dilatation, avascular zones and tortuous capillaries,38 while presence of diabetes mellitus further aggravates structural and functional capillary density in patients with chronic kidney disease.39 Capillary rarefaction is particularly common in patients with hypertension, both as a cause and consequence of high blood pressure.40 Last but not least altered capillaroscopic parameters indicative of peripheral microangiopathy have been described in patients with pulmonary arterial hypertension associated with various autoimmune diseases41 or due to congenital heart disease,42 and chronic thromboembolic pulmonary hypertension.43 Dermal capillary alterations detected with NVC and their clinical significance are being thoroughly investigated in patients with RA and have been summarized in detail elsewhere.44The dermal capillary network represents an “open window” for the study of the microcirculation. NVC has been widely applied as a bedside aid in rheumatology, especially in the diagnosis and follow-up of patients with systemic sclerosis. In these patients, peripheral microvascular abnormalities detected with NVC reflect the severity of visceral organ involvement24h BP and its circadian rhythmArterial stiffness, specifically AIx and PWV which represent the most widely used markers of large artery stiffening.Microangiopathy of the nailfold capillaries.Patients’ haemodynamic profile throughout a whole 24h period Prothrombotic markersEstimated cardiovascular riskThe present study aims to provide further insight on the effects of treatment with JAK inhibitors on blood pressure and haemodynamic parameters, microvascular function, and subclinical macrovascular injury among patients with RA. More specifically, we aim to investigate whether treatment with JAK inhibitors in patients with RA induces alterations in:This is a prospective, observational cohort study, that will be conducted by the Fourth Internal Medicine Department at Hippokrateion General Hospital of Thessaloniki in collaboration with the Second Medical Department of the same hospital.45 who are eligible for treatment with JAK inhibitors  for first time, irrespective of previous administration of conventional or biologic DMARDs based on international recommendations (EULAR 2020).15This study enrols adult patients with an established diagnosis of RA according to the American Rheumatism Association 1987 Revised Criteria,46Exclusion criteria include: age <18 years, inability to comprehend and sign the informed consent, previous exposure to JAK inhibitors, concomitant active malignancy or other disease with poor prognosis, recent major adverse cardiovascular event  within the past 6 months, and stage III–IV heart failure according to the New York Heart Association (NYHA) criteria.Recording of medical history and current medical treatmentAnthropometric measurements, clinical examination and assessment of disease severity with calculation of DAS28 (Disease Activity Score in 28 joints)Evaluation of functional ability and quality of life through specifically designed questionnairesOffice blood pressure recordingEstimation of 10-year cardiovascular riskVideocapillaroscopy of the nailfold capillary networkAssessment of 24h blood pressure, its day- to night-time variation and haemodynamic parameters with the Mobil-O-Graph deviceBlood sampling, centrifugation and thawing of the supernatantRA patients eligible for treatment with JAK inhibitors who will be selected on the basis of inclusion and exclusion criteria to participate in the research protocol will undergo the following procedures, before the initiation of JAK inhibitors:All patients will be re-evaluated and the above procedures will be repeated at 3 and 6 months following the baseline visit, whilst the patients are under treatment with JAK inhibitors.21 The Mobil-O-Graph  device will be applied to all participants, which has been approved by Food and Drug Administration (FDA) and the European Union and has been validated according to the protocols of the European and the British Society of Hypertension48. Automatic BP readings will be performed at 20-min intervals during the day and at 30-min intervals during the night. Only ABPM reports with a minimum of 70% successful readings will be regarded as technically sufficient. Mean 24h, day- and night-time BP will be obtained, as well as the nocturnal fall in BP (%), also defined as “% dipping”. According to the dipping values, individuals will be classified as “dippers” (≥10%) and “non-dippers” (<10%).24h blood pressure recording is recommended as the ideal method of BP monitoring according to current hypertension guidelines.Moreover, arterial stiffness indices  and haemodynamic parameters  are simultaneously obtained at each blood pressure measurement. The mean values of the above markers will be included in the analysis.NVC is an established non-invasive method to assess the capillary vasculature of the digital arteries, which provides information on the structural and functional abnormalities of the capillaries. It is performed at room temperature (22 °C–23 °C) with the patient seated and resting for 15 minutes. NVC will be performed at the Fourth Internal Medicine Department at Hippokrateion Hospital using an Optilia Digital Capillaroscope. Pictures and videos of 15 seconds duration will be captured using the 200x magnification video camera from the 2nd to the 5th finger of each hand. The images will be analysed with Optipix capillaroscopy software 1.7.x on a computer. The NVC parameters to be measured are: capillary density, defined as the number of capillaries in the first row in 1mm (capillaries / mm), capillary width and length (μm), the presence of micro-bleeding, oedema, thrombi, and the presence of any abnormalities in the morphology or disorder of capillary architecture. These parameters will be determined on each nail and the average of all measurements for each patient will be calculated at the end. In addition to quantitative and qualitative parameters, a semi-quantitative score will be established to assess the severity of peripheral microangiopathy.Routine blood tests will be performed for the evaluation of haematological and biochemical parameters , erythrocyte sedimentation rate, and C-reactive protein.In addition, blood samples will be collected, centrifuged and frozen at −80°C. Levels of the following prothrombotic markers will be simultaneously measured with ELISA (enzyme-linked immunosorbent assay) using commercially available kits: von Willebrand Factor antigen (vWF:Ag) and activity (vWF:RCo), thrombomodulin and ADAMTS13 activity.49. In our study, the relevant algorithm from the Framingham Heart Study will be used to calculate 10-year risk of general cardiovascular disease.50Cardiovascular risk calculators specifically developed for RA patients have not been proved to be superior to the general population cardiovascular risk calculators, including Framingham Risk ScoreTo determine potential differences at 3 and 6 months following treatment with JAK inhibitors compared to baseline, in the following parameters: a) 24h BP, b) arterial stiffness, c) microangiopathy of dermal capillary network, d) prothrombotic markers.- To determine potential differences in the haemodynamic profile and the estimated 10-year cardiovascular risk of patients with RA at 3 and 6 months post-treatment with JAK inhibitors, compared to the baseline visit.- To detect potential associations of prothrombotic markers with 24h BP, arterial stiffness and microangiopathy of the dermal capillary network.A total of 30–50 patients will be studied.Data analysis will be performed using SPSS  software, version 22. Results will be expressed as frequencies for qualitative variables, and as mean±standard deviation (m±SD) or median (interquartile range) for continuous variables. Comparisons of variables will be performed between the baseline and the follow-up visits. Comparison of frequencies will be performed by Pearson chi-square test. Comparison of differences between mean values will be performed with Student’s t-test or Mann–Whitney test. Correlations between the main continuous variables will be assessed using the parametric Pearson or the nonparametric Spearman’s Rho correlation coefficient. Linear regression and logistic regression analysis will be performed to investigate whether treatment with JAK inhibitors is associated with NVC parameters and parameters obtained from 24h ambulatory blood pressure recording after adjustment for other variables. A probability value of p≤0.05 will be considered statistically significant.19 More recent evidence shows an increased risk of major adverse cardiovascular events associated with JAK inhibitors in RA, although the underlying mechanisms remain unclear.17 It has been argued that the patients’ aggravated cardiovascular profile with presence of multiple CVD risk factors may account, at least partially, for this observation.18 Hypertension is highly prevalent in RA and contributes substantially to the increased CVD burden associated with the disease,11 while ambulatory blood pressure monitoring is superior to conventional blood pressure measurements in terms of CVD risk prediction.21 Furthermore, subclinical microvascular injury is present in patients of RA before the establishment of overt CVD51 and is considered as an intermediate pathophysiological process towards the development of cardiovascular complications.6 At the same time, large artery stiffening represents a surrogate marker of CVD with incremental predictive value beyond traditional cardiovascular risk factors.28 However, the impact of JAK inhibition on blood pressure including its 24h variation, and markers of micro- and macrovascular injury has not been investigated so far in patients with RA.Despite their clinical efficacy in alleviating symptoms and progression of RA, cardiometabolic effects of JAK inhibitors in patients with RA remain in comparison underinvestigated, especially in the long-term. JAK inhibitors may confer increased risk for circulatory disorders, specifically thromboembolic events, and adversely affect lipids and platelet count.Therefore, shedding light on the impact of JAK inhibitors on the above critical parameters  and the prothrombotic markers that will be assessed, will add substantial information to the available literature regarding cardiovascular aspects of JAK inhibitors in RA. It is anticipated that our findings will have direct clinical implications. They will either highlight potential pleiotropic beneficial effects of JAK inhibitors on the cardiovascular system, or by contrast detect and highlight potential negative aspects which should be taken into consideration by treating physicians, in order to take actions targeting at their proper monitoring and management.Besides, evaluation of changes in patients’ haemodynamic profile and circulating biomarkers of thrombotic predisposition will point towards underlying pathophysiological mechanisms mediating cardiovascular effects of JAK inhibitors in RA. Considering the innovative study design, our results will most probably have an international impact following their dissemination in conferences and the press and their publication in peer-reviewed journals.


The prevalence of cerebral small vessel disease (CSVD) is increasing due to the accelerating global aging process, resulting in a substantial burden on all countries, as cognitive dysfunction associated with CSVD is also on the rise. Clock genes have a significant impact on cognitive decline and dementia. Furthermore, the pattern of DNA methylation in clock genes is strongly associated with cognitive impairment. Thus, the aim of this study was to explore the connection between DNA promoter methylation of PER1 and CRY1 and cognitive dysfunction in patients with CSVD.We recruited patients with CSVD admitted to the Geriatrics Department of the Lianyungang Second People’s Hospital between March 2021 and June 2022. Based on their Mini-Mental State Examination score, patients were categorized into two groups: 65 cases with cognitive dysfunction and 36 cases with normal cognitive function. Clinical data, 24-h ambulatory blood pressure monitoring parameters, and CSVD total load scores were collected. Moreover, we employed methylation-specific PCR to analyze the peripheral blood promoter methylation levels of clock genes PER1 and CRY1 in all CSVD patients who were enrolled. Finally, we used binary logistic regression models to assess the association between the promoter methylation of clock genes (PER1 and CRY1) and cognitive dysfunction in patients with CSVD.p < 0.001). (3) There was no significant correlation between the promoter methylation rates of PER1 and CRY1 in peripheral blood and circadian rhythm of blood pressure (p > 0.05). (4) Binary logistic regression models showed that the influence of promoter methylation of PER1 and CRY1 on cognitive dysfunction were statistically significant in Model 1 , and it still existed after adjusting for confounding factors in Model 2. Patients with the promoter methylation of PER1 gene  and the promoter methylation of CRY1 gene  were at greater risk of cognitive dysfunction compared with those with unmethylated promoters of corresponding genes in Model 2.(1) A total of 101 individuals with CSVD were included in this study. There were no statistical differences between the two groups in baseline clinical data except MMSE and AD8 scores. (2) After B/H correction, the promoter methylation rate of PER1 was higher in the cognitive dysfunction group than that in the normal group, and the difference was statistically significant (adjusted The promoter methylation rate of PER1 gene was higher in the cognitive dysfunction group among CSVD patients. And the hypermethylation of the promoters of clock genes PER1 and CRY1 may be involved in affecting cognitive dysfunction in patients with CSVD. Cerebral small vessel disease (CSVD) is a heterogeneous disease caused by both genetic and vascular risk factors. It involves structural and functional abnormalities in small cerebral vessels and can cause variety of neuroimaging changes and neurological symptoms, including cognitive decline . Despite24-h ambulatory blood pressure monitoring (ABPM) has been widely used in clinical practice and scientific research due to its ability to reflect blood pressure variation and circadian rhythm. As this application deepens, the relationship between blood pressure and cognitive function has gradually become a hot spot in the current research field. By monitoring ABPM in CSVD patients, Circadian rhythm of blood pressure, an essential aspect of circadian rhythms, is likewise regulated by the circadian clock. On a molecular level, this clock involves a complex set of autoregulatory transcription-translation feedback loops. And circadian rhythm mainly relies on the expression and function of clock genes and their encoded proteins involved in the feedback loops . The priResearchers in the biomedical field have found that genetic analysis can help clarify the relationship between epigenetics, the circadian clock, and cognition. Methylation of the CpG island region of DNA promoter is one of the major regulatory mechanisms of gene transcription. Several studies have found that DNA methylation of clock genes is closely associated with cognitive impairment . But untFrom March 2021 to June 2022, there were 217 individuals admitted to the Geriatrics Department of the Lianyungang Second People’s Hospital. Patients over 18 years old diagnosed with CSVD according to the Chinese consensus on diagnosis and therapy of cerebral small vessel disease 2021  were incMini-Mental State Examination was used to evaluate the cognitive function of enrolled patients, including five main components: orientation (0–10 points), memory (0–3 points), attention and numeracy (0–5 points), recall ability (0–3 points), and language ability (0–9 points). The total score was 30 points. The higher the score was, the better the cognitive function was. The normal threshold of MMSE score was defined as : illiterA volume of 5 mL venous blood was collected from subjects at about 9 am after fasting for 12 h and placed into EDTA anticoagulation tubes, and then being mixed for 10–20 min and stored at −80°C. The Genomic DNA was extracted in strict accordance with the instructions of TIANamp Genomic DNA Kit . Then, about 1 μg of each genomic DNA sample was removed and modified according to the requirements of the modification kit Zymo DNA Methylation Kit .Next, we analyzed the promoter sequences of clock genes PER1 and CRY1 at Methprimer onlineIn the 50 μL MSP reaction system, the disulfite modified genomic DNA template was 1.5 μL, the 2 × Taq PCR Master Mix was 25 μL, the upstream primer was 0.8 μL, the downstream primer was 0.8 μL, and ultra-pure water was added to make up the remaining volume. The mixture was then placed on a PCR instrument  for amplification. The specific reaction conditions were as follows: pre-denaturation at 95°C for 5 min, denaturation at 95°C for 30 s, annealing at 55°C for 30 s, extension at 72°C for 30 s, amplification for 40 cycles, and then extension at 72°C for 5 min, and finally cooling at 16°C for 2 min.Upon completion of the PCR amplification, the amplified products were subjected to 2.0% agarose gel electrophoresis, and the images were recorded by the gel image analysis system. The presence of partial methylation in the DNA promoter region was represented by “M’’ and the absence of methylation was represented by “U’’, as shown in All patients were required to have a successful 24-h ABPM  within 48 h after diagnosed with CSVD, measured by a trained nurse. In the equipment used, blood pressure was measured every 30 min during the day (7:00–21:00) and every 60 min during the night (21:00–7:00). Each monitoring lasted for more than 25 h to ensure complete recording for 24 h, and eligibility was defined as valid data >80% for 24 h. Patients were asked to get enough rest or sleep at night and maintain normal activities during the day. Daily activities, sleep and wake times needed to be recorded in a diary. After wearing the device for at least 24 h, the device was removed and its data downloaded for analysis. Then relevant blood pressure parameters were collected, such as 24-h mean systolic blood pressure, 24-h mean diastolic blood pressure, 24-h mean standard deviation of systolic blood pressure, 24-h mean standard deviation of diastolic blood pressure, daytime mean systolic blood pressure (dmSBP), daytime mean diastolic blood pressure (dmDBP), nighttime mean systolic blood pressure (nmSBP), and nighttime mean diastolic blood pressure (nmDBP). And then we calculated the ratios of night systolic and diastolic blood pressure reduction separately: the ratio of night systolic blood pressure reduction = (dmSBP-nmSBP)÷dmSBP × 100%, the ratio of night diastolic blood pressure reduction = (dmDBP-nmDBP) ÷ dmDBP × 100%. We defined the ratio of night systolic blood pressure reduction as the ratio of night blood pressure reduction (ΔMBP) when the circadian rhythms of blood pressure shown by the ratio of night systolic and diastolic blood pressure reduction were inconsistent. Next, the circadian rhythms of blood pressure were classified according to ΔMBP: extreme-dippers (≥ 20%); dippers (10–20%); non-dippers (0–10%); and risers < 0%; . The claThe head MRI data of all subjects were acquired using a MAGNETOM Spectra 3.0 T magnetic resonance scanner with 16-channel coils. The sequences included: T1-weighted sequences (T1WI): TR 1,750 ms, TE 21.8 ms; T2-weighted image (T2WI): TR 3,598 ms, TE 107.3 ms; fluid-attenuated inversion recovery (FLAIR): TR 8,400 ms, TE 87 ms; diffusion weighted imaging (DWI): TR 6,000 ms, TE 73.5 ms; and susceptibility-weighted imaging (SWI): TR 37.5 ms, TE 22.9 ms, FOV 240 mm × 240 mm, and matrix 416 × 320. The CSVD total load score in this study included the four most classic imaging manifestations of WMH, LI, CMB, and PVS, with a total score of 0–4. It could reflect the severity of CSVD and was used as an ordered categorical variable in this study. A score of 0–1 was defined as mild, 2 as moderate, and 3–4 as severe . The evap values were adjusted according to the method of Benjamini-Hochberg (B/H) to control the false discovery rate (FDR). If the corresponding B/H-adjusted p value was lower than 0.05, the difference was considered to be statistically significant.Statistical analyzes were performed using the SPSS software  and graphics were drawn by GraphPad Software . Kolmogorov–Smirnov test was used to evaluate the normality of numerical variables. Continuous variables of normal distribution were analyzed by independent sample T-test and expressed as mean ± SD. Continuous variables of skewed distribution were analyzed by Mann–Whitney U test and described by median and quartile range (IQR). And categorical variables were compared using the Chi-square test or Fisher’s exact test. We also used binary logistic regression models to assess the association between the promoter methylation of clock genes (PER1 and CRY1) and cognitive dysfunction in patients with CSVD. Due to the number of statistical analyzes we did, bilateral From May 2021 to June 2022, a total of 101 patients  were included in the study. The clinical parameters of the subjects were shown in p < 0.001). However, there was no difference in the promoter methylation rate of the CRY1 gene between the two groups (adjusted p = 0.243), as shown in After B/H correction, the promoter methylation rate of the PER1 gene was higher in the cognitive dysfunction group than that in the normal group, and the difference was statistically significant (adjusted p > 0.05), as shown in There were no statistically significant differences in ABPM parameters such as 24-h mean systolic blood pressure, 24-h mean diastolic blood pressure, 24-h mean standard deviation of systolic blood pressure, 24-h mean standard deviation of diastolic blood pressure, dmSBP, dmDBP, nmSBP, and nmDBP, and the classification of circadian rhythms of blood pressure between the two groups (p = 0.046). Unfortunately, after B/H correction, there was no statistically significant difference between the two groups (adjusted p = 0.203).On the basis of the MRI data, we observed 40.6% cases with moderate–severe WMHs, 12.9% with enlarged perivascular spaces 2–4 Level, 13.9% with CMB, and 96.0% with LI. In these four separate imaging findings, there was no statistically significant difference between the two groups. Although it could be seen from p < 0.001; p = 0.025), which still existed after we adjusted for confounding factors in Model 2. It was observed from Model 2 that patients with the promoter methylation of PER1 gene  and the promoter methylation of CRY1 gene  were at greater risk of cognitive dysfunction compared with those with unmethylated promoters of corresponding genes, as shown in We then used binary logistic regression models to investigate the relationship between the promoter methylation rates of clock genes and cognitive dysfunction in CSVD patients. The univariate analysis showed that the influence of promoter methylation of PER1 and CRY1 on cognitive dysfunction were all statistically significant in Model 1 (p < 0.001). To the best of our knowledge, this is the first study to investigate the relationship between the promoter methylation of peripheral blood clock genes PER1 and CRY1 and cognitive dysfunction in patients with CSVD patients.In the present study, we demonstrated that, in patients with CSVD, the methylation level in the promoter regions of the PER1 gene was higher than that in the normal group  were not administered to assess patients’ sleep quality and duration of the night in detail, which may affect DNA methylation. Second, we only measured the methylation level of clock genes at one point in time. Third, as a single-center study with a small sample size, there was a certain selection bias. In addition, as it was a cross-sectional study, we could not explain the causal relationship and specific mechanism between the promoter methylation of PER1, CRY1 and cognitive impairment in CSVD patients.The promoter methylation rate of PER1 gene was higher in the cognitive dysfunction group among CSVD patients. And the hypermethylation of the promoters of clock genes PER1 and CRY1 may be involved in affecting cognitive dysfunction in patients with CSVD.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 the Ethics Committee of Lianyungang Second People’s Hospital. The patients/participants provided their written informed consent to participate in this study.YX and XS conceived and designed the research. YX and YW analyzed the data and drafted the manuscript. YX, YJ, ML, WZ, ZG, and ZS collected the data and performed the research. ZS and XS reviewed and edited the manuscript. All authors contributed to the article and approved the submitted version.This study was supported by Open-end Funds of Jiangsu Key Laboratory of Marine Pharmaceutical Compound Screening (HY202203), Science and Technology Project of Lianyungang Health Commission (202024), Scientific Research Project of Bengbu Medical College (2020byzd341), Jiangsu Provincial Geriatric Health Research Grant Project (LD2021034 and LR2021049), Jiangsu Province Postgraduate Practice Innovation Program (SJCX21_1726), and Jiangsu Province “Six One Project” Top Talent to be funded project (LGY2019062).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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