The aim of this study was to estimate the prevalence of concurrent diagnoses of asthma/COPD and examine its full spectrum of comorbid disorders in Germany. We used nationwide outpatient claims data comprising diagnoses of all statutory health insurees (40+ years) in 2017 . The ICD-10 codes J44 (COPD) and J45 (asthma) were used to identify patients. The odds of 1,060 comorbid disorders were examined in a case–control study design. Of all insurees, 4,632,295 (11%) were diagnosed with either asthma or COPD. Of them, 43% had asthma only, 44% COPD only and 13% both diseases. The prevalence of concurrent asthma/COPD was 1.5% with a slightly higher estimate among females than males (1.6% vs. 1.4%) and constant increase by age in both sexes. Comorbid disorders were very common among these patients. 31 disorders were associated with a strong effect size (odds ratio > 10), including other respiratory diseases, but also bacterial  and fungal infections . Patients with concurrent asthma/COPD suffer from comorbid disorders involving various body systems, which points to the need of a multidisciplinary care approach. Regular screening for common comorbid disorders may result in better clinical course and prognosis as well as improvement of patients’ quality of life. However, the term ‘ACOS’ is no longer advised as it contains various clinical phenotypes with possibly different underlying pathophysiological mechanisms. Recently, the Global Initiative for Asthma (GINA) and the Global Initiative for Chronic Obstructive Lung Disease (GOLD) provided a stepwise approach to diagnose the asthma-COPD overlap (further referred to as ACO) and initial treatment strategy3. Many questions regarding etiology and underlying mechanisms remain still unanswered. In particular, there is no well-accepted definition of ACO; diagnostic criteria have not yet been developed either. It is still unknown whether ACO represents a distinct phenotypic condition or is just a disease that features clinical characteristics of both diseases. As a consequence, there is uncertainty regarding the actual disease occurrence. Previous studies reported prevalence estimates for ACO among patients with asthma or COPD varying widely from study to study from 15 to 55%4. The prevalence variations resulted mainly from different case definitions, but also from other methodological differences across studies. In contrast, there is agreement that patients with ACO exhibit higher morbidity and mortality compared to patients with asthma or COPD only1. Patients with ACO have more rapid and severe disease progression including more frequent exacerbations and a higher risk of some comorbid diseases6. In particular, cardiovascular diseases are more common among ACO patients as compared to individuals without ACO7 or patients with asthma or COPD alone10. This results in greater healthcare utilization and poorer quality of life8.Asthma and chronic obstructive pulmonary disease (COPD) are common chronic diseases characterized by airflow obstruction. Some patients may display clinical features of both diseases, the condition called initially the asthma-COPD overlap syndrome (ACOS)11. No single study was found in Germany11. The aims of this study were thus to estimate the prevalence of concurrent diagnoses of asthma and COPD in the general German population for the first time and examine the full spectrum of comorbid disorders coexistent in these patients using nationwide ambulatory claims data comprising information on all statutory health insured (SHI) adults in Germany. Using a case–control study design we compared the odds of 1060 comorbid disorders in these patients and controls matched by sex, age and region of residence.In Germany, research on the epidemiology of ACO is lacking. A recently published systematic review of the global prevalence of ACO reported a pooled estimate of 2.0% based on 27 population-based studies mostly from industrialized countries such as Canada, USA and several European countriesOf the 40,477,745 SHI-individuals, 4,632,295 11%) were diagnosed with either asthma or COPD. Of them, 43% had asthma only and 44% COPD only , followed by metabolic and musculoskeletal diseases  among patients with asthma/COPD are presented in Table –5). Figure Out of the total 1079 three-character ICD-10 codes from 14 chapters, we identified 1064 codes among patients with asthma/COPD diagnoses and 1069 codes in the control population, with an overlap of 1060 codes found in both groups. Of the 1060 comorbid disorders examined, 987 (93%) disorders were significantly different among patients with asthma/COPD as compared to controls at the significance level of 5%. After Bonferroni correction, 879 (83%) remained significant . Thus, our weighted estimate of 1.39% is slightly lower than the pooled estimate reported by Hosseini et al., but lies within the 95% confidence interval. It is also in a good agreement with large-scale studies from Canada 13, Denmark 14, South Korea 15 and the Netherlands 16. In addition, it should be noticed that our estimate was based on a nationwide population-based sample and can thus be considered highly representative.We observed that 1.50% of the general population was affected by concurrent diseases, corresponding to the absolute number of approximately 608,000 SHI-patients in Germany. The post-stratification weighting—which aims to adjust for possible demographic differences between the study and the source population and thus to provide a nationally representative estimate—resulted in a slightly lower prevalence of 1.39%. Recently, Hosseini et al. reported a global pooled prevalence of ACO in the general population of 2.0% (95% CI: 1.4–2.6%) with the lowest and highest estimates of 0.3% (the UK) and 5.0% , respectively6. However, the prevalence estimates from international studies vary as well. In the above mentioned systematic review Hosseini et al. reported ACO estimates in asthma and COPD adult patients ranging between 11 and 51% and between 13 and 55%, respectively11. We observed comparable estimates of concurrent asthma/COPD in asthma and COPD patients (about 23%). In other words, every forth patient with asthma and COPD displayed concurrent diagnoses. The large variations in prevalence estimates across studies may be explained by varying case definitions but also by other methodological differences 16. A uniform, broadly accepted definition of ACO does not yet exist. A joined endeavor of GINA and GOLD resulted in a clinical description of ACO which involves “persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD”2. A few research groups published case definitions and diagnostic criteria based upon expert consensus which are restricted to certain countries18. Previous studies used various definitions based on laboratory findings, symptoms or diagnoses19. In the current analysis we used nationwide outpatient claims data which contain diagnoses of asthma and COPD coded according to the ICD-10-GM classification20. There is no specific ICD-10 code for ACO, and we used a combination of asthma and COPD diagnoses to define an overlap. We applied a very conservative case definition (diagnoses in at least two quarters) to largely exclude false positive cases. This approach is widely accepted in analysis of routine-based claims data and has already been used in studies on asthma and COPD22 and rather under- than overestimates morbidity. Our approach of defining the overlap is rather indirect and should be considered as approximation to an epidemiological prevalence assessed in a study design with objectively measured parameters. Nevertheless, our prevalence is similar to estimates from other studies which applied case definitions based on objectively measured parameters.According to previous studies, ACO affects on average every third asthma patient and every fourth COPD patient23. In addition, asthmatics have higher risk of further respiratory, but also cardiovascular and metabolic diseases23. Due to the common risk factors (in particular smoking), COPD is associated with bronchial carcinoma and coronary heart disease24. Not surprisingly, mental disorders such as depression and anxiety are very common among both, asthma and COPD patients26. Research on comorbid disorders in patients with ACO is lacking. Existing evidence shows that patients with ACO have a more rapid disease progression than patients with asthma or COPD alone1. As a consequence, they have worse quality of life and higher rates of health care utilization. We found a few studies that focused only on specific comorbid disorders. For example, van Boven et al. examined the prevalence for 16 comorbid disorders in a sample of ACO patients treated in primary care in Spain (n = 5093)27. The most prevalent comorbid disorders in this study were hypertension (49%), anxiety (38%), diabetes (22%), osteoporosis (19%) and allergic rhinitis (16%). Ding et al. compared selected comorbid disorders in three patient groups  and observed that patients with ACO (n = 523) had higher prevalence of hypertension (56%), elevated cholesterol/hyperlipidemia (29%), arthritis (17%), depression (21%), obesity (13%) and gastroesophageal reflux disease (19%) (compared to asthma patients)10. In addition, ACO patients had higher estimates of diabetes (22%) and osteoporosis (11%) as compared to COPD-only patients10. In contrast to the above mentioned studies that focused on selected comorbid disorders, we applied a comprehensive exploratory approach by examining a wide spectrum of comorbid disorders (1060 disorders from 14 disease groups). Comorbid disorders were examined at the level of the first three characters of the ICD-10 code, which represent the main disease category. Overall, comorbid disorders were very common in patients with concurrent asthma/COPD as compared to the control group. Notably, 83% of the examined comorbid disorders were still significantly higher in patients with concurrent asthma/COPD after Bonferroni correction. We found disorders involving all body systems, including mental diseases. The most prevalent were disorders of the circulatory system as well as metabolic and musculoskeletal disorders. In addition, every second patient with asthma/COPD suffered from mental, gastrointestinal and other pulmonary diseases.Comorbid disorders in patients with asthma or COPD have been extensively examined. Asthma is associated with allergic diseases such as allergic rhinitis, allergic conjunctivitis and atopic dermatitis28. Therapy with inhaled corticosteroid may explain the higher risk of osteoporosis as observed in COPD patients29, although the evidence is controversial30.The large nationwide sample allowed us to identify comorbid disorders with a small size effect , but still significant after correction for multiple testing, which could not be observed in other studies with smaller sample sizes. Common risk factors may explain the coexistence of some diseases . Persistent systemic inflammation in ACO patients may contribute to the development of cardiovascular diseasesWe made use of nationwide claims data comprising information of about 86% of the total German population. Thus, prevalence estimates can be considered highly representative. In addition, data contain all diagnoses made in an outpatient setting which allows to obtain a nearly complete picture of the comorbidity profile of patients with concurrent asthma/COPD. We applied a hypothesis-free approach to examine the full spectrum of comorbid disorders in these patients. These are unique strengths of the study; to the best of our knowledge, such approach has never been done before.., at least two diagnoses of each, asthma and COPD, in different quarters of the year) might further contribute to misclassification and result in prevalence underestimation. Thus, some patients, e.g. with well-controlled asthma might not be diagnosed in 2017 even if they visited a physician in that year. On the other hand, claims data are primarily collected for reimbursement purposes and not for morbidity estimation and are known to overestimate the true epidemiological prevalence, in particular, if a case definition is only based on a single diagnosis. Previous research on asthma and COPD based on routine data thus applies a more conservative case definition33. Furthermore, per case definition , patients with concurrent asthma/COPD diagnoses have higher rates of health care contacts, in particular, if patients visit different physicians as compared to controls. Thus, the chance of getting other (comorbid) diagnoses may be higher in these patients. In addition, we were restricted to the variables available in our dataset . Other potentially confounding variables such as socio-economic status were not available in the data. Finally, it has to be mentioned that some of the associations might still be false positive even after the correction for multiple testing. On the contrary, some real associations may have been overlooked due to the very strict p value.Our study has potential limitations. Our analysis was based on outpatient claims data containing diagnoses coded according to the ICD-10-GM classification. There is no specific code for ACO, instead, we used the codes for asthma (J45) and COPD (J44) to indirectly define an overlap. Objectively measured, clinical and laboratory  data were not available to validate the diagnosis. In addition, a short time period of one year in which the cases were identified might result in misclassification since diagnoses made outside this period were not considered. However, our sample comprised nearly 99% of all SHI-individuals in Germany in 2017. Also, a conservative case definition applied in our study morbidity is very common in these patients and requires a special attention of researchers and clinicians. Due to the broad comorbidity spectrum, these patients might benefit from a multidisciplinary care approach. Timely identification of comorbid disorders may help to improve their clinical course, prognosis and quality of life.34, 41,062,196 of them were statutory insured35. Thus, the study population included approx. 86% of the total German population and nearly 99% of the total SHI-population.The present study is based on outpatient claims data received from all regional Associations of Statutory Health Insurance Physicians (ASHIPs) in Germany. In total, there are 17 ASHIPs, of whom 15 coincide with 15 German federal states whereas two ASHIPs exist in the federal state of North Rhine-Westphalia. The data contain diagnoses of all SHI-individuals in Germany who visited a SHI-authorized physician in the year 2017. The diagnoses are coded according to the German modification of the 10th edition of the International Classification of Diseases and Related Health Problems (ICD-10-GM). The study population comprises insurees with available information on sex, age (40+ years) and region of residence . The German population consisted of 47,185,969 inhabitants over 40 years in 201737 and J45 ‘asthma’31 were diagnosed in at least two different quarters in 2017, resulting in total of four diagnoses . In addition, all diagnoses should have a diagnostic modifier “confirmed diagnosis” in contrast to ‘suspected disease’ or ‘cured disease’. The former is usually given for chronic disease cases and for those patients requiring pharmacological therapy38.We defined a patient with concurrent diagnoses, when each ICD-10 codes J44 ‘other chronic obstructive pulmonary disease’34 was used to create the respective weights. A post-stratification weighting was only used in the total sample of the SHI-population to estimate a nationally representative prevalence of concurrent asthma/COPD diagnoses.We first calculated the crude prevalence of concurrent diagnoses in patients with either asthma or COPD and in the whole study SHI-population. For the latter, we applied post-stratification weighting to obtain a nationally representative prevalence estimate. Sex and age (5-year age groups) distribution of the German population from the year 2017 obtained from the Federal Statistical Office20. In this analysis we used codes with the first three characters, which represent the main disease category . We included the first 14 chapters of the ICD-10-GM classification, which represent specific diseases  was considered statistically significant.Using the case–control study design we compared comorbid disorders among patients with and without concurrent diagnoses . A control group was retrieved from a sample of SHI-individuals who also visited a SHI-authorized physician in 2017 for reasons other than asthma and/or COPD. We selected SHI-insurees without a single diagnosis of asthma and/or COPD with available information on sex, age and region of residence (ASHIP). Of them, we only retrieved individuals matched by sex, age and regional ASHIP with the highest case-to-control ratio of 1:9 . For all individuals, i.e., with and without asthma/COPD, we extracted all diagnoses using the procedure mentioned above . The ICD-10 consists of 22 chapters representing broad disease categories with codes containing 3–5 charactersThe datasets analysed during the current study are not publicly available due to data protection regulations by the German Social Security Code  V).Supplementary Information


The key role of arterial hypertension in chonic kidney disease (CKD) progression is widely recognized, but its contribution to tubulointerstitial damage (TID) in glomerulonephritis (GN) remains uncertain. Hence, the objective of this study is to clarify whether TID is associated with glomerular damage, and whether the damage at the tubulointerstitial compartment is more severe in hypertensive patients. The study included retrospectively consecutive patients referred to the Nephrology Unit with diagnoses of primary glomerulonephritis, lupus nephritis (LN), and nephroangiosclerosis (NAS) at biopsy. At least six glomeruli per biopsy were analysed through light and immunofluorescence microscopy. Global glomerulosclerosis (GGS%), TID, and arteriolar hyalinosis (AH) were used as markers of CKD severity. Of the 448 patients of the cohort, 403 received a diagnosis of GN, with the remaining being diagnosed with NAS. Hypertension was found in 52% of the overall patients, with no significant differences among those with GN, and reaching 88.9% prevalence rate in NAS. The hypertensive patients with GN had more marked damage in glomerular and tubular compartments than normotensives independently of the amount of proteinuria. Moreover, hypertension and GGS% were found to be strongly associated with TID in GN. In GN patients, not only the severity of glomerular damage but also the extent of TID was associated with high blood pressure. In 1968, Risdon et al. first reported a significant relationhip between the extent of tubular damage and creatinine clearance ,4,5,6,7.The key role of arterial hypertension in CKD progression is widely recognized. The hypertensive kidney disease is known as nephroangiosclerosis characterized by arteriolar hyalinosis and glomerulosclerosis , but theAll patients attending the Nephrology and Dialysis Unit of San Carlo Borromeo Hospital, Milan, Italy, between January 1992 and April 2006 who had renal biopsy diagnoses of primary glomerulonephritis, lupus nephritis (LN), and nephroangiosclerosis (NAS) were consecutively included in the study. Inclusion criteria were (a) persistent non-nephrotic proteinuria (PP), defined as proteinuria <3.5 g/24 h and normal serum albumin, or nephrotic syndrome (NS) ; (b) absence of previous nephrotic syndrome in the patients with PP; (c) typical features of glomerulonephritis or nephroangiosclerosis at light and immunofluorescence microscopy; (d) no clinical, imaging, or laboratory signs of secondary GN except for LN; (e) at least six glomeruli in the biopsy. High blood pressure (BP) was defined as office BP ≥140/90 mmHg at least on three occasions or antihypertensive treatment . CKD wasAt follow-up, the outcomes were progression to end-stage renal disease (ESRD) or remission. In NS patients, remission was established as complete if proteinuria was ≤0.30 g/24 h, or partial if proteinuria was ≤2.0 g/24 h; in PP patients, remission was assessed if both proteinuria ≤0.30 g/24 h and normal renal function were found at the last observation.The study complied with the Declaration of Helsinki and the local Institutional Reviw Board (IRB). All patients gave their written informed consent to the renal biopsy and use of data for scientific purposes.Proteinuria was measured in 24 h urine collection and second morning urine sample by the Coomassie blue method (modified with sodium-dodecyl-sulphate) and expressed as 24 h proteinuria and protein creatinine ratio (mg urinary protein/g urinary creatinine). Serum and urinary creatinine were measured enzymatically and expressed in mg/dL. Serum and urinary IgG, transferrin, α2-macroglobulin (α2m), albumin, and α1-microglobulin (α1m) were measured by immunonephelometry and expressed as urinary protein/creatinine ratios. NAG (N-acetyl-β-glucosaminidase) was measured by a colorimetric assay performed using 3-cresolsulfonphthaleyn-N-acetyl-β-D-glucosaminide that is hydrolized by NAG with the release of 3-cresolsulfonphthaleyn sodium salt, which is measured photometrically at 580 nm on a HITACHI Instrument; the results were expressed in units/g urinary creatinine. Estimated glomerular filtration rate (eGFR) was measured by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula . The folt test, and Mann–Whitney or Kruskall–Wallis were used to compare quantitative variables among/between groups for variables with or without normal distribution, respectively. Distribution of categorical variables was compared by chi-square analysis.Normal distribution was assessed with the Kolmogorov–Smirnov test, and quantitative variables that showed a skewed distribution underwent appropriate transformation to achieve normal distribution. One-way ANOVA followed by Bonferroni’s post hoc test, or p < 0.05.Ordinal regression analysis to identify factors associated with TID used the test of parallel lines to assess whether the assumption of proportional odds was satisfied, Pearson P to evaluate the goodness of fit test, and Nagelkerke value to assess the proportion of variation of the outcome (TID) explained by factors and covariates. For regression analysis, TID score was cropped into three levels corresponding to absence of TID, focal TID, and diffuse TID. Significance was set at n = 448) at baseline are shown in n = 127, 28%), idiopathic membranous nephropathy , lupus nephritis , focal segmental glomerulosclerosis , crescensic IgA nephropathy , membranoproliferative glomerulonephritis , and minimal change disease . In 45 patients (10%), the diagnosis was nephroangiosclerosis (NAS)   A.p < 0.001 vs. any other group). The overall mean age was 43 years; NAS patients were older than those of any other GN group  and in each GN group except for LN, which was characterized by a female prevalence  and more prominent damage in glomerular and tubulointerstitial compartments, in addition to higher excretion of albumin/creatinine, IgG/creatinine, and α1-microglobulin/creatinine   .p < 0.01) than normotensive patients. When considering GN patients for nephrotic (NS) or persistent proteinuria (PP), no significant difference was found in eGFR.Patients with hypertension were older (p < 0.001 vs. normotensives) and higher excretion of IgG and α1-microglobulin (p < 0.001 vs. normotensives) (p < 0.001) and higher protein excretion than normotensives (p = 0.007)  . GN pati= 0.007) . eGFR wa= 0.007) .p < 0.02) and had lower eGFR (p < 0.05).No significant difference was observed between hypertensive and normotensive patients in the NAS group ; NAS patp < 0.0001) (p < 0.0001)  A, but no 0.0001) B. A larg 0.0001) C, wherea 0.0001) D.TID score increased along with GGS% in GN patients , and thiIn NAS patients, GGS% and TID did not differ between hypertensive and normotensive patients, or NS and PP  but, becAt ordinal regression analysis, we found that hypertension and GGS% were the factors associated with TID in GN.Model 5 was not considered because the test of parallel lines showed that assumption of proportional odds was not satisfied.2 = 34.43, p < 0.0001), with hypertension explaining 11% of the variation between TID scores  . The odds of developing TID in patients with GN and hypertension was 3.61  times that in normotensives  . Leaving= 0.115) .p < 0.0001 both)  and hypertensives (models 1b and 2b) (01 both) .2 = 4.97, p < 0.03)  times in those showing GGS% than in those having no GGS  .When we performed the regression analysis by omitting the advanced CKD stages, i.e., stages 4 and 5 , we found very similar results, supporting the association of GGS and high blood pressure with TID in GN patients.n = 177; PP, n = 182) who had a follow-up longer than 2 months (NS: 63 (29–121), PP: 60 (34–88), median (IQR) months). The hypertensive patients developed ESRD more frequently than normotensives (p = 0.0037). When considering the patients by immunosuppressive treatment, no difference was found between hypertensives and normotensives treated with steroids and cyclophosphamide (p = 0.07). However, when analyzing the patients not undergoing immunosuppressive treatment, a greater proportion of hypertensives developed ESRD than did normotensives (p = 0.02).We considered 359 patients  study has shown that, in a general population cohort, hypertension status is associated with faster kidney function decline and that the slope of eGFR decline can be attenuated by antihypertensive treatment . Our stuAnother finding of the present study was that tubular damage is greater in GN if hypertension coexists. By occupying 80% of total kidney volume, the tubules represent the dominant compartment and, being tightly connected to the interstitium and vessels that interact with the mesangium, they are easily vulnerable to the events that injure glomeruli . Hence, Only in last decade, experimental  and clinWhether high blood pressure contributes to the development of TID in GN remained to be established. In 2006, Ikee et al., examining biopsies from patients with IgA GN, not only observed that TID correlated with GGS% but also that it was more pronounced in the hypertensive patients, suggesting, but not proving, that hypertension worsened the damage at both tubular and glomerular levels in IgA GN . Later, Strengths of the study are (1) the large cohort of GN patients included all frequent GN subtypes; (2) the biopsy analysis was performed by one pathologist who used an identical procedure and, moreover, included reproducible and quantitative measurements of GGS% and semi-quantitative measurement of TID and AH scores.The limitations of the study are as follows: (1) Since arterial hypertension can be either the cause or consequence of CKD and both hypertension and CKD can be silent for years ,33, makiThe present study, by examining a large cohort of GN patients, has provided data that collectively support a role of hypertension in the tubular decline in most common primary GN. The hypertensive patients more frequently developed focal or diffuse TID than normotensives did and had greater excretion of low molecular weight proteins, such as α1m. In the hypertensives, the tubular damage was greater than that in normotensives even if we separately consider the subgroups of patients with nephrotic syndrome and persistent proteinuria.


Global Initiative for Asthma (GINA)-defined criteria for asthma control include questions about daytime symptoms, limitation of activity, nocturnal symptoms, need for reliever treatment and patients’ satisfaction. Patients with nocturnal symptoms like wheezing and cough often suffer from lower sleep quality and impaired daytime performance. The lack of an appropriate method for standardized and objective monitoring of respiratory symptoms leads to difficulties in asthma management. The aim of this study is to present a new method for automated wheeze and cough detection during sleep and to assess the actual level of asthma control by the Asthma Control Test (ACT).The 2. Most of the patients had been taking an ICS/LABA combination and would resort to a SABA as their rescue medication.Respiratory symptoms like wheezing and cough were recorded with the LEOSound-Monitor for one night in 55 asthmatic patients in their individual domestic setting. Patients were asked to assess their level of asthma subjectively with the ACT. The study consisted of 37 women and 18 men, with a mean age of 41 years, and a mean BMI of 27 kg/m60% of the participants were classed as having controlled, and 40% were classed as having partially- or uncontrolled asthma. During sleep wheezing was found in 8 of the 55 asthma patients (14.5%) and coughing was found in 30 patients (54.5%). The median ACT score in wheezing-patients was 14, while in non-wheezing patients it was 21. Uncontrolled asthma was found in 6 of the 8 wheezing-patients. Coughing versus non-coughing patients did not show a significant difference in the ACT-score .Wheezing is a sign of uncontrolled asthma. The ACT-score in wheezing patients is worse compared to patients without wheezing. LEOSound proofed to be a useful tool in providing an objective evaluation of respiratory symptoms, like coughing and wheezing. In clinical practice, this may allow an improvement in asthma therapy. Bronchial asthma is one of the most common chronic diseases affecting worldwide about 300 Million people of all ages and of all ethnic backgrounds. Furthermore, a lack of optimal medical care is described as a factor of preventable deaths . MedicatMulticentre studies like REALISE and AIRE provide information about effectiveness and adherence to medication over nearly 15 years. Asthma is still poorly controlled in more than 50% of patients despite the availability of very effective drugs –10. In aThe aim of this study was i.). Analyse the patients’ judgement of asthma control and ii.). Monitor respiratory symptoms like wheezing and cough during sleep.We subselected 55 patients from a previous, not yest published, study, which focused on the phenotypes of eosinophilic and non-eosinophilic asthma. Inclusion criteria were an age between 18 and 65 years as well as a diagnosis of bronchial asthma. In addition, we limited the patients’ nicotine abuse to a maximum of 10 pack years. Informed written consent to participate in the study was obtained from every patient. Exclusion criteria were the presence of any acute lung disease (e.g. bronchitis) or severe infectious disease . Before the overnight study took place, the measurement procedure was explained to the patient, including the positioning of the three microphones. The microphones and the device were designed to ensure maximum comfort, which resulted in a high compliance of the participants. The duration of the overnight monitoring was between 7 and 9 h. The data collection took place between September 2018 and October 2019. Besides, the patients were asked to assess their level of asthma with the ACT. The study was approved by the Ethics Committee of the Philipps University of Marburg (Az.: 94/18).The LEOSound Lung-Sound-Monitor is a mobile device validated for automatic long-term recording and analysis of normal and adventitious respiratory sounds like cough and wheezing in adults and children . The sys2 (standard deviation ±6.1). Table Thirty-seven women and 18 men, aged between 20 and 67 years, were included. The average age of the participants was 41 years with a mean BMI of 26.5 kg/mAsthma control was determined using a validated questionnaire  . We deciStatistical analysis was performed using IBM SPSS Statistics Version 25 (IBM GmbH). The Kolmogorov-Smirnov-Test was used to test for normal distribution. Where the normal distribution hypothesis was rejected, non parametric methods were used for both descriptive and interferential statistical calculations. As coughing and wheezing variables were not found to be normally distributed, median and range were used to describe all parameters. For some normally distributed variables such as age, average and standard deviation (AVG ± SD) were reported as well.p ≤ 0.05.Kruskall-Wallis one-way analysis of variance was used to compare the three Asthma Control groups. A statistically significant test result was obtained, if The Mann-Whitney test was also used to compare wheezing and non-wheezing patients and coughing and non-coughing patients.60% of the patients were classed as having controlled asthma, and 40% of the patients as having partially- or uncontrolled asthma. In 33 patients the asthma status was classified as ACT-1, in 10 patients as ACT-2 and in 12 patients as ACT-3. Table p = 0.001). Table Lung sound recordings showed wheezing during sleep in 8 out of 55 patients 14.5%) with a median duration of 9.5 min. The maximum wheezing duration was 30.5 min. With respect to ACT, the median score of the non-wheezing group was 21, whereas within the wheezing group the median score was 14 points. Six out of 8 wheezing patients were found in the ACT-3 Group, which means their current asthmatic status was uncontrolled. Statistical calculation showed a significant difference between the wheezing- and the non-wheezing group  with respect to their asthma control . Nearly In addition, Morice et al. presented in their guidelines the need for an objective assessment of respiratory symptoms, like cough and wheezing . So far,In clinical practice, cough monitors are already in use. After significant progress and development in objective cough monitoring, tools are ready for standard deployment . NeverthIn this study we only included adults. However, we expect objective monitoring of respiratory symptoms like cough and wheezing to have an even greater impact on children. Asthmatic children and adolescents are more likely to show impaired daytime performance compared to healthy controls –25. NighInternational multicentre studies such as AIRE (2000) and REALISE 2014) provide information about the reality of asthma treatment and control  provide . DespiteIn 2014 Price et al. published the REALISE study, in which more than 8000 asthma patients from 11 European countries were surveyed for asthma control . In thisThe study by Olaguibel et al. revealed that uncontrolled asthma, as assessed by the Asthma Control Questionnaire (ACQ), may be independent of asthma severity . The stuIn this study, patients were monitored for only one night. Although asthma has a large symptom variability, and respiratory symptoms may differ from one night to another. Nevertheless, the monitoring for one night seems relevant since respiratory symptoms were detected. The aim of the study was to highlight the necessity for and the clinical impact of objective monitoring of respiratory symptoms like cough and wheezing in patients with asthma. Moreover, the sample size of only 55 patients is arguably a limitation of this study. A larger sample size may provide more solid evidence. However, analysis and statistical calculation of our data already showed an appropriate application of this study with respect to 55 patients.In our opinion, cough and wheezing during sleep have a direct impact on sleep and quality of life in patients with asthma. Consequently, for the assessment and evaluation of wheezing and cough events, objective approaches like respiratory sound monitoring seem most appropriate. This study presented that a device for long-term monitoring of respiratory sounds is a helpful tool to monitor time course of cough and especially wheezing in patients with obstructive respiratory diseases. Generally, patients may not necessarily notice the respiratory symptoms during sleep. Therefore, the objective evaluation may have a huge clinical impact by adjusting and improving the therapy according to the respiratory symptoms. Moreover, this study only focused on adults whereas the objective evaluation of respiratory symptoms seems to have even more profound relevance on children’s health. Especially small children are not as able as older patients to notice and report their respiratory symptoms. This, further research including children may demonstrate. In addition, polysomnographic research may elucidate the impact of sleeping behavior in wheezing and non-wheezing patients on daytime performance and productivity.


Fetal undernutrition programs hypertension and cardiovascular diseases, and resistance artery remodeling may be a contributing factor. We aimed to assess if fetal undernutrition induces resistance artery remodeling and the relationship with hypertension. Sprague–Dawley dams were fed ad libitum (Control) or with 50% of control intake between days 11 and 21 of gestation . In six-month-old male and female offspring we assessed blood pressure (anesthetized and tail-cuff); mesenteric resistance artery (MRA) structure and mechanics (pressure myography), cellular and internal elastic lamina (IEL) organization  and plasma MMP-2 and MMP-9 activity (zymography). Systolic blood pressure  and plasma MMP activity were assessed in 18-month-old rats. At the age of six months MUN males exhibited significantly higher blood pressure (anesthetized or tail-cuff) and plasma MMP-9 activity, while MUN females did not exhibit significant differences, compared to sex-matched controls. MRA from 6-month-old MUN males and females showed a smaller diameter, reduced adventitial, smooth muscle cell density and IEL fenestra area, and a leftward shift of stress-strain curves. At the age of eighteen months SBP and MMP-9 activity were higher in both MUN males and females, compared to sex-matched controls. These data suggest that fetal undernutrition induces MRA inward eutrophic remodeling and stiffness in both sexes, independent of blood pressure level. Resistance artery structural and mechanical alterations can participate in the development of hypertension in aged females and may contribute to adverse cardiovascular events associated with low birth weight in both sexes. Fetal life is a key developmental period and a determinant of future health. Barker’s hypothesis states that undernutrition during critical periods of gestation leads to inadequate fetal growth and programs adult disease . The fetHypertension development has been consistently associated with suboptimal intrauterine growth, demonstrated in humans  and confPathological vascular remodeling is associated with alterations in extracellular matrix (ECM) degradation, and metalloproteases (MMPs)—key enzymes responsible for ECM turnover—have been proposed to play a role in this process . BesidesMales seem to be more susceptible to adverse fetal environments than females, and the majority of studies, including ours, evidence that female rats do not develop hypertension or develop milder forms in adult age ,8,16,17.The aim of the present work was to assess, in a rat model of maternal undernutrition during gestation (MUN), sex differences in the development of mesenteric resistance artery (MRA) remodeling and mechanical function. We have also evaluated the relationship between remodeling, hypertension and MMP. We observed that male and female offspring from MUN rats develop MRA inward eutrophic remodeling and stiffness in adult age, independent on their level of blood pressure. Males develop hypertension in adult age and females in ageing. MRA remodeling can participate in the later development of hypertension in females and can contribute to the cardiac dysfunction previously reported in MUN rats in ageing. Plasma MMP activation is likely a consequence of hypertension, but we cannot discard an activation in the vascular wall, which could contribute to the observed structural and mechanical alterations. o. 85-23, revised in 1996), Spanish legislation (RD 1201/2005), and follow the rules of the Declaration of Helsinki. The experiments were approved by the Ethics Review Board of Universidad Autónoma de Madrid  and by the Ethics Board of the Regional Environment Committee of Comunidad Autónoma de Madrid . Experiments were performed on Sprague–Dawley rats from the colony maintained in the Animal House at Universidad Autónoma de Madrid (ES-28079-0000097). All experimental procedures conformed to the Guidelines for the Care and Use of Laboratory Animals  and relative humidity (40%). A model of fetal programming induced by maternal undernutrition during gestation (MUN) was used, as previously described . BrieflyAfter birth, the pups were sexed and weighed and the litter was standardized to 12 rats, 6 males and 6 females if possible . Experiments were conducted in male and female offspring at two age points, adult rats (6 months old) and aged rats (18–20 months old), using offspring from different dams (minimum 3 different litters). On the day of the experiment, after blood pressure measurements, the rats were euthanized by overdose of anesthesia and the blood was collected in chilled heparin-coated polypropylene tubes. Blood was centrifuged at 800g for 20 min at 4 °C to obtain plasma. 3, 1.2 mM KH2PO4, 1.2 mM MgSO4, 10 mM EGTA, 11 mM glucose) and 3rd order branches  were carefully dissected. In 6-month-old rats the mesenteric bed was excised, placed on chilled zero-calcium Krebs–Henseleit solution  and to a PowerLab data acquisition system/8SP  and pressure wave was continuously recorded for 45 min. The diastolic and systolic blood pressure  and heart rate  were analyzed. Quantification was performed averaging the data in the pressure wave trace for approximately 1 min during the last part of the recording period [SBP was measured non-invasively using a tail-cuff coupled to a pressure acquisition system , as previously described . Briefly2 and 5% CO2, to maintain a pH between 7.3 and 7.4. The artery was secured with nylon suture between two glass cannulas in an organ bath placed on the stage of an inverted microscope  coupled to a CCD camera . After a 15 min equilibration period, intraluminal pressure was reduced to near zero (5 mm Hg) and the arterial segment was exposed to increasing intraluminal pressures in 20 mmHg steps . The passive increase in lumen diameter with increasing distending pressure was considered an indication of segment viability. At each pressure, the artery was allowed to stabilize for three minutes and an image was taken (10× objective). ImageJ software was used to measure internal and external diameters at each intravascular pressure , and from them, wall thickness (WT) and cross-sectional area (CSA) were calculated. MRA segments were mounted on a pressure myograph , as previously described . Brieflyinc) was used. Einc was obtained by fitting the stress-strain data from each MRA to an exponential curve using the equation: 2) and WT is wall thickness at each pressure.0 is the diameter at 5 mmHg and Di is the internal diameter at each pressure.To evaluate the degree of arterial stiffness incremental Young’s Elastic Modulus  for 1 h. Thereafter the segment was stored in 4% PFA for confocal microscopy study. From each stress-strain curve, β values were obtained. For a given level of wall stress (σ), Ev/v dilution from stock solution) for 15 min, washed for two periods of 15 min each in saline solution and mounted intact on a slide provided with a small well (to avoid compression), containing Citifluor mounting medium .Confocal microscopy was used to quantify cell distribution in the adventitia and media, and the internal elastic lamina fenestra organization in the pressure-fixed MRA segments. To assess cellular arrangement the segments were stained with DAPI  with the Excitation = 405 nm/Emission = 410–475 nm wavelengths to visualize cell nuclei (DAPI). Stacks of serial optical sections (1 µm thick) were captured in three randomly chosen regions, starting from the outermost nuclei (adventitia) to the last smooth muscle cell (SMC) visible in the image. At 80 mm Hg, the endothelial cells were not clearly visible for accurate quantification. Quantification was performed with MetaMorph® image analysis software . From each stack of images, we quantified adventitial cell and SMC number (identifiable by the shape and orientation of their nuclei), layer thickness and layer volume (layer thickness × image area). From these data, cell density was calculated in each layer (number of cells/layer volume).MRA segments were visualized with a laser scanning confocal microscope (LeicaIEL organization was assessed as previously described . IEL wasv/v dilution) was added to plasma samples and loaded to sodium dodecyl sulfate (SDS)-polyacrylamide gels containing 0.1% gelatin. Proteins were separated by electrophoresis at 180 V for 120 min. Thereafter, gels were washed with distilled water, incubated with the enzymatic activation buffer  for 1h at room temperature and subsequently with Triton X-100-free activation buffer for 24h at 37 °C. Gels were stained for 10 min with Coomassie Brilliant Blue  and thereafter washed for 1 min with a solution containing 40% methanol and 10% acetic acid in distilled water. Finally, gels were incubated in a stop solution  for 24–48 h, and imaged with ChemiDoc XRS+ Imaging System . Bands were quantified with Image Lab 3.0 software .MMP-2 and MMP-9 activity assays were performed by gelatin zymography in plasma samples from 6- and 18-month-old rats. Four μg of proteins were used for MMP-2 and 20 μg of proteins were used for MMP-9. Laemmli solution (0.5M Tris (pH 6.8), 25% glycerol, 20% SDS, and 0.01% bromophenol blue; 1:5 t test, 1 or 2-way ANOVA. Statistical significance was established at p-value < 0.05. Statistical analysis was performed with GraphPad Prism . The Kolmogorov-Smirnov test was used to check the normal distribution of the variables. Data are expressed as mean ± standard error mean (SEM). Statistical differences between MUN and control rats of each sex were analyzed by Student’s p-value < 0.05) and females . At the age of 6 months, there was no significant difference in body weight between groups either in males  or in females . Similarly, at the age of 18 months, no differences were observed between MUN and control rats, either in males  or females . Birth weight was significantly lower in MUN rats compared to Controls, both in males . The 6-month-old MUN females exhibited significantly lower SBP values compared to MUN males  or females . These data indicate that exposure to undernutrition induces resistance artery inward eutrophic remodeling, independent of sex.MRA internal and external diameters were significantly smaller in MUN male and female rats compared to sex-matched controls at all intraluminal pressures tested . MRA croConfocal microscopy was used to analyze cellular density and thickness in adventitia and medial layers. We did not detect statistical differences in adventitial layer thickness between MUN and control MRA, either in males or in females A. HoweveConfocal microscopy showed that media thickness was larger in MUN rats, both in males and females A. The SMIn MUN rats, the stress-strain relationship was shifted to the left and β value derived from the exponential curve was significantly higher compared to Controls, both in males A and femNo significant differences in fluorescence intensity A or feneIn 6-month-old rats, we did not detect differences in MMP-2 activity between MUN and Control rat, either in males or in females. MMP-9 activity was significantly higher in MUN males compared to Control, but there was no statistical difference between MUN and control females A. In 18-This study aimed to assess if exposure to undernutrition during fetal life induces resistance artery remodeling, its relationship with hypertension, and the possible influence of sex. Our main findings are that fetal undernutrition programs MRA inward eutrophic remodeling and stiffening. These structural and mechanical alterations are present in adult MUN rats from both sexes. Since males and females exhibit different levels of blood pressure at this age, these data suggest that remodeling may occur prior to the development of hypertension, as we have previously demonstrated in conduit vessels from 21-day-old MUN rats. Resistance artery remodeling may be a contributing factor to the maintenance of hypertension in MUN males and later development of high blood pressure in aged MUN females. Our data also suggest that plasma MMP activation may be the result of hypertension affecting all the vasculature. However, we cannot discard that alterations in local MMP expression or activity may contribute to the observed remodeling. We suggest that resistance artery remodeling can contribute to cardiovascular organ damage associated with low birth weight, particularly in ageing, when the protection of females due to estrogen loss is blunted.CVDs are still the leading cause of death due to non-communicable diseases, despite efforts to control lifestyle factors. It is now well accepted that fetal stress and associated inadequate growth contributes to the development of hypertension, which is a risk factor for coronary heart disease and stroke ,3. The mThe association between inadequate fetal growth and CVD has been proposed to take place through two main pathways: cardiovascular remodeling and metabolic programming. In our rat model of low birth weight, we found that adult rats exposed to undernutrition during fetal life exhibit remodeling of third order branches of the mesenteric artery (MRA), which is an example of resistance artery in the rat. The structural alteration was found in both MUN males and females, despite the fact that at the age of 6 months, only males developed hypertension. This suggests that the process of vascular remodeling in rats exposed to undernutrition may be independent on the level of blood pressure. It is likely that vascular structural alterations are initiated early in life. This is supported by data from our previous study in rat aorta, showing that both MUN males and females exhibit remodeling by the age of 21 days, when males have not developed high blood pressure yet . Early sResistance artery remodeling is well known to be a contributing factor for hypertension development, through the increase in peripheral resistance. We were surprised to find that, despite the presence of MRA inward eutrophic remodeling, MUN females did not develop hypertension. This finding suggest that females may have mechanisms, which may counteract increased peripheral resistance. Sex differences in fetal programming of hypertension have been attributed to sex hormones, which exert actions on several blood pressure regulatory systems . Among oThe vascular structural alteration observed in MUN MRA was characterized by a reduced lumen size with no differences in cross sectional area, and, therefore, can be classified as inward eutrophic remodeling . This tyMMPs are the key enzymes responsible for degradation of various ECM proteins in the vascular wall, including collagen, elastin, glycoproteins, and proteoglycans, and MMP dysregulation is associated with pathological vascular remodeling . In ratsThe majority of studies regarding vascular remodeling in fetal programming have focused on elastic arteries. The present data evidence that resistance vessels also undergo structural and mechanical alterations. Small artery remodeling is not only a key determinant of peripheral resistance and hypertension, but also a contributing factor to adverse cardiovascular events ,11,43 anFetal undernutrition induces MRA inward eutrophic remodeling in males and females, independent of blood pressure level.MRA remodeling in MUN rats is associated with cellular and ECM alterations and stiffening.MUN females develop hypertension in ageing, and MRA remodeling may be a contributing factor.Increased plasma MMP-9 activity is associated with hypertension.Resistance artery remodeling induced by fetal undernutrition may contribute to organ damage and development of CVD.


Sestrins (Sesns), a group of oxidative stress-related proteins, have been reported to be involved in various cardiovascular diseases, including aortic dissection and chronic heart failure. This study is aimed at investigating the level of circulating Sesn1, Sesn2, and Sesn3 in hypertension patients. n = 140), grade II (n = 180), and grade III (n = 80) hypertension.  Plasma levels of Sesn1, Sesn2, and Sesn3 in 400 hypertensive patients and 100 normotensive subjects were detected using enzyme-linked immunosorbent assay (ELISA) kits. The hypertension patients were divided into groups with grade I  and diastolic blood pressure (DBP). Moreover, Sesn1, Sesn2, and Sesn3 levels were elevated in patients with dipper hypertension and further increased in patients with nondipper hypertension. In addition, smokers, as well as patients with higher levels of angiotensin II (Ang II) and carotid atherosclerotic plaque (CAP), exhibited increased Sesn1, Sesn2, and Sesn3 levels when compared with patients without these clinical characteristics. Furthermore, plasma levels of Sesn1, Sesn2, and Sesn3 were negatively correlated with the presence of CAP.  Circulating Sesn levels are increased in patients with hypertension and may be a target for the prevention and treatment of clinical hypertension. Hypertension is the most common risk factor of cardiovascular disease, leading to significantly higher morbidity and mortality than other risk factors. Numerous previous studies have used the immune effects and inflammatory response of blood vessels to strengthen the pathogenesis of hypertension , 2. In rin vivo and in vitro [Sestrin (Sesn) family members, including Sesn1, Sesn2, and Sesn3 in mammals, are proteins that regulate oxidative stress both in vitro , 7. Sesnin vitro –10. A nuin vitro –13.Sesn1, Sesn2, and Sesn3 were also shown to play a critical role in cardiovascular diseases . Elevaten = 140), grade II hypertension (n = 180), and grade III hypertension (n = 80). All subjects underwent ambulatory blood pressure monitoring to determine the type of hypertension and were further divided into two groups, namely, the scoop-shaped hypertension group (n = 240) and nonscoop-shaped hypertension group (n = 160). In addition, all subjects received a carotid ultrasound to determine the presence of carotid atherosclerotic plaque (CAP). The blood samples were collected from the People's Hospital of Guangxi Zhuang Autonomous Region from March 2016 to May 2018. All patients signed informed consent forms, and the study was approved by the Ethics Committee of the People's Hospital of Guangxi Zhuang Autonomous Region.In the present study, 100 normotensive and 400 primary hypertension patients were enrolled. The patients diagnosed with diseases, including secondary hypertension, chronic heart failure, chronic renal failure, stroke, valvular heart disease, collagen disease, advanced liver disease, malignant disease, septicemia, or other diseases that may affect Sesn expression, were excluded from this study. According to the value of systolic blood pressure (SBP) and/or diastolic blood pressure (DBP), the hypertension patients were divided into three groups, namely, grade I hypertension  kits were purchased from Cloud-Clone Corp. (USA). The performance of these ELISA kits was tested. The lower detection limit of Sesn1 was approximately 10.5 ng/mL, the intra-assay and interassay coefficients of variation were <5% and <7%, respectively, the recovery range was between 90.5 and 115.2%, and the sensitivity was approximately 1.0 ng/mL. The lower detection limit of Sesn2 was approximately 0.5 ng/mL, the intra-assay and interassay coefficients of variation were <4% and <8%, respectively, the recovery range was between 93.4 and 110.5%, and the sensitivity was approximately 0.2 ng/mL. For Sesn3, the lower detection limit was approximately 3.2 ng/mL, the intra-assay and interassay coefficients of variation were <4.5% and <9.5%, respectively, the recovery range was between 92.5 and 116.6%, and the sensitivity was approximately 0.5 ng/mL.Plasma samples were taken from liquid nitrogen and defrosted at 4°C. The plasma levels of Sesn1, Sesn2, and Sesn3 were detected using the respective ELISA kits, according to the manufacturer's instructions. All tests were performed in duplicate.t-test was performed to compare the difference between the two groups, and one-way ANOVA, followed by the LSD test, was performed for multiple comparisons between more than two groups. The categorical variables are presented as counts (percentages) and compared with the chi-square test. The correlations between Sesn2 levels and blood pressure (including SBP and DBP) were calculated using Spearman's correlation analysis. The simple linear regression analysis and subsequent multiple linear regression analysis were performed to investigate the role of Sesns in the presence of CAP. All the data were analyzed using the SPSS 23.0 software, and p < 0.05 was considered statistically significant.Data regarding the enumeration variables were expressed as the mean ± standard deviation (SD). Student's Compared with the control group, hypertension patients exhibited higher SBP, DBP, high-density lipoprotein cholesterol (HDL-C), creatinine (CREA), C-reactive protein (CRP), homocysteine (Hcy), and angiotensin II (Ang II). No other differences in clinical characteristics were identified between the two groups, including age, male gender, smoking, the duration of hypertension (history), heart rate (HR), body mass index (BMI), total cholesterol (TC), total triglycerides (TG), low-density lipoprotein cholesterol (LDL-C), fasting glucose (Glu), and hemoglobin a1c (HbA1c). In addition, the SBP, DBP, CREA, CRP, Hcy, Ang II, and CAP percentages were shown to gradually increase between the grade I, grade II, and grade III groups. The history in the grade II and grade III groups was higher than that in the grade I group, while the level of high-density lipoprotein cholesterol (HDL-C) in the grade III group was lower than that of the other two groups. The clinical characteristics of each group are listed in In addition, the dipper group and nondipper group exhibited higher SBP, DBP, CREA, CRP, Hcy, and Ang II when compared to the control group. Moreover, SBP and CRP were higher in the dipper group when compared with the nondipper group, while DBP, HR, CREA, and CAP percentages exhibited the opposite trend. The clinical characteristics of the dipper and nondipper groups are listed in r values and p values are listed in Plasma Sesn1 levels were significantly increased in hypertension patients when compared with the control group and gradually increased between the grade I, grade II, and grade III groups . Plasma According to the results of the ambulatory blood pressure monitoring, the hypertension patients were divided into the dipper and nondipper groups. The ELISA results revealed that plasma Sesn1, Sesn2, and Sesn3 levels gradually increased between the dipper and nondipper groups Figures .β-blockers, CCB, and diuretics did not affect Sesn expression. Sesn1, Sesn2, and Sesn3 levels in each group are listed in Subjects were divided into two groups based on the median of several characteristics, such as HDL-C, CREA, CRP, Hcy, Ang II, smoking status, CAP, and medication use. The results showed that smokers and patients with CAP and higher Ang II (≥Median) exhibited higher plasma Sesn1, Sesn2, and Sesn3 levels. HDL-C, CREA, CRP, Hcy, and use of ACEI/ARB, β value, 95% CI of β, and p values are listed in To determine the effects of Sesns on CAP occurrence, Sesn1, Sesn2, and Sesn3 levels, as well as smoking status, SBP, DBP, LDL-C, Glu, CRP, Hcy, and Ang II were used to perform simple linear regression analysis. The results revealed that Sesn1, Sesn2, Sesn3, smoking, SBP, DBP, CRP, Hcy, and Ang II showed a trend. These variables were further used to perform a multivariate linear regression analysis. The results showed that Sesn1, Sesn2, and Sesn3, respectively, were independently associated with the presence of CAP. The In the present study, the plasma levels of the antioxidant proteins Sesn1, Sesn2, and Sesn3 in hypertension patients were detected. The results of our study revealed that Sesn1, Sesn2, and Sesn3 levels were significantly increased in hypertension patients when compared with the normotensive subjects. A further analysis showed a positive correlation between plasma Sesn levels and blood pressure values, including SBP and DBP. In addition, we identified a variety of variables, including smoking status, Ang II, and CAP, which could promote Sesn expression. Furthermore, the results of the multiple linear regression analysis suggested that Sesn1, Sesn2, and Sesn3 levels were negatively correlated with the presence of CAP. Our study is the first to show the increased expression of Sesns in hypertension patients, which may have a protective effect against the development of CAP.Elevated Sesn levels have been widely reported in a variety of diseases. In a previous study, circulating Sesn1, Sesn2, and Sesn3 were reported to be increased in patients with coronary artery diseases, while the amplitude of the increase in Sesn levels was closely related to the degree of stenosis and oxidative stress in CAD patients . In anotIn this study, we found that plasma Sesn levels were increased in patients with hypertension and were positively correlated with the value of blood pressure. These results suggest that there are different degrees of oxidative stress imbalance among hypertensive patients. Moreover, intense oxidative stress may be one of the key players in the pathogenesis of hypertension. As such, it may be useful to pay attention to the dynamic changes in both blood pressure and oxidative stress.In healthy subjects, blood pressure variability over a 24 h period presents as a double peak and a valley; namely, the highest blood pressure appears in the morning and afternoon, while the lowest blood pressure appears at night. This is due to a drop in sympathetic nerve excitability in the evenings and is called the dipper blood pressure. In some patients with hypertension, this blood pressure trend is disrupted and the blood pressure at night is higher than that in the morning, which is called nondipper hypertension. Since nondipper hypertension is not easy to detect and the damage to target organs is significantly higher than that of dipper hypertension, nondipper hypertension is more harmful to patients , 26. ThePreviously, we revealed that Sesns are involved in the regulation of hypertension, mainly via its antioxidant effects. In an early study, Yang et al. reported that silencing Sesn2 aggravated oxidative stress and elevated the blood pressure in dopamine D2 receptor (D2R) knockout-induced hypertension mice . In a reSmoking, angiotensin, atherosclerosis, and a variety of antihypertensive drugs are closely related to oxidative stress –31. To dIn conclusion, we found that plasma Sesn1, Sesn2, and Sesn3 levels were increased in hypertension patients and positively correlated to the blood pressure values. Nondipper hypertension patients exhibited higher plasma Sesn1, Sesn2, and Sesn3 levels when compared to dipper hypertension patients. Moreover, Sesns may be involved in hypertension or CAP through the regulation of oxidative stress. As such, Sesns may be a novel target for the treatment and prevention of hypertension and CAP. However, there were some limitations in the present study. The oxidative stress markers such as SOD and MDA levels were not quantified in the patients included in the study, and the correlation between SOD, MDA, and Sesns was not analyzed. Moreover, while there is a strong relationship between inflammatory response and oxidative stress, Sesn expression and oxidative stress levels can affect each other. However, we did not explore the potential link between them.


Diabetic patients are at the risk of cardiac autonomic neuropathy (CAN) and arterial stiffness. This study aimed to investigate the association of heart rate variability (HRV) as an index for CAN and pulse wave velocity (PWV) as an index for arterial stiffness.Uncomplicated diabetes type-2 patients who had no apparent history of cardiovascular condition underwent HRV and PWV measurements and the results were compared with the control group consisting of non-diabetic peers. Also, the findings were adjusted for the cardiovascular risk factors and other confounding factors.A total of 64 diabetic patients  were compared with 57 controls  in this study. Hypertension, dyslipidemia, and thereby systolic blood pressure and statin use were significantly more frequent in the diabetic group, while the serum levels of cholesterol, HDL-C and LDL-C were significantly higher in the controls. Pulse wave was significantly increased in the diabetic patients (p<0.001). Main HRV parameters were significantly lower in diabetics than in controls. After adjustment for the confounders, PWV and HRV remained significantly different between the groups . Multiple logistic regression of the association between pulse wave velocity and HRV index was independently significant both in diabetics and controls.There exists a significant relationship between heart rate variability and arterial stiffness as a measure for atherosclerosis in diabetic patients, although the role of the confounding factors is noteworthy. More than half of the mortality in diabetic patients occurs due to cardiovascular disease . AlthougOn the other hand, heart rate variability (HRV) can be assessed easily to measure CAN, much earlier than its clinical appearance . It has The aims of the present study were to investigate (i) the association of disturbed PWV, as an index for increased arterial stiffness, and HRV, as an index for CAN, in the presence or absence of uncomplicated diabetes mellitus and (ii) the relation of PWV with HRV in uncomplicated diabetic patients.In this case–control study, uncomplicated diabetic type 2 (T2DM) patients who were referred to the Diabetes clinic of Dr. Shariati hospital, Tehran University of Medical Sciences, Tehran, Iran, between August 2011 and December 2012 were recruited. The control group consisted of their spouse or relatives who were proved to be non-diabetic. The inclusion criteria were defined as both sexes, aged between 30 and 65 years. Individuals with clinically proven coronary heart disease, diabetic foot, diabetic retinopathy or nephropathy, renal failure (GFR < 90), history of malignancy, and cirrhosis were excluded from the study. Height was measured with a Stadiometer, and weight was assessed by a calibrated beam balance. Body mass index (BMI) was calculated as weight (Kg) divided by height (M) squared. Blood pressure was measured twice (5 minutes apart) using a standard calibrated mercury sphygmomanometer on both right and left arms after the participants had been sitting calm for at least 10 minutes. The highest blood pressure of two sides was considered as participant’s blood pressure.All the participants signed an informed consent at the time of recruitment and the study protocol was approved by the ethics committee of Tehran University of Medical Sciences, and the board of research at Dr. Sahriati hospoital.Diabetes mellitus was defined as patients with fasting blood sugar (FBS) ≥ 126 mg/dL, or 2-h postprandial glucose ≥200 mg/dL or those who were using insulin or oral hypoglycemic agents. Hypertensive patients were those with systolic blood pressure of ≥than 140 or diastolic blood pressure of ≥90 mmHg or were using antihypertensive drugs.Venous blood samples were drawn from the anticubital vein in the morning after 12 h fasting. The blood samples were centrifuged, and then serum was collected for measuring the biochemical parameters.1C was detected by High-performance liquid chromatography (HPLC) , coupled with fluorescence detector. The method was validated over a linearity range of 1–100 μmol/L of the plasma. The intra- and interassay coefficients of variation (CVs) for all of the measurements were <4%, which was less than allowed CVs.In all the participants, FBS and 2-h postprandial glucose levels were measured. Plasma levels of glucose, triglyceride (TG), total cholesterol, high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), creatinine, and blood urea nitrogen (BUN) were measured by a colorimetric method using Pars Azmoon® kit with an autoanalyzer . HbA2) were obtained. Total power (TP) of HRV was also calculated to be used in regression analysis as a global marker of cardiac autonomic function.Evaluation of HRV was performed in a quiet and temperature-controlled room according to the guidelines of the Task Force for Pacing and Electrophysiology . ParticiNormalized HF and LF powers were determined by dividing their absolute powers by the total power minus the VLF component and multiplied by 100 , 12.From the electrocardiographic recording, the following statistical and geometric time domain indices were calculated from RR intervals: standard deviation of the NN intervals (SDNN), and the square root of the mean squared difference of successive NNs (RMSSD). Frequency domain variables including total, HF, and LF powers and LF:HF ratio were derived from spectral analysis of successive R-R intervals .HRV measurement was performed after Valsalva and standing maneuvers in addition to supine state, using SphygmoCor software . For Valsalva maneuver, the participant was requested to blow into the mouthpiece of the device manometer to a pressure of 40 mmHg for 15 seconds. Then the Valsalva ratio was calculated as the relationship between the longest and shortest R-R intervals after strain. For the standing maneuver, the participant was requested to breathe at a normal pace for 5 minutes in the supine state. Then, the participant was asked to change position from supine to a full upright and remain erected until the end of the test. The standing ratio was calculated as longest R-R interval around the 30th beat after standing up to the shortest R-R interval around the 15th beat during standing.PWV was measured using the SphygmoCor System , with the individual in the supine position. The pulse waves of the carotid and femoral arteries were analyzed, estimating the delay according to the ECG wave and calculating PWV. PWV was calculated as the ratio of the distance travelled  and the foot-to-foot time delay between the pulse waves and expressed in meters per second (m/sec).Continuous data are presented as mean ± SD. For comparing data with normal distribution, unpaired t-test was used. Correlation of variables was demonstrated using Pearson’s and Spearman’s correlation coefficients in normal distributed parametric and nonparametric variables, respectively. For assessment of the association of variables, linear regression and logistic regression were used for parametric and binary variables, respectively. P-values were always 2-sided, and P < 0.05 was considered significant. The SPSS statistical software package  was used for data analysis.A total of 64 diabetic patients  were compared with 57 controls  in this study. Table .6%) wereTable After adjustment for the confounding variables, including age, BMI, hypertension, dyslipidemia, smoking, statin use, FBS, total cholesterol and systolic blood pressure, PWV and HRV remained significantly different between the groups .As HF power was highly correlated with the total power and their observed associations were similar, we performed our analyses using total power. Unadjusted correlations between total power and cardiovascular parameters showed that the PWV was positively correlated with the total power in diabetic patients while the correlation was reverse in non-diabetic controls and total population. Also, hypertension and triglyceride levels were positively correlated with the total power in the diabetic patients Table .Table 3Multiple logistic regression showed that pulse wave velocity was independently associated with HRV index both in diabetics and controls Table . This reIn this study, we observed that considerable cardiac autonomic dysfunction exists in the uncomplicated diabetic patients in comparison with the normal controls, as well as an increase in the arterial stiffness, measured by pulse wave velocity.Current evidence confirms that HRV is a good measure of cardiac autonomic neuropathy in diabetic patients and its decrease is accompanied by increased mortality and morbidity . In our Decreased HRV in the uncomplicated diabetes patients of our study and previous studies highlights the obscure process of autonomic neuropathy in diabetic patients that begins even before clinical atherosclerotic cardiovascular disease becomes apparent .It has also been shown that surrogate atherosclerosis markers were associated with lower HRV, and increased carotid intima media thickness (CIMT) in T2DM participants was significantly associated with decreased HRV, independent from conventional cardiovascular risk factors . TherefoPWV is known as a potentially applicable atherosclerotic risk marker irrespective of classical cardiovascular risk factors and ethnicity . In prevBased on our findings and previous works, one could suggest that atherosclerosis, both as a result of diabetes and increased age is influenced by the cardiac autonomic neuropathy, which in turn results in increased risk of cardiovascular diseases and related mortality in the type 2 diabetes patients.Among limitation to the study, we can mention that our measurements were cross-sectional and we could not assess how the changes in both HRV and PWV through time, as well as the fluctuations in the serum glucose levels and glycosated hemoglobin, affect each other. We also did not perform glucose tolerance test in the normal controls, so there is a probability that those with glucose intolerance may have some degrees of disturbed HRV and PWV. Also the effects of the type of diabetes treatment and other prescribed medications on HRV and PWV need to be investigated in future studies.In this study, we observed increased arterial stiffness and decreased heart rate variability in the uncomplicated type 2 diabetes patients as compared with normal controls. The relationship between heart rate variability indices and pulse wave velocity was significant after adjustment for diabetes; however, this effect was lost after adjustment for confounders. Based on the findings of this study, it seems that there exists a relationship between heart rate variability and arterial stiffness as a measure for atherosclerosis in diabetic patients, although the role of the confounding factors should be taken into account.


Exercise induced albuminuria (EiA) is elevated in patients with metabolic dysfunction and diabetes, and may serve as an early biomarker for endothelial dysfunction and “kidney reserve”. However, the change in EiA levels over time and its interaction with metabolic dysfunction and glucose metabolism has never been studied. Therefore, we sought to determine EiA levels over time in a cohort of individuals attending a routine annual health survey.We prospectively enrolled 412 patients attending an annual healthy survey at our Medical Center. We collected urine samples for albumin and creatinine measurements before and immediately after completing an exercise stress test, along with multiple physiologic and metabolic parameters. Participants returned to a second follow up visit after a mean follow up period of 3 years (± 1.7 SD).Patients with diagnosed diabetes and subjects with HbA1c ≥ 6.5% significantly increased their EiA over time (median [IQR] change between visits = 19.5 [− 10.4–56.1] vs. − 1.1 [− 12.7–4.9] (p = 0.049) for diabetics vs non-diabetics respectively). Moreover, a diabetes diagnosis was significantly associated with a high increase in EiA over time (top 10th percentile) even after adjusting for age, BMI, eGFR, METs, self-reported history of heart disease, systolic and diastolic blood pressure; OR = 4.4 (1.01–19.3 95% CI) (p = 0.049). Finally, elevated fasting blood glucose (≥ 100 mg/dl) was the strongest and only significant predictor for a greater increase in EiA over time after adjusting for all five metabolic syndrome components; blood glucose, waist circumference, blood triglycerides, HDL cholesterol, and BP criteria; OR = 4.0 (1.6–9.8 95% CI) (p < 0.01).Patients with diabetes and/or elevated fasting blood glucose increase their exercise-induced urinary albumin excretion over time. The ability of EiA to predict major clinical outcomes in patients with and without diabetes needs to be determined in future studies. Diabetes and impaired glucose metabolism lead to endothelial dysfunction and kidney injury . ExcessiExercise induced albuminuria (EiA) appears earlier and may be a more sensitive biomarker for kidney endothelial damage . We and A recent report showed that changes in rest UACR over time modifies the risk of major clinical outcomes and mortality in diabetic patients . AccordiHere, we sought to determine the change in EiA levels over time in a cohort of diabetic and apparently healthy individuals, and to reveal the factors responsible for “abnormal” changes.We prospectively enrolled consecutive patients attending a routine annual health survey at the Tel-Aviv Medical Center Inflammation Survey (TAMCIS), a registered databank of the Israeli Ministry of Justice –16. Subj2) and patients with a prior incidence of stroke were also excluded. The final study cohort comprised 412 participants. Population characteristics are presented in Table We collected urine samples for albumin and creatinine measurements from participants before and after an exercise stress test and analyzed data collected from patients attending at least two consecutive visits at TAMCIS. Out of 433 subjects with at least two consecutive visits, we excluded 19 subjects due to lack of urinary tests . Patients with diagnosed kidney failure , which is an improved albumin detection method with an extended analytic range of 3–420 mg/l and coefficient of variation of 2% . It is aSeparation of HbA1c from non-glycated hemoglobin of whole blood samples in EDTA was done by Tosoh’s G7 HPLC . The concentrations of glycated hemoglobin (HbA1c) and the concentration of total hemoglobin were measured, and the ratio reported as % HbA1c. HbA1c levels were categorized into three states, healthy; < 5.7%, pre-diabetic; 5.7–6.4% and diabetic; ≥ 6.5% according to the American Diabetes Association (ADA) guidelines .We measured urinary albumin and creatinine before and after the exercise stress test. EiA was defined as the change in albumin excretion following exercise  divided by the rest urinary creatine measurement.Elevated EiA was defined as > 20 mg/g as this was the lower bound of the top quartile of the cohort. Similar cut-off values have been shown to be associated with metabolic dysfunction and abnormal cardiac findings in our previous reports , 22.Evaluation and diagnosis of metabolic syndrome (and it’s components) was performed based on the joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity . BrieflyBlood pressure was recorded as the mean of 2 seated measurements. Hypertension was defined as systolic blood pressure of 140 mmHg or higher, diastolic blood pressure of 90 mmHg or higher, or the use of antihypertensive medications. Diagnosed diabetes mellitus was defined as a self-reported physician diagnosis of diabetes or current use of diabetic medications.t-test for normally distributed variables and by the Mann–Whitney U-test for non-normally distributed variables. To assess associations among categorical variables, we used a χ2-test. Spearman’s test was used to assess the correlation between EiA levels on the first and second visit.All continuous variables are displayed as means (SD) for normally distributed variables or median [interquartile range (IQR)] for variables with abnormal distribution. Categorical variables are displayed as numbers (%) of patients within each group. The different biomarkers in patients with and without diabetes were compared by a Student’s We used Kruskal–Wallis’s test with Dunn’s test for multiple comparisons to evaluate the difference in EiA according to categorized HbA1c levels.To identify possible confounders, we performed a multivariate binary logistic regression to predict a high increase in EiA between visits . The model was adjusted for the following covariates measured during the participants` first visit: age, diabetes diagnosis, body mass index (BMI), eGFR, self-reported history of heart disease, systolic and diastolic blood pressure at rest and metabolic equivalents (METs). To determine the relative effect of each metabolic syndrome component on the increase in EiA between visits, we used the same model adjusted to all five components . The same model was then used to predict a high increase in rest UACR between visits . We performed an additional binary logistic regression to predict a high increase in EiA adjusted to the following covariates: age, sex and the continuous change between visits in fasting blood glucose, BMI, eGFR, systolic and diastolic blood pressure, and METs.We used the R statistical package  along with IBM SPSS Statistics 25.0 statistical package  and GraphPad Prism version 8.00  for all statistical analysis.Baseline characteristics are presented in Table Rest UACR levels were 3.7 mg/g [1.3–8.7] during the first visit and 2.4 mg/g [1.2–5.5] for median [IQR] during the follow up visit. The median change in rest UACR was − 0.4 mg/g [− 4.5 to 1.7] [IQR].Urinary albumin concentrations were elevated after exercise across all consecutive visits. The median change in urinary albumin from before to after exercise was 2.3 mg/l [− 0.1 to 12.1] [IQR] on the first visit and 1.5 mg/l [0–9.4] [IQR] on the second visit. The exercise induced change in UACR (EiA) was 3.9 mg/g  for median [IQR] on the first visit and 2.4 mg/g [0–13.4] during the follow-up visit.EiA measurements demonstrated a significant correlation between the two visits Fig. a. ElevatNext, we sought to characterize the change in EiA over time. The majority of the cohort demonstrated a minor change in EiA levels between the two visits; median change in EiA = − 0.9 − 12.3 to 5.1] [IQR]  even after adjusting for age, BMI, eGFR, METs, self-reported history of heart disease, systolic and diastolic blood pressure; OR = 4.4 (1.01–19.3 95% CI) (p = 0.049). Moreover, the continuous change in fasting blood glucose concentration between visits was the only significant predictor of a high increase in EiA over time after adjusting for age, sex and the respective changes in BMI, eGFR, systolic and diastolic blood pressure, and METs; OR = 1.05 (95% CI 1.01–1.09) (p = 0.03).Finally, we wanted to determine which parameters of the metabolic syndrome were associated with the observed increase in EiA levels over time. Elevated fasting blood glucose criteria (≥ 100 mg/dl) was the strongest and only significant predictor for an elevated increase in EiA over time after adjusting for all five metabolic syndrome components; blood glucose, waist circumference, blood triglycerides, HDL cholesterol, and blood pressure criteria Fig. . When coNotably, although patients with hypertension had higher EiA levels compared with normotensive subjects on both visits (median [IQR] = 8 mg/g [0–32] vs 3.5 mg/g − 0.2 to 15.8] (p = 0.04) on the first visit and 4.2 [0.3–19.2] vs 2.2 [− 0.2 to 12.3] (p = 0.08) on the second visit), they did not change their EiA levels over time differently than normotensive individuals; change in EiA = − 1.9 [− 17.9 to 5.9] vs. − 0.8 [− 10.9 to 5.1] for median [IQR] (p = 0.36) respectively. Hypertensive patients taking antihypertensive medications (n = 58) had a greater reduction in EiA between the two visits compared with untreated individuals, albeit not statistically significant; change in EiA between visits = − 3.1 mg/g [− 24.1 to 11.5] vs. − 1.6 mg/g [− 12.9 to 4.2] for median [IQR] (p = 0.7). The majority of treated patients used angiotensin converting enzyme inhibitors (ACEi) and/or angiotensin receptor blockers (ARBs) (70%)  which may imply that these individuals adopted a healthier life style after their first visit to our annual heath survey. This trend cannot necessarily be generalized to other populations. Nonetheless, the group of individuals who regressed their EiA from abnormal values at baseline to normal values on the second visit were the ones who had the greatest reduction in fasting blood glucose levels. This strengthens our main hypothesis that glucose metabolism is the main predictor of EiA in presumably healthy adults. A second limitation is that part of our observed changes in EiA over time could be attributed to the ‘regression to the mean phenomenon’  which neIt should be noted that our current threshold for an increased change in EiA (top 10th percentile) was statistically driven in order to study the extremities of the cohort and will have to be adjusted in future prospective studies that will measure clinical outcomes.Finally, the current study cohort was notably male dominant (85% men) and limited our ability to determine statistically significant sex-and-gender related differences in EiA levels over time. Our past report shows that elevated EiA is associated with abnormal ECG findings in apparently healthy women rather than men . Thus, fWe conclude that individuals with diabetes and/or elevated fasting blood glucose increase their EiA levels over time. EiA should be further studied as an early and sensitive biomarker for kidney reserve and endothelial dysfunction in patients with metabolic syndrome.


Introduction: One of the main factors contributing to the development of nutritional deficits in chronic heart failure (CHF) patients is the systemic inflammatory process. Progressing inflammatory response leads to exacerbation of the disease and could develop into cardiac cachexia (CC), characterized by involuntary weight loss followed by muscle wasting. The aim of this study was to assess the relationship between rs767455 (36 T/C) of the TNFRSF1A and the occurrence of nutritional disorders in CHF patients with cachexia. Materials and Methods: We enrolled 142 CHF individuals who underwent cardiac and nutritional screening in order to assess cardiac performance and nutritional status. The relationship between TNFRSF1A rs767455 genotypes and patients’ features was investigated. Results: A greater distribution of the TT genotype among cachectic patients in contrast to non-cachectic individuals was found . We noted a significantly lower albumin concentration (p = 0.039) and higher C-reactive protein (CRP) levels (p = 0.019) in patients with the TT genotype. Regarding cardiac parameters, CHF individuals bearing the TT genotype demonstrated a significant reduction in ejection fraction (EF) (p = 0.033) in contrast to other genotype carriers; moreover, they had a significantly higher concentration of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) in the blood (p = 0.018). We also noted a lower frequency of TT genotype carriers among individuals qualified as grades I or II of the New York Heart Association (NYHA) (p = 0.006). The multivariable analysis selected the TT genotype as an unfavorable factor related to a higher chance of cachexia in CHF patients (Odds ratio (OR) = 2.56; p = 0.036). Conclusions: The rs767455TT genotype of TNFRSF1A can be considered as an unfavorable factor related to a higher risk of cachexia in CHF patients. TNFRSF1A. The protein encoded by this gene belongs to the TNF receptor family. This major receptor for TNF-alpha activates NF-kappaB, mediates apoptosis, and regulates inflammation [Chronic heart failure (CHF) is a clinical syndrome characterized by systemic inflammation and immune system activation . The incammation .TNF/lymphotoxin gene cluster and TNFRSF1A was investigated in relation to the outcome of Hepatitis C Virus (HCV) infection. Genetic polymorphism in the TNF/lymphotoxin and TNFRSF1A genes was demonstrated to have an impact on the susceptibility and chronicity of HCV infection among the Chinese Han population [TNFRSF1A:rs767455 (36T/C) was found to have an impact on anti-TNF-alpha clinical outcomes among patients with Crohn’s disease. It was associated with a higher incidence of infections with Mycobacterium avium subsp. paratuberculosis (MAP).The effect of single nucleotide polymorphisms (SNPs) rs2229094, rs1041981, and rs1799964 of the TNFRSF1A gene status and the development of nutritional disorders in patients with CHF. The aim of this study was to assess the relationship between SNPs (36T/C) of the TNFRSF1A gene and the occurrence of nutritional disorders in CHF patients with cachexia.To our knowledge, there are no studies on the correlation between the There were 142 CHF individuals (mean age: 72 ± 13 years) enrolled in the study group. All individuals were patients of the Clinic of Cardiology and Internal Medicine, Department of Cardiology, Military Hospital in Lublin, Poland, in the period between 2013 and 2015. The European Society of Cardiology (ECS) criteria were applied for the CHF diagnostic purposes and supplemented by patients’ clinical screenings and echocardiographic assessments (ejection fraction (EF); left ventricular end-diastolic and end-systolic diameters (LVEDd and LVESd); left anterior descending artery (LAD); tricuspid annular plane systolic excursion (TAPSE); right ventricular outflow tract (RVOT), followed by laboratory tests , lipidogram, creatinine and hemoglobin concentration). To assess the extent of the disease, the New York Heart Association (NYHA) functional classification was applied. The following inclusion criteria for the study participants were defined: (1) age >18 years and Polish ethnicity; (2) signed informed consent to participate in the study; (3) a lack of metallic implants or an implanted cardioverter defibrillator. The exclusion criteria were the following: (1) acute coronary syndrome; (2) extreme renal failure; (3) recent coronary artery bypass grafting (within the last 6 months); (4) hyper- or hypothyroidism. Characteristics of the study group are presented in We adapted Evans’s criteria for cachexia detection, as follows: a weight loss of ≥5% or more in 12months or less in the presence of underlying illness, plus three of the following criteria: decreased muscle strength, fatigue, anorexia, low fat-free mass index, abnormal biochemistry (increased inflammatory markers: C-reactive protein >5.0 mg/L), anemia (hemoglobin <12 g/dL), and a low concentration of serum albumin (<3.2 g/dL)) . The obsThe nutritional screening included anthropometric measurements , followed by a subjective global assessment (SGA) questionnaire. The parameters reflecting nutritional status and the body composition were derived from bioelectrical impedance analysis (BIA) and included fat mass (FM) and fat-free mass (FFM). Additionally, the phase angle (PA) (at a 50 kHz frequency) and capacitance of cell membrane (Cm) values were derived from the BIA. Similar conditions of the BIA measurements were provided for all study participants. The ImpediMed bioimpedance analysis SFB7 BioImp v1.55 device  was used to measure the parameters reflecting the body composition.TNFRSF1A SNP: rs1799964) .We collected 5 mL of peripheral blood from each patient participating in the study. The samples were stored at −80 °C until further laboratory analysis. DNA isolation was performed by the column method using a dedicated kit according to the manufacturer’s recommendations . The genotyping reaction based on the Real-Time PCR technique was performed on a StepOnePlus device  according to the manufacturer’s protocol (using a Genotyping Master Mix and TaqMan probes specific for t-test (parametric) or the Mann–Whitney U (non-parametric) test was used. To assess the cachexia probability, depending on selected demographic, clinical, and genetic factors, logistic regression  and multivariable logistic regression analysis were used. Results p < 0.05 were considered statistically significant. The Bonferroni–Holm (BH) method was used to counteract the problem of multivariable comparisons [p values were introduced to the analysis and included in the tables demonstrating the study results.MedCalc 15.8 computer software was used for statistical analysis purposes . Data distribution of the studied parameters was checked by the Shapiro–Wilk test. Based on the results, either parametric or non-parametric statistical tests were applied. Differences between the values of the studied parameters independent of the studied SNP were recorded with the use of ANOVA or the ANOVA Kruskal–Wallis test. To analyze the differences in the values of the studied parameters between the cachectic and non-cachectic groups, either the Student parisons . The adjTNFRSF1A rs767455 was obtained in the whole study group: TT in 38 patients (26.7%), CT in 64 patients (45.1%), and CC in 40 individuals (28.2%). The distribution of genotypes was consistent with the Hardy–Weinberg’s equilibrium (HWE) in the whole study group (p = 0.241). The distribution of studied SNPs did not depend on the clinical demographic features of CHF patients (p > 0.05).Based on the genotyping data, the following distribution of the TNFRSF1A genotypes in CHF patients (p = 0.039) and higher C-reactive protein (CRP) levels (median CRP concentration = 12.43 mg/L (TT) vs. 4.60 mg/L (CC) and 7.70 mg/L (CT); p = 0.019) in patients with the TT genotype. Regarding the cardiac parameters, CHF individuals bearing the TT genotype demonstrated a significant reduction in EF (mean EF = 36 ± 14% (TT) vs. 43 ± 15% (CT) and 43 ± 15% (CC); p = 0.033) in contrast to other genotype carriers; moreover, they had a significantly higher concentration of NT-proBNP in the blood (median NT-proBNP concentration = 3953 pg/mL (TT) vs. 2697 pg/mL (CT) and 2077 pg/mL (CC); p = 0.018). We also noted a lower frequency of TT genotype carriers among individuals qualified to grades I and II of the NYHA . Additionally, both male and female TT carriers had significantly lower values of PA measuring at 50kHz in contrast to other genotype carriers .First, we compared clinical demographic, cardiac, and nutritional factors in accordance with the presence of patients . We notep = 0.022), increased NT-proBNP  and creatinine  plasma concentration. Moreover, both cachectic males and females demonstrated significantly lower values of PA at 50 kHz  in comparison with non-cachectic patients. We also recorded a greater distribution of the TT genotype among the cachectic patients in contrast to the non-cachectic individuals .In the subsequent stage of the study, we divided the CHF patients into two cohorts in relation to cachexia presence. Afterward, we compared the clinical, nutritional, and cardiac parameters between the groups . Despitep < 0.001) as the most significant factor affecting cachexia in CHF patients. Similar results were derived from multivariable regression analysis, and the patients with low albumin levels had over a sevenfold greater chance of developing cachexia . As for the impact of TNFRSF1A genotypes on cachexia incidence, both the univariate  and multivariable  analyses selected the TT genotype as an unfavorable factor related to a higher chance of cachexia in CHF patients.Eventually, we enrolled all studied parameters to uni- and multivariable regression analysis to identify the factors affecting the chance of cachexia in CHF individuals. In CHF is a growing public health problem. Because the incidence of CHF increases with age, largely due to risk factors such as hypertension or the chronic inflammatory state associated with chronic diseases, the epidemic of CHF is likely to grow in the future. Chronic inflammation developing on the basis of increased cytokine production, characteristic of patients with CHF, may result in the occurrence of nutritional status disorders and, consequently, may lead to irreversible changes, such as cachexia . Among mTNFRSF1A gene status and nutritional disorders. The available studies focus mainly on the role of this gene SNP in the course of gastrological conditions—mainly HCV and Crohn’s disease [It should be noted that the available literature lacks studies directly related to the relationship between  disease . Qasem e disease .In another study,  the impaTNFRSF1A gene and the occurrence of nutritional disorders in CHF patients with cachexia. The most interesting aspects of our findings that should be highlighted are the following: (a) significantly lower albumin concentration  vs. 3.42 ± 0.65 g/dL (CC) and 3.40 ± 0.58 g/dL (CT); p = 0.039) and higher CRP levels (median CRP concentration = 12.43 mg/L (TT) vs. 4.60 mg/L (CC) and 7.70 mg/L (CT); p = 0.019) in patients with the TT genotype; (b) patients with the TT genotype demonstrated a significant reduction in EF (mean EF = 36 ± 14% (TT) vs. 43 ± 15% (CT) and 43 ± 15% (CC); p = 0.033), significantly higher concentration of NT-proBNP in the blood (median NT-proBNP concentration = 3953 pg/mL (TT) vs. 2697 pg/mL (CT) and 2077 pg/mL (CC); p = 0.018) in contrast to other genotype carriers. What is worth mentioning is that both male and female TT carriers had significantly lower values of PA measuring at 50kHz compared to other genotype carriers . Low PA values were found in many chronic conditions, including cancers [It is difficult to compare our results to other studies, as there are no available reports regarding the correlation betweenrs767455 (36T/C) of the  cancers ,22,23,24 cancers , AIDS [2 cancers .p = 0.005). What is more, the assessment of the TNFRSF1A genotype impact on the incidence of cachexia revealed, in both univariate  and multiple  analysis, that the TT genotype was an unfavorable factor related to a higher chance of cachexia in CHF patients. This might be a particularly useful tool for clinical specialists to use with their patients and to monitor those with the TT genotype.We also found that the low level of albumin among patients with CHF resulted in a sevenfold greater chance of developing cachexia . Despite these limitations, to our knowledge, this is the first study attempting at an assessment of the TNFRSF1A:rs767455 genotype, demonstrating that it may be a useful marker in determining the risk of nutritional disorders in patients with CHF. CHF patients with low albumin levels had over a sevenfold greater chance of developing cardiac cachexia. The TNFRSF1A: rs767455 TT genotype was found to be an unfavorable factor related to a higher risk of cachexia in CHF patients. At the molecular level, this genotype will preferably exert TNF-alpha as a proinflammatory cytokine in many tissues, which will stimulate and increase an ongoing inflammatory process.Searching for new markers of inflammation involved in the development of malnutrition and cardiac cachexia, and explaining the mechanisms of their action, may allow for a more efficient diagnosis of nutritional disorders, faster implementation of nutritional treatment, and the development of new therapies. The presence of the studied SNPs in the regulatory region of the