ERAP1 and ERAP2 was investigated in 17,255 Caucasian female participants from the Women's Genome Health Study. All subjects were free of hypertension at baseline. During an 18-year follow-up period, 10,216 incident hypertensive cases were identified. Multivariable linear, logistic, and Cox regression analyses were performed to assess the relationship of genotypes with baseline BP levels, BP progression at 48 months, and incident hypertension assuming an additive genetic model. Linear regression analyses showed associations of four tSNPs  with baseline systolic BP levels. Three tSNPs  were associated with baseline diastolic BP levels. Multivariable logistic regression analysis showed that ERAP1 rs27772 was associated with BP progression at 48 months (p = 0.0366). Multivariable Cox regression analysis showed an association of three tSNPs  with risk of incident hypertension. Analyses of dbGaP for genotype–phenotype association and GTEx Portal for gene expression quantitative trait loci revealed five tSNPs with differential association of BP and nine tSNPs with lower ERAP1 and ERAP2 mRNA expression levels, respectively. The present study suggests that ERAP1 and ERAP2 gene variation may be useful for risk assessment of BP progression and the development of hypertension.Recent studies have demonstrated the importance of endoplasmic reticulum aminopeptidase (ERAP) in blood pressure (BP) homeostasis. To date, no large prospective, genetic–epidemiological data are available on genetic variation within ERAP and hypertension risk. The association of 45 genetic variants of  Elevated blood pressure is an important risk factor for the development of stroke, heart failure, and cardiovascular and renal disease. However, elevated blood pressure is controlled in only 54% of the US population with hypertension . This isEndoplasmic reticulum aminopeptidase-1  and -2  are multifunctional aminopeptidases that have been proposed to play important roles in the pathophysiology of inflammatory and immune disorders associated with the major histocompatibility complex class I (MHC-I), preeclampsia, and hypertension [In vitro, ERAP1 catalyzes the conversion of AngII to angiotensin III and IV [in vivo—results that are consistent with a role of ERAP1 in blood pressure homeostasis [ERAP1 and ERAP2 genes that are associated with preeclampsia [ERAP1 rs30187 gene variant and hypertension was reported in a small cohort of 143 hypertensive and 348 normotensive Japanese subjects. Of importance, this variant was associated with reduced trimming efficiency of ERAP1 to inactivate AngII and increase bradykinin levels [no association between genetic variants at the ERAP1 locus and essential hypertension in 1700 hypertensive and 1700 normotensive subjects [I and IV , and ERAI and IV . Recent eostasis . Furtherclampsia , 9, hemoclampsia , and hypclampsia . In partn levels . Moreoven levels . Howeversubjects . Furthersubjects –20.ERAP1 and ERAP2 gene loci as risk markers for hypertension. We thus evaluated the potential association of 33 ERAP1 and 12 ERAP2 tagging single-nucleotide polymorphisms (tSNPs) with (i) baseline systolic and diastolic blood pressure, (ii) blood pressure progression, and (iii) incident hypertension in a large prospective cohort of 17,255 initially healthy US white women.However, to date, no systematic, prospective epidemiological data are available that examine the relevance of the Details of the study design have been previously described , 22. In Blood pressure at randomization was self-reported by the participants, a group where self-report of blood pressure has proven highly accurate –27. WomeTo assess blood pressure progression, we created categories of self-reported blood pressure at 48 months of follow-up identical to those at baseline as previously described , 22. Blor2 ≈ 0.80) genotyping using the genome-wide Illumina Infinium II HumanHap300 panel [As described elsewhere, DNA extracted from the baseline WGHS blood samples underwent tSNP  Project consortium: GTEx Analysis Release V6p (dbGaP Accession phs000424.v6.p1). Effect estimates and p values were directly extracted from the GTEx dataset summary statistics report .To determine the relationship between gene variants and mRNA expression levels, we explored publicly available Expression Quantitative Trait Loci (eQTL) data  for ERAPin vitro) data are available on the interplay between various blood pressure regulatory peptides and ERAPs in relation to expression levels. In vitro, AngII activates endothelial cells, leading to increased angiogenesis and reactive oxygen species production among other effects [in vitro studies, the human endothelial cell line, EA.hy926 (American Type Culture Collection: CRL-2922), was used; this cell line was previously documented by us and others to be responsive to AngII and aldosterone activation [μM), an AngII type I receptor antagonist. Total RNA was extracted using the RNeasy Mini kit  following the manufacturer's instructions. cDNA was synthesized from 3 μg of total RNA with the First Strand cDNA Synthesis kit . PCR amplification reactions were performed with TaqMan gene expression assays for ERAP1 (Hs00429970_m1) and ERAP2 (Hs01073631_m1) in triplicate with the ABI Prism 7000 Sequence Detection System . The cycle threshold method was used following the manufacturer's recommendation to determine mRNA levels. Target gene expression was normalized to glyceraldehyde 3-phosphate dehydrogenase (GAPDH) and 18S rRNA levels.No  hormone use, was performed to assess the relationship of genotypes with baseline blood pressure measurements. Multivariable logistic regression analysis was performed to examine the associations between genotypes and blood pressure progression at 48 months, adjusting for age, BMI, history of diabetes, history of hyperlipidemia, current smoking status, exercise, alcohol use, education level, current (any) hormone use, and randomized treatment assignments. Hazard ratios (HRs) associated with each of the SNPs were calculated separately by Cox regression analysis, adjusting for age, BMI, history of diabetes, history of hyperlipidemia, current smoking status, exercise, alcohol use, education level, current (any) hormone use, and randomized treatment assignments. The proportional hazards assumption was examined for all of the models by including a genotype by logarithm of time interaction into each model. All analyses were carried out using SAS v9.1 package (SAS Institute Inc.) or R software, assuming an additive model for genetic effects. Because of the confirmatory nature of the current study and the extended data from several public consortia, a 2-tailed uncorrected (for multiple testing) p values <0.001. Results from the linear regression analyses showed evidence for differential associations of four SNPs  with baseline systolic blood pressure levels  with baseline diastolic blood pressure levels  with risk of incident hypertension  [ERAP1 genetic variants were associated with significantly decreased ERAP1 mRNA expression (p < 0.0025) except for rs27851 that showed an increase . RAAS plays a critical role in sodium, water homeostasis, and blood pressure regulation. Indeed, disordered RAAS activation is associated with endoplasmic reticulum stress, increased reactive oxygen species, and inflammation, thus contributing to the pathophysiology of stroke, hypertension, and heart failure –37. Our  tissues . We thusERAP, in particular ERAP1, may modulate RAAS activity which in turn may regulate ERAP1 levels through a potential negative feedback mechanism. ERAP regulates bradykinin and AngII levels. However, further studies are needed to characterize this novel relationship between endoplasmic reticulum activation and ERAP1 and RAAS activation for its potential therapeutic applicability in blood pressure regulation.Differential associations of ERAP gene variants with various outcomes have been reported , providiAs shown in Since several genome-wide association studies were conducted to determine the genetic risk factors for blood pressure –20, we fThe strengths of the present study are the overall sample size, the biological relevance of the polymorphisms considered, the prospective design, and the complete long-term follow-up among women. This is important as limited studies have addressed blood pressure outcomes in women exclusively and growing evidence shows that women are at a higher risk of developing hypertension-related cardiovascular diseases such as heart failure with preserved ejection fraction than men are . We alsoIn conclusion, the present findings provide evidence for the involvement of ERAP1 and ERAP2 gene loci in blood pressure regulation and the pathogenesis of hypertension with an added indication of ERAP1 gene locus as a potential therapeutic target for blood pressure management.


Introduction: No-reflowis one of the major complications of primary PCI in patients with acute STelevation myocardial infarction. This phenomenon is associated with adverseoutcomes in these patients. In the current study, we evaluated theeffectiveness of CHA2DS2-VASc score in predicting no-reflow phenomenon. CHA2DS2-VAScscore is a risk stratification method to estimate the risk of thromboembolismin patients with atrial fibrillation.Methods:  Intotal, 396 patients with ST elevation myocardial infarction who had undergone primaryPCI were evaluated in our study. Based on post interventional TIMI flow rateresults, the patients were divided into two groups: control group (294patients) and no-reflow group (102 patients). The CHA2DS2-VASc score wascalculated for each participant. Multivariate regression analysis was performedto determine the predictive value of this score.Results: Ourfindings showed that CHA2DS2-VASc score can predict no-reflow independently.Moreover, lower systolic blood pressure, higher diastolic blood pressure, grade0 initial TIMI flow rate and smaller stent size were other independentpredictors of the no-reflow in our study. We also defined a cut off value of ≥2 for the CHA2DS2-VASc score in predicting the no-reflow with a sensitivity of88% and specificity of 67%, area under curve: 0.83 with 95% CI (0.79-0.88).Conclusion:  The CHA2DS2-VASc scorecould be used as a simple applicable tool in the prediction of no-reflow beforeprimary PCI in the acute ST elevation myocardial infarction patients. No-reflow is defined as inadequate myocardial perfusion despite mechanical reopening of the culprit lesion with PCI. This phenomenon is related to higher incidence of complications, and short- and long-term morbidity and mortality in acute STEMI patients.4In patients with ST-segment elevation myocardial infarction (STEMI), the purpose of primary percutaneous coronary intervention (PCI) is immediate return of normal blood flow in the infarct-related artery.6 A multifactorial and complex pathophysiology has been suggested for mechanism of this event.8 Unfortunately, there is no widely accepted risk stratification method for the prediction of this complication.This phenomenon occurs in 0.6% to 5% of elective PCIs, but a higher incidence has been reported in patients who underwent primary PCI.9 The components of this score are related to atherosclerosis, vascular spasm and microvascular dysfunction similar to common risk factors of the no-reflow.10CHA2DS2-VASc score is a clinical predictor of thromboembolism events and is recommended in clinical guidelines for oral anticoagulant therapy in patients with nonvalvular atrial fibrillation.In this study, we evaluated the CHA2DS2-VASc score as a simple tool for predicting the no-reflow among patients with STEMI who underwent primary PCI.11 Patients with symptoms lasting more than 12 hours before admission, no intervention because of patent or normal coronary arteries, stenosis in the venous graft as culprit lesion, decision of emergency surgery because of inappropriate coronary anatomy for intervention and coronary artery dissection as a procedural complication were excluded from the study. Bedside 12-lead electrocardiography and routine blood tests were obtained from all admitted patients. Bedside echocardiography was also performed for the patients. All data were acquired from hospital records retrospectively.This retrospective analytic-cross sectional study used the data of 396 consecutive patients from October 2015 to October 2016 who were admitted to our cardiovascular center with a diagnosis of acute STEMI and underwent primary PCI Acute STEMI was diagnosed when patients had symptoms of acute myocardial infarction and new ST segment elevation in at least 2 contiguous leads of ≥0.2 mV in men or ≥0.15 mV in women in leads V2 to V3 and/or of ≥1 mm (0.1 mV) in other contiguous leads or new left bundle branch block, later confirmed by creatine kinase (CK) and CK-myocardial band (CK-MB) isoenzyme increases and/or troponin increases.All the patients who were candidate for primary PCI, received 325 mg of aspirin and a single loading dose of 600 mg clopidogrel at the time of diagnosis of STEMI coronary angiography was performed using standard technique. Immediately after the decision of coronary intervention, 50-70 unit/kg of intravenous bolus dose of unfractionated heparin was administered to the patients who were not treated with enoxaparin before the coronary angiography. For patients who have received an initial enoxaparin dose of 1 mg/kg before the angiography, no additional booster dose of enoxaparin was administered within 8 hours of the first dose. An additional booster enoxaparin of 0.3 mg/kg was given intravenously between 8–12 hours after the first dose. Thrombus aspiration catheter usage and administration of eptifibatide  were chosen according to the interventional cardiologist’s decision. The TIMI flow grades were evaluated by 2 blind cardiologists. The frame rate of cine images were 30 frames per seconds. Analysis of cineangiograms was performed by using an Axiom  workstation.12 Definition of the TIMI flow grades was as follows: Grade 0 refers to no flow at all after the culprit lesion. In grade 1, the contrast material flow after occlusion site but fails to opacify the entire artery. Grade 2 refers to opacification of the entire artery distal to the obstruction point, however the flow is slower than normal, and grade 3 refers to normal coronary flow.13The study population was divided into two groups of control and no-flow according to their final angiographic TIMI flow rates resulting from primary PCI. The control group was defined as the TIMI flow rate >2 and the no-reflow group was defined as the TIMI flow rate ≤2, despite mechanical reopening of the infarct-related artery in patients without dissection of the coronary artery.14 Congestive heart failure, hypertension, diabetes mellitus and hyperlipidemia was diagnosed based on patient’s past medical history.The CHA2DS2-VASc score was the sum of 1 point each for the presence of congestive heart failure, hypertension, diabetes mellitus, age of 65 to 74 years, female sex, and vascular diseases  and 2 points for age ≥ 75 years and a history of stroke or transient ischemic attack (TIA).15Peripheral arterial disease (PAD) was defined as the documentation of stenosis of 50% in noncoronary arteries. Definition of the chronic renal failure was based on a creatinine clearance of less than 60 mL/minute, which was calculated by Cockroft formula.Quantitative variables were defined as mean value ± standard deviation (SD), and qualitative variables were defined as frequency and percentage.t test, respectively. Multivariate logistic regression analyses were performed to determine the independent predictors. Variables that could be a predictor of no-reflow with a significant P value were entered into multivariate analysis. The results of univariate and multivariate regression analyses were presented as odds ratio with 95% CI. The ROC curve was also used to demonstrate the sensitivity and specificity of CHA2DS2-VASc score and its cut-off value in predicting the no-reflow. A P value < 0.05 was considered as statistically significant. Statistical analyses were conducted using STATA version 13.0.The Kolmogorov-Smirnov test was used to evaluate whether the distribution of continuous variables was normal. Categorical and continues variables, were analyzed using chi-square test and independent sample Demographics, clinical and angiographic data of the patients are listed in P < 0.001) and prevalence of grade 0 initial TIMI flow rates was significantly higher in them .Compared to control group, patients in the no-reflow group were older . Furthermore, in comparison to control group, all components of CHA2DS2-VASc score, including history of heart failure, hypertension, age between 65 and 74, diabetes mellitus, history of stroke/transient ischemic attack, vascular disease, age ≥75, and female gender were significantly higher in the no-reflow group. History of previous MI and peripheral arterial disease were more common in the no-reflow group, but history of previous by-pass surgery did not differ between the two groups .The mean CHA2DS2-VASc score was 1.6 ± 1.4 and it was significantly higher in the no-reflow group compared to the control group  compared to the control group. Anemia, chronic renal failure and hyperlipidemia were also more prevalent in them than in the control group.Patients with the no-reflow had significantly lower mean glomerular filtration rate, left ventricle ejection fraction, systolic blood pressure (SBP) and diastolic blood pressure (DBP) and they had significantly higher in-hospital mortality rate .There was no significant difference between two cohorts in duration from symptoms initiation to primary PCI  and thrombus aspiration  based on operator decision were similar in the two cohorts. These variables interpreted as a consequence of high risk lesions and therefore were not entered in the regression analysis.Use of eptifibatide infusion  of the no-reflow. Moreover, other independent predictors of the no-reflow in our study were lower SBP, higher DBP, grade 0 initial TIMI flow rate and lower stent diameter.Results from the multivariate logistic regression analysis showed that CHA2DS2-VASc score is a significant independent predictor . Then, we performed a ROC analysis as depicted in Predictive power of individual characteristics of the CHA2DS2-VASc score was determined in a separate univariate and multivariate regression analysis and is shown in 16 which evaluated the predictive power of CHA2DS2-VASc score in 1781 patients with STEMI who underwent primary PCI.Our study declares the usefulness of CHA2DS2–VASc score in predicting no-reflow phenomenon after primary PCI in STEMI patients. Moreover, we reached a cut-off value of ≥2 for predicting no-reflow possibility in these patients. These findings are in concordance with a previous study of Ipek et al17Primary PCI is the preferred revascularization method in most patients with a diagnosis of acute STEMI, but acute reduction in myocardial blood flow after this procedure despite a patent epicardial coronary artery, the so-called “no-reflow phenomenon”, leads to adverse outcomes in these patients.19 The reason is complexity of proposed pathophysiologic mechanisms for no-reflow phenomenon.Although there are few experimental therapies to solve this complication but no standard treatment has yet been defined.20 Using a simple and quick scoring system for risk stratification of no-reflow in STEMI patients who are candidate for primary PCI, enables physician to choose the best treatment strategy. In this regard due to similarity of underlying mechanisms of no-reflow phenomenon with major risk factors of thromboembolic events among patients with atrial fibrillation we chose CHA2DS2-VASc score for deciding about revascularization method.Some studies suggest deferring stent strategy to reduce no-reflow after PCI.21 hypertension and ischemic cardiomyopathy,5 as well as age 65-74 years and age ≥7516 were predictors of no-reflow in our study similar to previous studies.Congestive heart failure,22 Similarly, although peripheral arterial disease can increase mortality and morbidity in ACS patients but no specific study has shown the correlation between PAD and no-reflow.24 Indeed impaired microvascular reperfusion due to diabetes explains this association and in the same manner the similar vascular mechanism of PAD with coronary artery disease can determine the association between PAD and no-reflow.In our cohort, multivariate analysis showed that diabetes mellitus and peripheral arterial disease are associated with no-reflow during primary PCI. This finding is not similar to earlier studies which did not find diabetes mellitus as a predictor in spite of demonstrating an association between hyperglycemia and no-reflow.25 lower stent diameter and length lesion >20 mm26 are independent predictors of no-reflow. Our results also showed that lower stent diameter can predict no-reflow. Based on our findings grade 0 TIMI flow rate at initial angiography also was an independent predictor of no-reflow similar to another previous study.27Various clinical and angiographic predictors of no-reflow have been proposed in previous studies. For example, thrombus burden and its angiographic features,28 This mechanism and oxidative stress of ischemic endothelial cells along with vasoconstriction can reduce perfusion of microvasculator and lead to no-reflow.Our findings also revealed that lower systolic blood pressure is correlated with increased risk of no-reflow independently. It might be related to reduction of coronary arterial perfusion pressure due to decreased blood pressure. Moreover, swelled myocardial cells concomitant with interstitial edema might lead to microvascular compression.30 There is also an association between abnormal vascular function and stroke.31 Although, in our cohort after multivariate analysis there was no significant relationship between no-reflow and female gender and stroke.Many of the risk factors such as hypertension, diabetes mellitus and female gender that were discussed above are associated with microvascular dysfunction.9 consisted of similar risk factors of microvascular dysfunction as an important mediator of no-reflow. The components of this score are common risk factors of atherosclerosis, vascular spasm, microvascular dysfunction as well as no-reflow and stroke.10 Thus, it is anticipated that CHA2DS2-VASc score could predict no-reflow phenomenon as we confirmed in our cohort. Furthermore, use of this score is very simple and makes it a quick tool to predict no-reflow before primary PCI.CHA2DS2-VASc score used to predict thromboembolic events in patients with atrial fibrillation rhythm,Retrospective design of our cohort, is one of the limitations of the study. Many of variables in this study were based on a review of pervious clinical history of the patients in an acute phase of STEMI and it may affect our results. Another important issue is limited sample size. Finally, there are multiple risk factors for the no-reflow that we did not assess them and it might have affected our multivariate analysis.16 Although, it is suggested that the predictive power of this score should be reevaluated in a prospective study with a larger sample size and with more comprehensive risk factors to confirm our results.In conclusion, we showed the CHA2DS2-VASc score potential to predict the no-reflow phenomenon in the patients with STEMI before primary PCI and this finding was similar to a previous study.Our study was approved by the local ethics committee. . All the participants filled out the signed consent form.All authors declare no competing financial interests exist.


The aim of this study was to describe, through a systematic review, the acute and chronic effects of isometric handgrip exercise on cardiovascular variables in hypertensive individuals. In this systematic review, we included studies that analyzed whether a single bout or a program with isometric exercises affect cardiovascular variables in hypertensive adults. The electronic database PubMed/Medline was searched for relevant studies published until May 2017. Of the 2927 studies initially identified, 2916 were excluded based on title and abstract and five on the basis of full-text assessment, leaving six studies remaining. In addition, one further study cited in the references of the included articles was included in this review, totaling seven studies included (five studies on the chronic effects of isometric handgrip exercise on cardiovascular parameters). None of the acute studies observed post-exercise hypotension. The majority of the chronic studies found decreases in office blood pressure after isometric handgrip training, with training ranging from 6 to 10 weeks, while heart rate variability parameters were improved in one study and did not change in another. Reduction in oxidative stress was observed; however, this variable was only analyzed in one study. In hypertensives, acute responses to isometric handgrip exercise are very limited due to the small number of studies, therefore more research is required. Furthermore, chronic isometric handgrip training reduces blood pressure; however, there is still a gap in the knowledge on the effects of this modality of exercise on other cardiovascular variables—such as endothelial function, oxidative stress, and cardiac autonomic modulation—which should be addressed in future studies. Hypertension affects more than 1 billion people . InterveMeta-analytical studies ,5,6,7,8 To date, no meta-analytical study or systematic review has focused on the acute effects of isometric exercise on cardiovascular variables in hypertensive subjects. Since an acute bout of exercise can transiently improve cardiovascular homeostasis, as well as predict chronic effects of training ,14, it iIn addition to office blood pressure, exercise interventions have been shown to improve other cardiovascular variables highly related to cardiovascular risk, including endothelial function, arterial stiffness, and ambulatory blood pressure . HoweverTherefore, the aim of this report was to describe, through a systematic review, the acute and chronic effects of isometric handgrip exercise on blood pressure and other cardiovascular variables in hypertensive individuals.This review analyzed the acute and chronic effects of isometric handgrip exercise on some important cardiovascular parameters in hypertensive adults. Original studies published in indexed journals in the electronic database PubMed/MedLine  were searched. No language restrictions were imposed.The electronic search was performed using advanced tools that allow the combination of descriptors and terms, defined in Medical Subject Headings (MeSH). The search strategy was performed by four blocks of terms such as exercise , outcomes , age (adult OR young adult OR aged), and population (high blood pressure OR hypertension OR hypertensive). Subsequently, the search results were combined . The seaEligibility criteria for inclusion were: (a) isometric handgrip exercise interventions; (b) evaluating at least one cardiovascular parameter; (c) sample including only hypertensive subjects of any age. The sample data extracted from the studies included, but were not limited to, variables related to patient characteristics , intervention protocol , and cardiovascular variables. Study quality was assessed using the Tool for the Assessment of Study Quality and reporting in Exercise (TESTEX) scale . This scTwo experienced researchers independently performed the electronic search, article selection, and data extraction and the results were compared. Disagreements were discussed and a third researcher made the final decision.The results of the literature search are presented in n = 2), heart rate (n = 2) by ECG, systemic vascular resistance (n = 1), cardiac index (n = 1) by means of impedance cardiography, and rate pressure product (n = 1). The duration of follow-up after the exercise bout was 60 minutes in one study [ne study  and 24 hne study .The synthesis of acute studies revealed that systolic blood pressure remained unchanged immediately after exercise , while in = 5), diastolic (n = 5), and mean blood pressure (n = 5); ambulatory blood pressure (n = 1); cardiac autonomic modulation indices, such as heart rate variability (n = 2); and blood pressure variability (n = 1). The vascular variable evaluated was oxidative stress (n = 1). Four studies performed four sets with two minutes of contraction, with a one-minute rest interval, at 30% of maximal voluntary contraction, three times per week, while one [In the five chronic studies, the number of subjects ranged from 10 to 40 individuals. Four studies were randomized controlled trials ,21,22,24hile one  performeOffice systolic blood pressure was significantly reduced in four studies (80.0%) and unchanged in one study. Office systolic blood pressure reductions ranged between 5 to 19 mmHg. Office diastolic blood pressure was significantly lower following isometric handgrip training in one study (6 mmHg) and unchanged in four studies. Mean blood pressure reduced in three studies (60.0%) (3 to 6 mmHg) and was unchanged in two studies. Ambulatory blood pressure did not change after isometric training . One stuThe major findings of this systematic review are three-fold: (a) only two studies investigated the acute effects of isometric handgrip exercise on cardiovascular variables in hypertensives; (b) the only study available suggested that one single bout of isometric handgrip exercises does not decrease office blood pressure; and (c) the majority of the chronic intervention studies reported significant reductions in blood pressure; however, the chronic effects of handgrip training on cardiac autonomic modulation remain unknown.Our study demonstrates the lack of evidence analyzing the acute effects of a single bout of isometric handgrip exercise on cardiovascular parameters in hypertensive individuals. Two studies were identified ,19, of wMoreover, there was relative homogeneity regarding the isometric exercise protocols used among the chronic intervention studies. That is, four out of five studies required their participants to complete four sets with two minutes of contraction, with 30% maximum voluntary contraction. Overall, these studies demonstrated reductions in office blood pressure, mainly systolic blood pressure. Only one study  used a dAlthough decreases in blood pressure following handgrip training programs have already been described in previous meta-analytical studies ,5,6,7,8;The studies presented controversial results on the effects of handgrip exercise training on cardiac autonomic modulation. Taylor et al.  observedThis study has potential practical applications. The American Heart Association in 2013 classified isometric exercise as Level of Evidence C and Class of Recommendation IIb, due to the absence of studies with hypertensives. However, in this review, we verified that four out of five studies (80.0%) demonstrated reduced office blood pressure after isometric handgrip training, which strengthens the efficacy of this kind of exercise in the treatment of hypertension, in particular, as handgrip isometric exercise may be performed anywhere, is easy to perform, and is of short duration (about 30 min/week). Moreover, no study reported any acute or chronic adverse events of isometric handgrip exercise, demonstrating the safety of this type of exercise. Araujo et al.  found a In conclusion, the available literature indicates that acute isometric handgrip exercise does not affect post-exercise blood pressure in hypertensive subjects, although the need for further studies is clear. On the other hand, chronic isometric handgrip training significantly decreases blood pressure. However, given the limited available data on the effects of isometric handgrip training exercise on other cardiovascular variables, such as endothelial function, oxidative stress, and cardiac autonomic modulation, more research is warranted.


Background: Eosinophilic airway inflammation is common in asthma patients and appears to be associated with severe exacerbations and loss of asthma control.Objective: To describe the resource utilization and clinical characteristics of patients with eosinophilic asthma.Design: Asthma patients ≥18 years with ≥1 blood eosinophil count in secondary care (South West Finland) during 2003‒2013 were included. Clinical characteristics  and asthma-related resource utilization  were retrieved. Resource utilization rates were compared for patients with blood eosinophil ≤ or >300 cells/μL, using adjusted negative binomial regression models.Results: Overall, 4,357 eligible patients were identified , of which 1,927 (44%) had >300 eosinophil cells/μL blood. Patients with ≤300 and >300 eosinophil counts, exhibited similar clinical characteristics, including advanced age, poor lung function, and overweight. Comorbidities such as pneumonia, sinusitis, and nasal polyps, were more frequent among those with >300 eosinophil cells/μL blood compared with patients with lower counts. Eosinophil counts >300 cells/μL were associated with greater hospital admissions  and outpatient visits  compared with patients with lower eosinophil counts. Rates of ER visits were similar between the patient groups .Conclusions: Hospital admissions and outpatient visits occurred more often for patients with eosinophil counts >300 cells/µL, than for patients with lower eosinophil counts. Routine blood eosinophil screening might be useful to identify patients with an eosinophilic phenotype eligible for more targeted treatments. Asthma is a serious global health problem, affecting more than 315 million people in all age groups worldwide –5. HowevApproximately 50% of all asthma patients suffer from eosinophilic inflammation –12. ElevThe burden caused by eosinophilic asthma in Finland is not clearly described. To potentiate informed decisions on optimized asthma care management in Finland, we sought to better understand the burden of eosinophilic asthma. The objective of this study was to describe the clinical characteristics and asthma-related health care resource utilization of eosinophilic asthma patients in Finnish secondary health care.This was a non-interventional study in secondary care of South West Finland hospital district . Data on clinical characteristics  and asthma-related resource utilization  was retrieved from the Auria Biobank  Research Database.The study population comprise of adult, physician diagnosed asthma patients : J45 and J46) with data available in the Auria Biobank Research Database, and at least one measurement of blood eosinophils between 1 January 2003 and 31 August 2013.Asthma-related health care resource utilization was defined as the number of hospital admissions and days, emergency room (ER) visits and secondary care outpatient visits with an asthma diagnosis. The date of the first asthma diagnosis during the study period was defined as the index date. All patients were followed from the index date until death or the end of study (31 August 2013).Patients were classified based on their greatest blood eosinophil counts  during the observation period and grouped into ≤300 eosinophil cells/μL and >300 eosinophil cells/μL according to clinical practice. Health care resource utilization was described using increments of eosinophil cutoff of >150, >300, >450, and >600 cells/μL.Lung function, BMI and comorbidities (Charlson Comorbidity Index ) were dePatients who had sputum eosinophil sample taken within a three months time-window from the greatest blood eosinophil sample were classified in a semi-quantitative manner based on the visual number of eosinophil cells per sputum strand into three sputum eosinophil subgroups: ‘none’ and ‘moderate,’ and ‘dominant.’ Sputum eosinophil samples were collected, processed, and analyzed by specialized staff at the TYKSlab .2 test was used for categorical variables. Variables measured on the interval or ratio scale were compared with an ANOVA test or a Mann-Whitney U test if the distribution were skewed.Distribution of clinical characteristics was compared between patients ≤300 and >300 eosinophil cells/μL blood. The χn = 56) who had a follow-up period less than 1 month were excluded.Asthma-related health care resource utilization was reported as crude rates per patient-year . Furthermore, a negative binomial regression model (for over dispersed outcome data) was used to compare the rates of resource utilization events  for eosinophil counts. The negative binomial analyses were adjusted for the following confounders: age, sex, and comorbidity. As a sensitivity analysis, patients , and poor lung function  , of which 4,357 (57%) patients had at least one blood eosinophil count (median 270 eosinophil cells/μL blood). A total of 1,927 (44%) patients had blood eosinophil count >300 cells/µL and the majority patients were women . Both paDuring the observation period, covering a total of 20,819 patient-years, the main driver of the asthma-related health care resource utilization was outpatient visits with a rate of 1.09 visits per patient-year, followed by hospital admissions (0.29 admissions per patient-year) and emergency room visits (0.11 visits per patient-year) . The aven = 623 [14%]) the RR was 1.19  for hospital admissions and 1.40  for outpatient visits (The adjusted rate ratios (RR) were slightly greater for patients with eosinophil count >300 cells/µL for hospital admissions  and outpatient visits  compared to those with lower count ,b). Amont visits ,b) compat visits ).10.1080The sensitivity analysis indicated that excluding patients with less than 1 month follow up did not alter the results (data not presented).p < 0.01) between blood and sputum eosinophil count  who had sputum eosinophil sample taken within a 3 months’ time-window from the blood eosinophil sample (mean: 10.5 days [SD: 20.7]) suggested a moderate Spearman correlation coefficient of 0.49 (il count .10.1080/There was no difference in the adjusted rate ratios (RR) of hospital admissions and outpatient visits for the moderate and dominant sputum eosinophil groups compared to the non-sputum eosinophil group . HoweverOf more than 4,300 adult asthma patients who had a recorded blood eosinophil count in secondary care, more than 40% had a blood eosinophil count of >300 cells/μL. The rate of hospital admission was 13% greater and the rate of outpatients’ visits was 11% greater, for these patients compared with the 300 cells/μL or less eosinophil group. These findings correspond to the findings of other observational studies –23 and sTraditionally, management of asthma patients has been based on assessment of symptoms, lung function, and use of rescue medication . HoweverComorbid upper airway disease is common in patients with asthma ,37, and This study has several limitations, and the findings should be interpreted with caution. We used the greatest blood eosinophil count during the study period as a proxy of eosinophil activation, which may have introduced non-differential misclassification leading to a potential attenuation of the results and in such a minor difference between the two groups (≤ and >300 cells/μL). Measures of blood eosinophil count tend to have a great deal of variability –43. MathIn addition, our study may have been prone to selection bias. The study population was identified in the Auria Biobank Research Database, which include patients having a tissue sample taken while being treated in secondary care in the South West Finland hospital district. However, most of the asthma patients typically are treated in primary care. Other observational studies investigating the relation between blood eosinophil count as a biomarker of eosinophils activation and asthma outcomes included patients from primary care –19,21–23Information on important confounding factors such as treatment and asthma control which could affect eosinophil level and disease progression  is lackiAlmost half of the patients identified initially with asthma  did not have any measure of blood eosinophil. Patients who have at least one measure of blood eosinophil may be different in clinical presentation or severity (more severe) compared with patients who never have an eosinophil test measured. Therefore, our results may not be generalized to the entire asthma population.Health care hospital admissions and outpatient visits were more often observed for patients with eosinophil counts >300 cells/µL blood than for patients with lower eosinophil counts. Routine blood eosinophil screening might be useful to identify patients with an eosinophilic phenotype for more targeted treatments, but also monitor and prevent disease activity in order to obtain disease control and reduce the utilization of health care resources.


Main findings in the biopsies were chronic glomerular and tubulointerstitial damage with glomerulosclerosis (8–75%), glomerular hypertrophy and mild to moderate tubulointerstitial changes. The morphology was more heterogeneous and interstitial inflammation and vascular changes were more common compared to our previous studies of MeN. In two patients the biopsies showed morphological signs of acute pyelonephritis but urine cultures were negative. Electrolyte disturbances with low levels of serum sodium, potassium, and/or magnesium were common. In the urine, only four patients displayed albuminuria, but many patients exhibited elevated α-1-microglobulin and magnesium levels. This is the first study reporting detailed biochemical and clinical data together with renal morphology, including electron microscopy, from Sri Lankan patients with CKDu. Our data show that there are many similarities in the biochemical and morphological profile of the CKDu endemics in Central America and Sri Lanka, supporting a common etiology. However, there are differences, such as a more mixed morphology, more interstitial inflammation and vascular changes in Sri Lankan patients.In Sri Lanka, an endemic of chronic kidney disease of unknown origin (CKDu) is affecting rural communities. The endemic has similarities with Mesoamerican Nephropathy (MeN) in Central America, however it has not yet been clarified if the endemics are related diagnostic entities. We designed this study of kidney biopsies from patients with CKDu in Sri Lanka to compare with MeN morphology. Eleven patients with CKDu were recruited at the General Hospital, Polonnaruwa, using similar inclusion and exclusion criteria as our previous MeN studies. Inclusion criteria were 20–65 years of age and plasma creatinine 100–220 μmol/L. Exclusion criteria were diabetes mellitus, uncontrolled hypertension and albuminuria >1g/24h. Kidney biopsies, blood and urine samples were collected, and participants answered a questionnaire. Included participants were between 27–61 years of age and had a mean eGFR of 38±14 ml/min/1.73m Chronic kidney disease (CKD) is a global health problem. The leading causes of CKD are diabetes mellitus, hypertension, and glomerulonephritis , but chrIn Central America, the CKDu endemic is called Mesoamerican Nephropathy (MeN), and men working with heavy physical labor in warm areas near the Pacific Ocean often develop the disease , 5. ClinKidney disease was the seventh most common cause of death and an increasing cause of death in Sri Lanka in 2012 according to the WHO . In the Most studies on CKDu in Sri Lanka have used dipstick albuminuria as a screening method, and subjects with albuminuria have been further analyzed with serum creatinine. Patients with CKDu often have low-range albuminuria (<1g/24h) , 11, 18,The renal morphology of CKDu in Sri Lanka has been reported in several studies , 20–23, The etiology behind CKDu in Sri Lanka has not yet been established, but researchers have proposed a wide range of different environmental exposures, such as pesticides, herbicides, fertilizers, heavy metals, water hardness , 24, 25,There are many similar features of the CKDu endemics in Central America and Sri Lanka, but no proper comparative study of the renal morphology and clinical characteristics has, as of yet, been made. To compare available studies from the two regions is complicated due to differences in study design, semi-quantification of morphology findings, etc. Thus, to make a detailed comparison of the endemics in Sri Lanka and Central America possible, we designed this study of renal biopsies, biochemical and clinical characteristics from patients with CKDu in Sri Lanka using similar inclusion/exclusion criteria and study design as in our previous studies of MeN in Central America , 7.2. Exclusion criteria were diabetes mellitus (fasting blood glucose >7 mmol/L), uncontrolled hypertension (>140/90 mmHg or more than one hypertensive drug prescription), proteinuria >1g/24h, or other known renal disease.Patients planned for kidney biopsy at Polonnaruwa General Hospital were recruited. Inclusion criteria were CKD of unknown cause, 20–65 years of age, and serum creatinine 100–220 μmol/L or eGFR 30–80 ml/min/1.73mThe study was performed during one week in May/June at Polonnaruwa General Hospital. Blood pressure was tested the day before and on the day of the biopsy. At the morning of the kidney biopsy, blood and urine tests were collected from fasting participants (no intravenous fluids). Ultrasound was performed before and during the kidney biopsy. Participants were interviewed and a questionnaire was filled in. All participants stayed for a 24-hour observation after the biopsy procedure. Within one week, collected samples were transported to Karolinska University Hospital (KUH) for analysis.Ultrasound-guided percutaneous kidney biopsies were performed using a spring-loaded biopsy needle . The biopsies were divided and placed in: 4% buffered formaldehyde, Zeus fixative solution, and 2% glutaraldehyde + 1% paraformaldehyde in 0.1 M phosphate buffer, respectively. Within one week the biopsies were transported to KUH. At KUH, the formaldehyde fixed tissue was embedded in paraffin, sectioned and stained with Ladewig, periodic acid Schiff (PAS), hematoxylin-eosin (HE), and periodic acid silver methenamine (PASM). The tissue in Zeus solution was rinsed and snap frozen, and cryosections were incubated with antibodies against immunoglobulins , C1q, C3, light chains kappa and lambda, and fibrinogen. Sections from the paraffin-embedded tissue and cryosections were evaluated with polarized light to detect any birefringent crystals. The tissue for transmission electron microscopy  was embedded in epoxy resin and then cut into 60 nm thin sections. Histological evaluation with light microscopy, immunofluorescence, and electron microscopy was performed separately by two senior consultants in renal pathology (AW and MS) who thereafter discussed the results to reach consensus. Interstitial fibrosis, interstitial inflammation, and tubular atrophy in the cortical area were semi-quantified similar to Banff criteria , as foll® Dobrava-Hantaan IgM test  was used to detect Dobrava and Hantaan virus IgM antibodies. ELISA was used to detect Puumula virus IgM and leptospirosis IgM. Samples positive on ELISA for leptospirosis IgM were send for confirmation with microscopic agglutination test testing for 15 different leptospira serovars at SSI Copenhagen, Denmark.The day before the kidney biopsy procedure, blood samples were analyzed for: RBC, WBC, platelets, INR, PT/aPTT, and/or bleeding time/clotting time at the laboratory of General Hospital Polonnaruwa. Just before the biopsy, new blood samples were collected, centrifuged, and the supernatant was transferred to transport vials stored at -40°C until transport on dry ice to KUH. At Karolinska University Hospital laboratory (KUHL), the samples were analyzed according to standard protocols for glucose, CRP, creatinine (IDMS traceable), BUN, sodium, potassium, magnesium, calcium, phosphate, albumin, alanine aminotransferase, uric acid, cystatin C (IFCC traceable), beta-2-microglobulin, aldosterone, renin, complement , antinuclear antibody, and anti-neutrophil cytoplasmic antibody screening, anti-glomerular basement membrane antibodies, and screening for hepatitis B and C and HIV. eGFR was calculated using the CKD-EPI equation for creatinine  and creaAt Polonnaruwa General Hospital, urine sediment and urine culture were analyzed before the biopsy in all but two patients (missing sediment) and three patients (missing urine culture) due to a logistic error. The missing samples were collected and analyzed 5–6 months later. At the morning of the biopsy, new samples were collected and stored at -40°C until shipment on dry ice to KUH. At KUHL, the urine was analyzed according to standard protocols for uric acid, sodium, potassium, magnesium, creatinine, albumin, α-1-microglobulin, and neutrophil gelatinase-associated lipocalin. Urine heavy metal  analysis was performed by ALS Scandinavia AB  using inductively coupled plasma mass spectrometry . KIM-1 wA questionnaire was completed by interview of the participants (by CJ). The questionnaire contained open and closed-ended questions concerning medical history , work history , work-related chemical exposure , liquid intake, water source, and smoking habits.The study received ethical clearance from the ethics review committee at the Faculty of Medicine & Allied Sciences, Rajarata University of Sri Lanka, Saliyapura (ERC/2016/06) and the regional ethical review board in Stockholm . All participants gave written informed consent.2 were included in the study.Thirteen patients were recruited to the study. Two patients were excluded because they did not fit the inclusion criteria, one patient due to high fasting blood glucose (16.7 mmol/L) and one patient due to more than one blood pressure medication. In total 11 patients with a mean age of 48 ± 11 years and a mean eGFR of 38 ± 14 ml/min/1.73mClinical and questionnaire data are presented in Most blood test results are presented in Urine test results are presented in Kidney biopsies were collected from all 11 patients. No adverse events were reported. The specimens contained 7–29 glomeruli (mean 17 glomeruli/specimen). Polarized light on paraffin-embedded tissues detected no crystals. Immunofluorescence showed no signs of immune complex disease. A summary of the light microscopy and electron microscopy findings are presented in Glomerular pathology: Global glomerulosclerosis was found in all patients, mean 43% (range 8–75%) of all glomeruli  the main finding was glomerulosclerosis, glomerular hypertrophy, and mild to moderate tubulointerstitial changes. Two of the patients also had signs of glomerular ischemia (Patients 6 and 7).In two patients (Patients 3 and 8) the main finding was chronic interstitial nephritis, with mild to moderate tubular atrophy, tubulitis (Patient 3), moderate to severe interstitial fibrosis, mild to severe interstitial inflammation, and moderate vascular changes.Pyelonephritis was the main diagnosis in two patients (Patients 10 and 11), with moderate to severe interstitial inflammation, granulocytes in the tubular lumina, tubulitis, mild to moderate interstitial fibrosis, and mild vascular changes.In one patient (Patient 8), the morphology indicated nephrosclerosis with moderate intimal thickening and mild smooth muscle hyperplasia of arteries, signs of glomerular ischemia, and mild to moderate tubulointerstitial changes.In this study we have examined kidney biopsies and biochemical characteristics of 11 male farmers with CKDu in Sri Lanka. We have used similar inclusion and exclusion criteria and study design as in our previous studies of CKDu in Central America, thus enabling a detailed comparison of the two endemics.The renal morphology in this study showed a more mixed pattern compared to our studies in Central America, where the morphology was relatively homogenous in all cases , 7. Six Of the remaining cases, two showed findings indicating active and chronic pyelonephritis with tubulitis, granulocytes found in the tubular lumina, and moderate to severe interstitial inflammation; two showed a morphological pattern of chronic tubulointerstitial nephritis with moderate to severe interstitial fibrosis and interstitial inflammation; and one showed nephrosclerosis with vascular changes, moderate intimal thickening, mild smooth muscle hypertrophy, and arteriolar hyalinosis.From our results one can speculate whether these heterogeneous findings in the kidney biopsies represents different stages or severities of one disease or represent different diseases, with multiple etiologies. Nanayakkara et al described in their study of kidney biopsies from CKDu patients in Sri Lanka that the tubulointerstitial damage sometimes was accompanied by massive interstitial inflammation, and they concluded that this was the primary lesion . In anotDue to the findings of interstitial inflammation and signs of pyelonephritis, we analyzed serum for Hantavirus and leptospirosis, common infections in rural Sri Lanka. Notably, elevated Hantavirus IgG-antibody levels, indicating a past infection, were found in 8 of 11 patients. IgM-antibody levels for Hantavirus and leptospirosis were negative. A recent publication from Sri Lanka showed that 55% of patients with CKDu were seropositive (IgG) for Hantavirus compared to 14% in controls but had no prior history of Hantavirus-associated illness . Also inSigns of chronic glomerular ischemia with wrinkling of the glomerular capillaries and/or thickening of Bowman´s capsule were found in seven of the included patients. Chronic glomerular ischemia is often found in ageing and hypertensive kidney disease where intimal thickening of renal arteries are apparent , 53. In The kidney morphology in the present study does not resemble Aristolochic acid nephropathy, an endemic nephropathy described in the Balkans . AristolIn MeN studies from Central America, low serum sodium, potassium and magnesium levels have been common features , 7. In tHeat stress with repeated volume and salt depletion has been proposed to be a main factor behind MeN in Central America , 59, a dUric acid has been suggested to be of significance in the pathogenesis of MeN in Central America, since uric acid crystals have been found in the urine of some sugarcane workers during harvest , 60. In Heavy metal exposure has been suggested as a possible etiology behind the CKDu endemic in Sri Lanka. In this study, urine measurements of six heavy metals all showed non-toxic levels, thus not supporting a direct nephrotoxic effect of heavy metals. However, one must take into consideration that urinary heavy metal levels mostly mirrors recent exposure, except for urinary cadmium, which has been found to correlate with the accumulation of cadmium in the kidney , 61.In summary, we found that the morphology and biochemical characteristics of CKDu patients in Sri Lanka have many resemblances with the CKDu epidemic in Central America, indicating a similar diagnostic entity. The search for common etiologies affecting both regions should be further studied. However, the mixed morphology pattern seen in Sri Lanka calls for larger biopsy studies with a focus on different possible etiologies affecting renal function in Sri Lanka, such as possible renal-damaging infections. Regarding future studies, we believe that studies of gene and protein expression in biopsy material would give important knowledge about possible etiologies and pathophysiological pathways in the CKDu endemics affecting both Sri Lanka and Central America.S1 TableN = 11.(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


To determine association of in-hospital outcome of AKI with etiology in newborns at a tertiary care hospital.This descriptive cross-sectional study was conducted at Department of Pediatric Neonatology, The Children's Hospital and Institute of the Child Health, Multan by using non-probability purposive sampling technique from June 2016 to June 2017. A total of 101 newborns diagnosed with acute kidney injury were registered. Etiological factors were assessed and these patients were followed till discharge to monitor in-hospital outcomes.Of these 101 newborns, 75 (74.3%) were boys while 26 (25.7%) were girls. Mean age of these newborns was 7.59 ± 6.13 days . Mean age of the boys was 5.73 ± 7.20 days while that of girls was 6.77 ± 6.16 days. (p=0.515). Mean weight of these neonates was 2545.05 ± 600.42 grams . Mean serum potassium level was 4.94 ± 0.92 mgEq/L ranging from 3.1 mgEq/L to 7.0 mgEq/L. Mean urea level was 73.35 ± 27.65 mg/dl ranging from 18 mg/dl to 206 mg/dl. Mean serum creatinine level was 1.98 ± 0.27 mg/dl, ranging from 1.6 mg/dl to 2.8 mg/dl. Mean serum sodium level was 145.72 ± 12.64 mgEq/L ranging from 126 to 166 mEq/L. Eighty one (80.2%) were term babies while 20 (19.8%) were pre-term babies. Of these 101 study cases, 29 (28.7%) delivered vaginally while 72 (71.3%) through cesarean section. Delayed crying was noted in 48 (47.5%), dehydration 13 (12.9%), sepsis in 36 (35.6%) and renal malformation in only 4%. Neonatal mortality in these patients was 15 (14.9%) while 86 (85.1%) were discharged from hospital after recovery.Acute kidney disease in newborns is associated with significant disease morbidity and mortality with asphyxia and sepsis are the main etiological factors responsible. It is predominantly more common in boys compared with girls. Mortality rate was high in our study and it was significantly associated with female gender. Mortality was also associated with elevated serum sodium and urea level. Acute kidney injury (AKI), formerly referred to as acute renal failure (ARF), is defined as an acute reduction in kidney function that results in a decline in glomerular filtration rate (GFR) leading to retention of urea and other nitrogenous waste products, and loss of fluid, electrolyte, and acid-base regulation.6Acute kidney injury, in different studies, has been reported to be ranging between 8% to 24% while these cases may further be classified in two groups i.e. Oliguric and Non-oliguric. However such reductions in urine output may also be seen in the absence of acute kidney injury, hence cannot be employed as sole criteria for the diagnosis.8The cause of AKI among newborns remains to be multi-factorial, and generally there are multiple related contributing agents associated with AKI in neonates. In majority of cases birth asphyxia and sepsis are commonly encountered underlying conditions of AKI in these patients while other conditions in neonates associated with development of AKI may be; dehydration, bleeding, respiratory distress syndrome (RDS), congestive cardiac failure (CCF) and nephrotoxic drug.10Among newborns common etiological factors include “Congenital malformations ; acquired kidney diseases including acute tubular necrosis, vascular events , or medications (angiotensin-converting enzyme inhibitor or indomethacin usage during pregnancy); and obstructive uropathy”.10Estimation of serum creatinine levels remains the simplest, robust and widely adopted means for the assessment of kidney functions which drops significantly from 1.1 mg/dl to 0.4 mg/dl during first two weeks of life following term delivery while from 1.3 mg/dl in case of preterm infants.16This study was done to determine association of outcome of AKI with etiological factors of acute kidney injury (AKI) among newborns of Southern Punjab, Pakistan owing to the scarcity of local data on this topic.This study was done at Neonatal Intensive Care Unit (NICU) of the Children's Hospital and institute of the Child Health, Multan which provides tertiary care level facilities to the population of 35 million people of Southern Punjab and associated areas of Sindh, Balochistan and Khyber Pakhtunkhawah. A total of 101 newborns with Acute Kidney Injury admitted to the NICU of our hospital were included in this cross-sectional study.Sample size was calculated by sample size calculator of Epi-info software of CDC by anticipating 20%Data obtained was entered in SPSS version 16 on the computer to analyze mean and standard deviations for the numerical study variables like age (in days), serum creatinine levels (in mg/dl), Serum sodium levels. Gender, mode of delivery, gestation, dehydration, sepsis, delayed crying, renal malformation and outcome (discharged/expired) were tabulated in terms of frequencies and percentages. Outcome was cross-tabulated against gender, gestation, mode of delivery, delayed crying, sepsis, renal malformation, dehydration and chi-square test was applied to see their impact on outcome while for numerical variables of the study independent sample t test was used at level of significance of 0.05.We recruited a total of 101 newborns with acute kidney injury. Of these 101 newborns, 75 (74.3%) were boys while 26 (25.7%) were girls. Mean age of these newborns was 7.59 ± 6.13 days . Mean age of the boys was 5.73 ± 7.20 days while that of girls was 6.77 ± 6.16 days. (p=0.515). Mean weight of these neonates was 2545.05 ± 600.42 grams . Mean serum creatinine level was 1.98 ± 0.27 mg/dl, ranging from 1.6 mg/dl to 2.8 mg/dl. Mean serum potassium level was 4.94 ± 0.92 mgEq/L ranging from 3.1 mgEq/L to 7.0 mgEq/L. Mean urea level was 73.35 ± 27.65 mg/dl ranging from 18 mg/dl to 206 mg/dl. Mean serum sodium level was 145.72 ± 12.64 mgEq/L ranging from 126 to 166 mEq/L. Eighty one (80.2%) were term babies while 20 (19.8%) were pre-term babies. Of these 101 study cases, 29 (28.7%) delivered vaginally while 72 (71.3%) through cesarean section. Delayed crying was noted in 48 (47.5%), dehydration 13 (12.9%), sepsis in 36 (35.6%) and renal malformation in only 4%. Neonatal mortality in these patients was 15 (14.9%) while 86 (85.1%) were discharged from hospital after recovery.Different studies reported from various parts of the world have documented high prevalence of predisposing factors of acute renal failure in boys as compared with girls. Similarly in our study there were 75 (74.3%) boys while 26 (25.7%) were girls. Gharehbaghi et al.In our study 80.2% were term babies while 19.8% were pre-term babies. Similarly, Gharehbaghi et al.Birth asphyxia and sepsis have been reported to be associated significantly with AKI in newborns all over the worldAcute kidney disease in newborns is associated with significant disease morbidity and mortality with asphyxia and sepsis are the main etiological factors responsible. It is predominantly more common in boys compared with girls. Mortality rate was high in our study and it was significantly associated with female gender. Mortality was also associated with elevated serum sodium and urea level.MAA: Conceived idea, study planning and designing, manuscript writing and data collection.AR: Supervised the research work, editing and proof reading of the manuscript and study planning.EA: Data entry, data analysis, data collection and manuscript editing.


Some longitudinal studies have shown that blood pressure tracks from adolescence to adulthood, yet there is limited evidence regarding the predictive factors of adulthood hypertension during adolescence. This study was conducted within the framework of the Tehran Lipid and Glucose Study (TLGS) to investigate the role of some factors in adolescence, measured in the first examination (1999–2001), to predict adulthood hypertension in the 4th examination (2009–2011).p-value <0.2 for enter and >0.05 for removal) was considered to keep significant covariates among common variables including gender, body mass index, waist circumference, wrist and hip circumferences, fasting blood sugar, triglycerides, high density lipoprotein cholesterol, total cholesterol (TC), systolic (SBP) and diastolic blood pressure (DBP). Variance inflation factor (VIF) showed some multicollinearity for anthropometric variables (VIFs between 3.5 and 10). Multivariable logistic regression revealed that gender, blood pressure, wrist circumference and total cholesterol in adolescents are important predictors for adulthood hypertension.Overall, 1579 subjects, aged 10–19 years, were used for the analysis of the current study. Mean age (SD) of participants at the baseline was 14.2 (2.5) years and 55% of them were female. A forward stepwise approach  contains supplementary material, which is available to authorized users. Hypertension is a major public health threat worldwide and the leading cause of cardiovascular disease (CVD), heart failure, end-stage renal disease, and premature mortality. Atherosclerosis begins in early life and is taken into account as a pediatric problem, making identifying and management of CVD risk factors before adulthood crucial –3.A systematic review of longitudinal studies has illustrated blood pressure tracking from childhood to adulthood . The assTehran Lipid and Glucose Study (TLGS) is community-based prospective study being performed on a representative sample of an urban Iranian population from Tehran. The study was initiated in 1999–2001 to estimate the prevalence of non-communicable disease risk factors. The study is ongoing and designed to continue and follow the participants for at least 20 years on triennial basis. Rationale and study design of TLGS has been discussed elsewhere , 15.n = 1205), 1579 subjects were considered for the current study. None of the selected subjects had any kind of cancer and 41 had non-ischemic cardiovascular disease who were not excluded. Interval time from adolescence to adulthood (from 1st exam to the 4th one in the TLGS) had a median of 10.5 years with an interquartile range of 9.5–11.3 years.Participants of the TLGS who attended both the first (1999–2001) and 4th (2008–2011) examinations were eligible for the present study. Of a total 2954 individuals, aged 10–19 years, 170 were excluded due to missing data at first examination. After excluding participants with missing data on SBP and DBP at 4th examination or lost to follow-up data ; intra-assay CVs were 1.7%. Estimated glomerular filtration rate (eGFR) was calculated by using equations of Schwartz , 23.The outcome, adult hypertension, was defined as SBP >140 mmHg, DBP >90 mmHg, or taking antihypertensive medications.Hypertension in adolescent was defined as age, gender and height specific blood pressure that was equal or greater than 95th percentile , 25.All continuous data with normal distribution are shown as mean (SD), skewed variables as median, inter-quartile (IQ range), and categorical variables are expressed as frequency (percentage). A t-test was used to evaluate the difference between continuous variables. Difference for categorical variables was assessed using Chi square test. The Mann-Whitney test was applied for TG as a not normally distributed variable.p-value of <0.2 for entry and a p-value of >0.05 for removal. The Area Under the Curve (AUC) and Hosmer-Lemeshow goodness of fit test were considered as discrimination and calibration indices of the model.Scatter plot with Loess-fitted line was used to show the relationship between anthropometric measures at adolescence with systolic and diastolic blood pressures at adulthood. Logistic regression analysis was used to study the effect of independent variables during adolescence on hypertension in adulthood. Multicollinearity of independent variables was checked via the variance inflation factor (VIF) statistic. A forward stepwise approach was considered to keep significant covariates among age, gender, BMI, waist, wrist, height and hip circumference, FBS, TG, HDL-C, TC, eGFR, SBP and DBP. To be more conservative for negative confounding and missing effective variables we considered a We calculated the probability of being lost to follow-up for each subject based on his/her baseline characteristics; it is a kind of propensity score (PS) estimated by logistic regression model . To corrAll interactions between sex and potential risk factors were checked; there was no significant interaction and a pooled gender analysis was implemented to improve the power.All analysis was executed using SPSS 20 statistical software.Mean (±SD) age of participants at baseline was 14 ±2.53) years and 55% of them were female. Included and excluded participants (for missing data) had no differences in characteristic at baseline, except for clinically negligible, albeit statistically significant, differences in gender, TG and eGFR variables . Of these, 5 (7.7%) were using hypertension drugs and others (92.3%) had systolic and/or diastolic hypertension as unknown hypertensive subjects.Individuals with early adulthood hypertension were one year older at baseline with higher BMI, WC, wrist and hip circumference. They also had higher level of SBP, DBP, TGs and TC; VIF values showed low level of co-linearity for most independent variables, except for the anthropometric ones, in which the range of VIFs was 3.5 to 10.2 of 4.3  showed a good performance of the model.Multivariable logistic regression with forward stepwise method revealed that among independent variables, the most important ones with significant effects on early adulthood hypertension were gender, adolescent blood pressure, wrist circumference and total cholesterol. Females had a 70% lower risk; each 10 mmHg increase in systolic and diastolic blood pressure increased the risk by 4 and 3% respectively, and each 1 mmol/L increase in TC increased the risk of hypertension by 39%. Among anthropometric variables, only wrist circumference with 50% per centimeter increase in risk of hypertension remained in the model (Table p < 0.001).Figure Hypertension is a crucial modifiable risk factor of mortality and morbidity originating in childhood . Early iThe association of childhood adiposity with several CVD risks like hypertension, hyperlipidemia and diabetes mellitus in adulthood has been reported in many studies , 28–32.P < 0.05); an association however was not demonstrated for FBS and HDL-C. Our results only showed a significant correlation between adolescent TC and adulthood hypertension using multivariable analysis. It was demonstrated that for each 1 mmol/L increase in TC during adolescence the risk of adult hypertension increased by 39%.In the Bogalusa , MuscatiThe relationship between elevated blood pressure and weight begins in early childhood. Obesity can progressively raise blood pressure by altering cardiac output, cardiac systolic and diastolic function, renal pressure natriuresis  and sympHu et al.  reportedThe present study consistent with data of others, reported a linear correlation between SBP and DBP in early adulthood with WC and BMI in adolescents; these anthropometric indexes were higher significantly in hypertensive compared to normotensive adults , 34, 41.Wrist circumference has not been measured and considered as a predictor of adulthood hypertension in any study ever published. Our findings indicated that wrist circumference in adolescence had a linear correlation with DBP and SBP in adulthood. Capizzi et al.  in a stuSimilar results have been recently documented in adults as well; in a cohort study of 3642 adult women, it was shown that wrist is an independent risk factor of incident hypertension and CVD events ; Amini eChildhood blood pressure has been reported as a predictor of adulthood hypertension in many studies , 48, 49.Gender has also been reported to be associated with hypertension in childhood and in later life by some studies; a Canadian study on a cohort of 1267 adolescents demonstrated a greater prevalence of higher SBP in boys than girls as they approach adulthood . Field eSince some studies have demonstrated the effect of adolescent’s height on blood pressure , 25, in To mention the strengths and limitations of our study, regarding the latter, we may not be able to generalize our findings to other populations and propose that our results hence be appraised in other countries in different ethnic groups. Although family history of hypertension and socioeconomic status have been cited to have association with adulthood hypertension, as a limitation of our study we did not have a reliable report in this regard. We also did not have any data regarding dietary habit, however it’s intermediate variables including BMI, WC, FBS, TG, TC and blood pressure have been included in the analyses. As strengths, we followed a large cohort of adolescents for 10 years to determine the predictive value of some variables for the incidence of hypertension in their adulthood. Although a part of our participants have been excluded because of missing data or being lost to follow-up, there was no clinically important difference between included and excluded subjects regarding studied variables at baseline.Regarding the importance of early identification of at risk population, we found that wrist circumference, as a simple and easy-measurable anthropometric index, besides adolescent total cholesterol and blood pressure, can be used as predictors of adulthood hypertension in adolescents.


We fitted this equation to the data set of Protocol I using the maximum likelihood principle, and we obtained the model p(t|y) = 0.000485y0.24788 exp(−0.000485y0.24788t). The cardiovascular event-free rate was computed as P(t) = 1/60Σi=1,…,60 exp(−0.000485yi0.24788t), based on this model and the BNP levels yi in a data set of Protocol II. We confirmed no difference between this model-based result and the actual event-free rate. In conclusion, the BNP levels showed a non-linear relationship with the day of occurrence of cardiovascular events in CHF patients.Brain natriuretic peptide (BNP) is the most effective predictor of outcomes in chronic heart failure (CHF). This study sought to determine the qualitative relationship between the BNP levels at discharge and on the day of cardiovascular events in CHF patients. We devised a mathematical probabilistic model between the BNP levels at discharge (y) and on the day (t) of cardiovascular events after discharge for 113 CHF patients (Protocol I). We then prospectively evaluated this model on another set of 60 CHF patients who were readmitted (Protocol II). P(t|y) was the probability of cardiovascular events occurring after >t, the probability on t was given as p(t|y) = −dP(t|y)/dt, and p(t|y) = pP(t|y) = αy Because chronic heart failure (CHF) is one of the most common fatal diseases and has an increasing prevalence worldwide2467911Using our database of patients who were admitted because of acute decompensated heart failure (ADHF) and were discharged as stable CHF after sufficient treatment, we performed this study with the following objectives: (1) to theoretically derive a probability formula that correlates the plasma BNP levels at discharge and the day of hospitalization or cardiac death in patients with stable CHF; (2) to obtain an actual probability model by fitting the theoretical probability formula to the clinical data of the retrospectively enrolled patients; and (3) to prospectively test whether the cardiovascular event-free rate using this model in CHF patients was consistent with the actual cardiovascular event-free rate in the patients.In Protocol I, we retrospectively enrolled CHF patients to constitute an actual probability model that would provide the day of cardiovascular events based on the plasma BNP levels alone. In Protocol II, we prospectively tested whether the expected date, as determined by the probability model, was consistent with the actual day of cardiovascular events.From our database of CHF patients, 113 ADHF patients who were admitted because of worsening CHF and were discharged after improvement of HF to New York Health Association (NYHA) I or II between January 2007 and December 2008 were retrospectively enrolled. The follow-up period was until December 2014. For patients who were admitted to the hospital several times during the follow-up period, the earliest date of hospitalization was recorded. CHF was diagnosed by an expert team of cardiologists using the Framingham criteriaWe prospectively enrolled 60 ADHF patients who were admitted because of worsening HF and were discharged after improvement of HF to NYHA I or II between May 2013 and December 2015. We followed-up these patients until the end of 2015. The primary endpoint was the day of the first re-hospitalization because of cardiovascular causes or cardiovascular death. An independent group of physicians in the emergency room of our institute made a decision on re-hospitalization when the CHF of the patients progressed and worsened; they also analysed the primary cause of re-hospitalization or death. We prospectively tested whether the predictive curves of the cardiovascular event-free rate produced by the mathematical model were significantly close to the Kaplan-Meier curves for the actual cardiovascular event-free rate during the follow-up period.γ) and the plasma BNP level at discharge from the hospital (y), respectively. Because daily production (∝pγ) and consumption (∝y) were considered to be almost equal in a given patient, pγ = θy holds. This equation was rewritten as:We assumed that the CHF severity in most patients did not significantly change after discharge and proportionally reflected the daily probability of cardiovascular events (p). We chose the plasma BNP levels as the most valuable index for assessing CHF severity because BNP is produced according to the progression of CHF and because BNP clearance from the blood is proportional to the extent of cardioprotection. On the basis of these assumptions, we estimated that the daily production and consumption of plasma BNP were proportional to the power of p  was designated as the probability that cardiovascular events did not occur before an interval (t) having elapsed from discharge under a given y. Then, p(t|y) was designated as the probability of cardiovascular events on day t and was equal to the daily reduction of P(t|y) /dt). At the same time, p(t|y) was equal to the probability of the first occurrence of a cardiovascular event on day t, denoted as pP(t|y), which is the probability that the event did not occur before day t but occurred on day t. Accordingly, we obtained the following differential equation:Because all patients were alive at discharge under a given y, P(0|y) = 1 holds. Then, we derived the following solution of this differential equation with Equation (1):i,ti)|i = 1,…,N}, the log-likelihood under this solution was represented as follows:Given a data set of Protocol I, DI = { is the probability of observing a patient with a BNP level of y at discharge and a cardiovascular event at day t in the data set. Similarly, P is the probability of observing a patient with a BNP level of y at discharge and a cardiovascular event after day T in the data set. p(y) is the distribution of y in the data set. Because the second term on the last line did not depend on parameters α and β, we searched for the combination of these parameters that maximized the first term on the data set DI by a standard non-linear optimization algorithm named the Nelder–Mead Simplex Methodwhere sy = {yi|i = 1, …, M}, was computed using an approximation of p(y) by its data distribution in DIIy:Under these optimum parameters obtained by DI of Protocol I, the model-based event-free rate (P(t)) at t for a BNP data set of Protocol II, DIIl, yu) at discharge in DIIy. This was performed by limiting the distribution p(y) into , i.e., limiting the patients to those having BNP levels in  in DIIy as y = {yi|yl < yi < yu in DIIy}. Thus, we showed an event-free rate curve P) for the patient group as:Moreover, the model obtained by DI enabled us to compute the event-free rate curve P(t) for a group of patients with BNP levels in a specific interval . This was a clinical study that enrolled patients with CHF, and all methods were performed in accordance with the relevant guidelines and regulations.Normally distributed data are expressed as the mean ± standard deviation; other values were reported as median and interquartile range (IQR). We performed the goodness-of-fit test and used the coefficient of determination as a measure to assess the significant relationships between the predictive curves and actual Kaplan-Meier curves of the cardiovascular event-free rate. The differences in the predictive curves among the different BNP levels were tested using the Wilcoxon signed-rank test. We estimated the error bounds of the parameters α and β by applying the standard bootstrap sampling0.24788 exp(−0.000485y0.24788t)  were retrospectively enrolled in this study . All pat.24788t) .2 = 0.92). The upper and lower 2σ bound lines of the model plot did not completely overlap with the actual Kaplan-Meier curve because the actual Kaplan-Meier curves also fluctuated due to their statistical uncertainty. 2 = 0.94, 0.90 and 0.95 for For Protocol II, the patients’ characteristics are shown in 0.24788 exp(−0.000485y0.24788t), and a model-based formula of the event-free rate, et al. obtained the predicted equation by fitting the survival to many factors using multivariate analysis and validating it with another cohort of CHFPlasma BNP levels are known to be related to the probability of cardiovascular events, such as hospitalization or cardiovascular death. However, there is no clear consensus on whether the plasma BNP levels quantitatively predict the time of occurrence of cardiovascular events. In the present study, we constituted a theoretical probability model to estimate the time of cardiovascular event occurrence based on the plasma BNP levels at discharge in CHF patients who were admitted to our hospital because of ADHF. We provided a non-linear probability model, p(t|y) = 0.000485yBNP is produced in cardiomyocytes by both ventricular stress and excess neurohumoral factors67These characteristics of BNP are different from those of other simple biological or physiologic markers of HF. For example, LV ejection fraction (LVEF) is one of the physiologic markers of HF, but treatment modalities, such as inotropic agents, that increase LVEF are not necessarily beneficial for HF. However, BNP is important for a biomarker-guided studyWhy can the plasma BNP levels at discharge predict the probability of cardiovascular events? It does not seem to be convincing that a one-time measurement of the plasma BNP level at discharge in each HF patient can predict the day of occurrence of cardiovascular events because the BNP levels may fluctuate weekly or monthly during outpatient follow-up, despite the constant intake of medications. These changes in the BNP levels may be attributed to daily changes in hemodynamic parameters, such as heart rate or blood pressure; excessive intake of water or salt; or temporal sympathetic activation in a patientIndeed, reports have shown that the pre-discharge BNP or NT-pro BNP levels that were measured only during hospitalization predicted clinical outcomes21BNP in plasma has been used as a sole biomarker for CHF and is recognized to precisely predict cardiovascular events. However, specialized medical care has been focused because many clinical, social, and genomic factors are involved in patients with CHF0.25 to obtain an index of CHF severity from the viewpoint of clinical events. The other impact of the present study is how to employ mathematical science in clinical practice. The most important information of the present study was that the increase in the risk for re-hospitalization was not proportional or linear to the increase in BNP levels for subjects with stable CHF following ADHF, even if the subsequent BNP levels were more than 100 pg/mL, although every 100 pg/mL rise was associated with a 35% increase in risk for subjects with stable CHF. The probability of occurrence of clinical outcomes in patients with CHF was related to the BNP levels at a power of approximately 1/4. We do not know how the changes in the BNP levels correspond to the quantitative improvement or worsening of CHF, and we believe that one of the advantages of the present study is that we can propose such an equation to yield quantitative meanings for the BNP values. It would be better to transform the BNP levels to 1/BNPThe present study had several limitations. First, because this was a single-centre study, the number of patients was limited, particularly that of subjects with ADHF. Second, the quantity of data was somewhat small. However, we obtained the probability equation for 113 patients in a retrospective study and provided evidence for the plausibility of this equation in 60 patients in a prospective study. In this sense, we suggest testing the present hypothesis using multicentre trials.Our study showed that the plasma BNP levels non-linearly predicted the day of occurrence of clinical events in patients with CHF. By using our equation, the impact of BNP levels on cardiovascular outcomes may be quantitatively evaluated.How to cite this article: Fukuda, H. et al. Non-linear Equation using Plasma Brain Natriuretic Peptide Levels to Predict Cardiovascular Outcomes in Patients with Heart Failure. Sci. Rep.6, 37073; doi: 10.1038/srep37073 (2016).Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.