A positive correlation was found between preoperative cortisol levels and all S100B concentrations. In addition, they are positively correlated with P(j-a)CO2 values. Conversely, postoperative cortisol inversely correlates with P(j-a)CO2 and postoperative S100B values. A negative correlation was observed between maximum systolic and pulse pressures and P(j-a)CO2 after carotid clamp and before the release of clamp. Our data suggest that preoperative cortisol, S100B, L-arginine reflect patients’ frailty, while these parameters postoperatively are influenced by intraoperative stress and injury. As a novelty, P(j-a)CO2 might be an emerging indicator of cerebral blood flow during CEA.Intraoperative stress is common to patients undergoing carotid endarterectomy (CEA); thus, impaired oxygen and metabolic balance may appear. In this study, we aimed to identify new markers of intraoperative cerebral ischemia, with predictive value on postoperative complications during CEA, performed in regional anesthesia. A total of 54 patients with significant carotid stenosis were recruited and submitted to CEA. Jugular and arterial blood samples were taken four times during operation, to measure the jugulo-arterial carbon dioxide partial pressure difference (P(j-a)CO Carotid endarterectomy (CEA) is a widely accepted method for the treatment of severe carotid stenosis and stroke prevention. During CEA, carotid cross-clamping is performed . CEA is Cortisol’s plasma concentration rises rapidly due to intraoperative stress ,17. We d2) are a marker of tissue hypoperfusion and can be the target of fluid resuscitation in circulatory failure, hypovolemic and septic shock [Arterial and venous blood gas sample measurements provide additional information on impaired oxygen and metabolic balance ,29. Venoic shock ,31,32. Iic shock ,34,35,36ic shock ,40,41,42ic shock .2 and lactate), potential cerebral injury (S100B), and perioperative stress (cortisol).We hypothesized that there might be minor ischemic events, which are difficult to identify, but which may still increase the distress of patients. They potentially increase the risk of other postoperative complications. Our main purpose was to describe the relation between indicators of brain perfusion (P(j-a)COThis prospective, observational clinical study was approved by the Clinical Centers Regional and Institutional Research Ethics Committee, N°4820. Data were extracted from a formerly recruited prospective database and analyzed retrospectively . InformeA total of 54 consecutive patients with significant carotid stenosis (between 70% and 95%) were recruited into this study at the Department of Vascular Surgery at the University of Pécs. The diagnosis of significant carotid stenosis was based on both carotid duplex ultrasound and CT angiography. Narrowing of the lumen between 70% and 99% was considered as significant carotid stenosis.All operations were performed in regional anesthesia. Deep and superficial cervical plexus blocks were performed in each patient, using 20 mL bupivacaine 0.5% and 10 mL lidocaine 1%. Additional local anesthetic, if necessary, was given by the surgeon. The patient’s awareness, verbal responsiveness, and the contralateral hand’s motoric function were evaluated. Any sudden decline in Glasgow coma score after clamp of carotid artery indicated shunt insertion.An arterial line was inserted by the anesthetist in the operating theatre. The internal jugular vein was directly cannulated by the operating surgeon, the tip of the catheter was positioned in the jugular bulb. Jugular and arterial blood gas samples were taken four times during operation: before carotid clamp (T1), 3 min after clamp (T2), 1 min before (T3), and 1 min after releasing the clamp (T4). Arterial and jugular venous blood gas analysis and lactate measurements were made at each time point by Radiometer Abl 800 flex .Arterial samples for the measurement of L-arginine, S100B, and cortisol were taken in lithium heparin tubes (1.) before the beginning of the operation, in the operation room, (2.) before, and (3.) after the release of the carotid clamp, and (4.) 2 h after the operation.g for 10 min, plasma samples were frozen within 60 min and stored at −80 °C until analysis, as previously described [After centrifugation at 3000× escribed ,40,43. B2) as a potential marker of anaerobic metabolism and perfusion was calculated using the following formula:Jugulo-arterial carbon dioxide tension difference (P(j-a)COIn addition, we have calculated the change of jugulo-arterial lactate difference between T4 and T1 as a parameter for “lactate production”:All parameters were measured at all specific time points during the perioperative period. Blood gas-derived variables and lactate were measured only during the operation.All patients’ maximum and minimum blood pressures were recorded throughout the procedure. Maximum and minimum systolic-diastolic differences, as pulse pressures, were counted.p-value < 0.05 was considered statistically significant.Data were evaluated using SPSS . Categorical data were summarized using means of absolute and relative frequencies (counts and percentages). Quantitative data are presented as mean and 95% confidence interval (CI), as well as mean ± SD. The Kolmogorov–Smirnov test was applied to check for normality. The chi-square test for categorical data and student t-test for continuous data were used for the analysis of demographic and clinical factors. Correlation analysis was performed calculating Spearman’s correlation coefficient (r). A Patients’ demographic and clinical characteristics are shown in Among 54 patients, 5 were shunted during operation. However, there were no between-group differences in age, body mass index (BMI), or any other parameters measured.2 through the operation is demonstrated in 2 increases until the end of the carotid clamp and decreases after the release of clamp. The opposite is seen in shunted patients, where P(j-a)CO2 decreases after carotid clamp and shunt insertion. After reperfusion (T3), the value of P(j-a)CO2 was lower than at T1.The temporal profile of P(j-a)CO2 values counted after carotid clamp, before and after release of clamp (P(j-a)CO2-2: r = 0.334, p = 0.043; P(j-a)CO2-3: r = 0.406, p = 0.013; P(j-a)CO2-4: r = 0.433, p = 0.007).Cortisol measured at the beginning of the operation showed a positive correlation with P(j-a)CO2 counted before and after carotid clamp and before release of clamp (P(j-a)CO2-1: r = −0.278, p = 0.048; P(j-a)CO2-2: r = −0.276, p = 0.05; P(j-a)CO2-3: r = −0.421, p = 0.002). The correlation was not significant after the release of clamp (P(j-a)CO2-4).In contrast, cortisol measured 2 h after CEA inversely correlated with P(j-a)CO2 correlations (cortisol-1—P(j-a)CO2-3, cortisol-4—P(j-a)CO2-3) are presented in Examples for the reversing tendency of cortisol and P(j-a)CO2 at all time points (P(j-a)CO2-1: r = 0.394, p = 0.003; P(j-a)CO2-2: r = 0.270, p = 0.048; P(j-a)CO2-3: r = 0.306, p = 0.024; P(j-a)CO2-4: r = 0.277, p = 0.043).Baseline S100B directly correlated with P(j-a)COp = 0.014) and inversely with cortisol after reperfusion , at the end of the operation.Moreover, baseline S100B directly correlated with baseline cortisol  and negative correlation with cortisol measured 2 h postoperatively , as shown in S100B measured 2 h after the operation showed a positive correlation with baseline cortisol COp = 0.027) and after the release of clamp .Change in jugulo-arterial lactate difference between T4 and T1 directly correlated with S100B values measured before , and with the postoperative 2 h S100B concentration , and consequently with all subsequent lactate concentrations. By the end of the operation, cortisol and L-arginine had an inverse correlation .The baseline L-arginine concentration inversely correlated with the baseline arterial lactate concentration CO2-2: r = −0.296, p = 0.030; max. syst. pressure and P(j-a)CO2-3: −0.314, p = 0.021; max. pulse pressure and P(j-a)CO2-2: r = −0.305, p = 0.025; max. pulse pressure and P(j-a)CO2-3: r = −0.332, p = 0.014). These associations are displayed in A negative correlation was observed between maximum systolic (max. syst.) and pulse pressures and P(j-a)COp = 0.009).A positive correlation was seen between postoperative 2 h cortisol and maximum pulse pressure  is a promising parameter for identifying discrepancies of cerebral circulation [2 in brain cells and elimination by cerebral blood flow. More CO2 is produced during aerobic circumstances than in anaerobic conditions [2 and lactate values. The possibility of major cellular anaerobic circumstances can be excluded in awake patients without acute neurological symptoms [2. Since intraoperative P(j-a)CO2 tends to be lower in shunted patients , perfusion seems to have a greater impact on jugular pCO2 COculation ,34,35. Inditions . Thus, tsymptoms . Converslar pCO2 .2, showed some notable statistical associations. In non-shunted patients, P(j-a)CO2 increases during carotid clamp and decreases after the release of the clamp, although it remains higher than the baseline (T1) value after reperfusion. After the release of the clamp, the greatly improved blood flow washes out the CO2 from the brain and immediately dilutes it. Thus, from T3 to T4 P(j-a)CO2 decreases, but still exceeds T1 values. At T4, due to the significantly improved cerebral blood flow, the high value of P(j-a)CO2 represents a considerably larger quantity of CO2 than at T1. Consequently, during the carotid clamp, more CO2 has to remain in the tissues since the reduced circulation is not able to transfer it. Thus, it seems that hypoperfusion is present through the clamp, even without any apparent symptoms. This phenomenon could not be observed in shunted patients. In this case, after shunt insertion the P(j-a)CO2 decreases. At reperfusion, P(j-a)CO2 becomes even lower than at the beginning of the operation, demonstrating the integrity of cerebral circulation throughout the carotid clamp. Briefly, the correlation is negative between P(j-a)CO2 and the quality of cerebral perfusion. The higher values of P(j-a)CO2 are referring to reduced perfusion, even without noticeable symptoms.From all of the blood gas-derived parameters, P(j-a)CO2 indicates worse brain perfusion. Surprisingly, higher postoperative cortisol is associated with lower P(j-a)CO2 and consequently better perfusion. Theoretically, this reversed correlation could be explained by the protective effect of higher blood pressures related to the increased stress [2 when the carotid artery is clamped, during the period of impaired cerebral blood flow. Postoperative cortisol, a possible indicator of overall procedural stress, is linked to increased blood pressure. Furthermore, higher blood pressure results in better perfusion (concluded from P(j-a)CO2) through the entire period of the carotid artery clamp. It has been a long-time recommendation to keep blood pressure elevated during CEA [Cortisol concentration might be not only the indicator of patients’ actual stress, but may represent a kind of general frailty . The incd stress . The posd stress ,13,17. Tring CEA ,15,50. OThe brain’s oxygen demand is feared to be higher in awake patients when regional anesthesia is chosen . Moreove2 (impaired perfusion), increased baseline cortisol, and decreased cortisol concentration by the end of the operation. The latter correlation could be explained either by the depressed ability to respond to stress due to frailty or by the better adaptation to stress after a previous injury. S100B may play a role in vascular adaptation after both severe and uneventful injuries [Elevated preoperative S100B, considered to be the sign of former cerebral ischemic events, is associated with higher P(j-a)COinjuries ,23,27.A similar reversing correlation was seen between postoperative S100B and cortisol, measured baseline and postoperatively. The change of jugulo-arterial lactate difference between the end and beginning of the operation, a possible indicator of “lactate production” is directly related to S100B by the end of the operation. Hence, the grade of hypoperfusion during clamp appears to have an impact on postoperative S100B values. Frail patients have higher baseline cortisol concentrations and are more sensitive to cerebral ischemia . Higher Inverse correlation between L-arginine and cortisol by the end of procedure shows the connection of circulation and stress. The protective function of L-arginine is already known ,40,43,53In shunted patients, concentrations of baseline arterial lactate, and cortisol by the end of the operation and 2 h postoperatively are significantly higher, L-arginine is lower. In non-shunted patients, the baseline cortisol concentration was positively related to the lactate values at all timepoints.The most important measured baseline variables like arterial lactate, cortisol, and S100B tend to demonstrate some kind of vulnerability, a former injury or impaired vascular state. The same derivates measured later, after the operation, can provide information about silent periprocedural injuries.2 inversely correlates with the quality of the brain’s blood flow, therefore it can be an adequate parameter to describe cerebral perfusion. The carotid artery’s clamp is potentially associated with a silent hypoperfusion. Our data also suggest that blood pressure plays a role in maintaining appropriate brain perfusion during CEA. In addition, higher cortisol and S100B might indicate a protective effect against distressing factors. The current study highlights that higher baseline arterial lactate, S100B and cortisol, and low L-arginine concentrations possibly predict patient’s increased vulnerability to stressor agents. In this study, we emphasize the relationship of jugulo-arterial carbon dioxide tension difference (P(j-a)CO2) to cerebral perfusion, intraoperative stress and ischaemia during CEA.In summary, P(j-a)CO


Worldwide, the prevalence obesity, diabetes, and chronic kidney disease is increasing apace. The relationship between obesity and chronic kidney disease is multidimensional, especially when diabetes is also considered. The optimal treatment of patients with chronic kidney disease includes the need to consider weight loss as part of the treatment. The exact relationship between obesity and kidney function before and after transplantation is not as clear as previously imagined. Historically, patients with obesity had worse outcomes following kidney transplantation and weight loss before surgery was encouraged. However, recent studies have found less of a correlation between obesity and transplant outcomes. Transplantation itself is also a risk factor for developing diabetes, a condition known as post-transplant diabetes mellitus, and is related to the use of immunosuppressive medications and weight gain following transplantation. Newer classes of anti-diabetic medications, namely SGLT-2 inhibitors and GLP-1 agonists, are increasingly being recognized, not only for their ability to control diabetes, but also for their cardio and renoprotective effects. This article reviews the current state of knowledge on the management of obesity and post-transplant diabetes mellitus for kidney transplant patients. Central problem  and may  problem . In addi problem . This fo problem . Novel t problem , may havIn this review, we study the importance of pre- and post-kidney transplantation obesity, as well as PTDM. Furthermore, we analyze the different therapeutic approaches currently available, including the new anti-diabetic drugs and their role in the treatment of obesity.Obesity is currently considered an important preventable risk factor for CKD. In the United States (U.S.), it is estimated that if it were possible to move individuals from the overweight and obese categories to ideal body weight, kidney disease could be prevented in 24.2% of men and 33.9% of women [2), with a rate of BMI change two-times higher than that estimated in the general population for all age groups [As with the trend for the general population, the incidence of obesity is also increasing in the dialysis population. Between 1995 and 2002, an increase in the BMI of those patients with ESRD was observed in the U.S.  [These patients may be excluded from transplantation due to concerns about reduced graft survival and increased risk of side effects, including patient survival after transplantation, owing to the perception that outcomes are worse in patients with ESRD and a high BMI (>30 kg/m2) ,17,18.However, data obtained by the UK National Health Service Blood and Transplant Registry showed that individuals transplanted during 2004–2010 had a significantly lower risk of death compared to those who remained on the waiting list in all BMI groups, including the >35 BMI group .Despite this, an obesity paradox in patients on dialysis has been observed, whereby a high BMI is associated with better survival, complicating the issue of how much weight loss should be recommended prior to transplantation . It is a2 for kidney transplantation, and instead suggested weight loss programs prior to referral [BMI-based cutoffs have been used as part of candidate selection for transplantation in most centers . Resultsreferral ,22.2 with diet and exercise under supervision [To optimize post-transplant outcomes, the existing clinical practice guidelines of the American Society of Transplantation and the European Renal Association recommend targeting a pre-transplant BMI of <30 kg/mervision ,24. Howeervision . Therefoervision . An oldeervision .A very low-calorie diet is difficult to follow in the long-term, especially in dialysis patients, given the dietary restrictions for CKD and the high protein intake recommended for these patients. Regular physical activity level should therefore always be considered as part of weight loss management , however2, in a weight loss program based on healthy eating habits (maintaining pre-established dietary restrictions) and higher energy expenditure, showed a modest effect only when a mild weight loss was required. The main problem described was the length of time required to reach weight loss goals, along with a frequent rebound weight gain effect [A study including 80 patients with stage 4–5 CKD and a BMI > 35 kg/mn effect .Unfortunately, most drugs utilized for weight loss , and sertraline (high dose)) are contraindicated for patients on dialysis .2, or >35 kg/m2 plus associated comorbidities, should be considered for bariatric surgery [Lafranca et al. recommended that obese kidney transplant candidates with a BMI > 40 kg/m surgery . This pr surgery .Several recent studies have reported successful transplant performance after bariatric surgery. Many of these are series of studies in which 55% to 100% of the patients undergoing bariatric surgery either receive a kidney transplant during follow-up or are successfully listed for transplantation . Side efThe prevalence of obesity among kidney transplant recipients in the U.S. had increased to over 30% (10% with morbid obesity) in 2011, whereas the obesity rate in the 1990s was less than 20% ,35. In cObesity is also a frequent complication that develops following kidney transplantation, especially during the first year. In a retrospective study conducted in Brazil involving 374 patients, 31.2% and 20.9% gained at least 10% or 5% of baseline weight, respectively, after the first year of transplantation .The term PTDM defines clinically stable patients who develop persistent post-transplant hyperglycemia . Its incPTDM is usually diagnosed at least 45 days post-transplant, using the American Diabetes Association (ADA) criteria for type 2 diabetes mellitus with the 75 g OGTT, or with alternative criteria of fasting plasma glucose ≥ 126 mg/dL, or symptomatic hyperglycemia with a plasma glucose ≥ 200 mg/dL, or a glycated hemoglobin (HbA1c) ≥ 6.5% ,41.Although PTDM shares features with type 2 diabetes mellitus, such as insulin resistance and obesity, the underlying processes are thought to be more complex . In geneThe risk factors for developing PTDM  include,In the context of obesity, an increased fat mass with adipose tissue dysfunction, characterized by altered lipid storage capacity and low-grade inflammation, favors the development of insulin resistance and impaired glucose metabolism by promoting an excess of fat storage in non-adipose tissues, such as the pancreas .Regarding viral infections, a higher incidence of PTDM with cytomegalovirus infections and hepatitis C has been reported. In the case of cytomegalovirus, one described mechanism may be due to impaired insulin release . HepatitHypomagnesemia was reported to be an independent risk factor for PTDM in a retrospective study of 948 kidney transplant patients. Magnesium is an intracellular cofactor necessary for different processes such as intermembrane glucose transport and glucose oxidation. Additionally, the use of certain drugs can cause hypomagnesemia .Finally, increased odds of developing PTDM among kidney transplant recipients with autosomal dominant polycystic kidney disease (ADPKD) have also been described , potentiGlucocorticoids cause hyperglycemia by increasing glucose resistance, decreasing insulin secretion, inducing beta cell apoptosis, and reducing the expression of glucose transporters . A largeCalcineurin inhibitors (CNIs), both cyclosporine and tacrolimus, increase the risk of PTDM by reducing insulin secretion with a direct toxic effect on pancreatic beta cells. This effect has been described to be more significant and in a dose-dependent manner, with tacrolimus than with cyclosporine . In factConcerning the different tacrolimus formulations, a study including 133 patients showed no differences in blood glucose levels two years after conversion from tacrolimus twice-daily to the once-daily extended-release tacrolimus formulation . FurtherM-TOR inhibitors may influence the PTDM development through different mechanisms, such as impaired insulin secretion and reduced insulin signal transduction . In one Other immunosuppressants, including azathioprine and mycophenolate mofetil (MMF), have not been shown to induce diabetes. The combination of tacrolimus and MMF or cyclosporine and MMF was found to have a lower PTDM rate than tacrolimus and azathioprine .Moreover, a review of five studies, which included 1535 kidney transplant recipient, concluded that belatacept-treated kidney transplant recipients had lower PTDM rates compared to those who received calcineurin inhibitors .Therapeutic options to prevent the risk of PTDM may involve reduced doses of steroids, minimization of tacrolimus exposure, and conversion from tacrolimus to belatacept, although the risk for rejection must be considered. We will have to wait until new immunosuppressive strategies, such as the use of an anti-CD40 monoclonal antibody that has shown efficacy in animal models of transplantation, with a significant reduction in the onset of primary autoimmune diabetes, can be used in humans ,67.2. The authors also found that increased BMI is a risk factor for death-censored graft survival, although they were not able to assess whether the risk is mediated by a higher incidence of comorbidities, such as diabetes and hypertension, or by factors intrinsic to obesity like hyperfiltration [BMI has been shown to be a strong independent risk factor for patient mortality and graft failure. Meier-Kriesche et al. demonstrated in a study of 51,927 kidney transplant recipients that the association between BMI and mortality after kidney transplantation follows a U-shaped pattern, with the lowest risk observed in patients with a BMI between 22 and 32 kg/mltration .Data from a French cohort including 4691 kidney transplant patients, 747 of whom were obese, also showed an increased risk of death in obese patients compared to non-obese subjects [2) has been consistently associated with an increase in the risk of death and graft loss [However, a meta-analysis demonstrated that obesity in kidney recipients who were transplanted after the year 2000 is not associated with graft failure or greater risk of death , althougaft loss ,17.Finally, a study showed that BMI and waist circumference were independent predictors of albuminuria, a predictor of allograft failure, cardiovascular disease, and mortality , in the Historically, obese kidney transplant recipients have tended to have a higher risk of delayed transplant function, wound complications, surgical site infection, and long-term hospitalization . Thus, o2 [It has been previously reported that the relative risk of delayed allograft function increases progressively with increasing BMI, being the highest risk in those with a BMI > 36 kg/m2 .2), while age and obesity were significant risk factors for hernia [2 suffered wound complications vs. only 20% of those with a BMI < 30 kg/m2 (p = 0.029) [In a series of 2013 transplant recipients, it was found that the most significant risk factor for a wound infection was obesity (BMI > 30 kg/mr hernia . A study= 0.029) . Robot-a= 0.029) .Finally, in a meta-analysis that included 21 retrospective observational studies with a patient sample size of 241,381, obese recipients showed a higher risk of having biopsy-proven acute rejection and delayed graft function, compared with their healthy BMI counterparts .2, there was an exponential increase in the relative risk for cardiovascular death [2) compared with a matched non-obese control group (BMI < 27 kg/m2), were primarily due to a higher mortality resulting from cardiac events [In one study in the BMI group > 36 kg/mar death , which har death . Worse oup BMI <  kg/m2, wc events .In a study that included more than 700 kidney transplant patients, the majority treated with tacrolimus, mycophenolate, and prednisone, pretransplant obesity was one of the factors that affected early and late PTDM, its reversibility, and its evolution from prediabetes to PTDM .Furthermore, in a retrospective study including 650 nondiabetic, nor obese patients, without documented ischemic heart disease, who received living-donor kidney transplants, the development of obesity at 6 months post-transplantation was associated with an increased risk of PTDM, hypertension, hyperlipidemia, and decreased patient survival at 5 and 10 years, probably due to greater cardiac morbidity .Regarding PTDM itself, Wauters et al. showed that PTDM increased cardiovascular risk and major cardiovascular events .In a study conducted in a large prospective cohort of 817 kidney transplant recipients, it was shown that increased daily-life moderate-to-vigorous physical activity was associated with a reduced risk of PTMD, as well as cardiovascular and all-cause mortality, although the association with PTDM was not significant after being adjusted for metabolic confounding factors, such as glucose level. The authors propose embedding physical activity in the health care management of kidney transplant patients .Concerning lifestyle interventions for the management of obesity and PTDM in kidney transplant recipients, the joint position statement of the Italian Societies of Nephrology Organ Transplantation and Diabetes, suggest to follow the nutritional recommendations developed for the general population with diabetes ,79. TheyIn addition to insulin treatment, anti-diabetic drugs for PTDM such as metformin, sulfonylureas, meglitinides, and dipeptidyl peptidase IV inhibitors (DPP4-i) have been used in kidney transplant patients according to patient characteristics and renal function as shown in Recent studies have shown the advantages of sodium-glucose cotransporter 2 (SGLT-2) inhibitors and glucagon-like peptide 1 receptor (GLP-1) agonists on cardiac and renal outcomes in non-transplant patients.SGLT-2 inhibitors are novel oral glucose-lowering medications that inhibit glucose and sodium reabsorption in the proximal tubule. As a result of the increased natriuresis and concurrent osmotic diuresis due to its glycosuric effects, SGLT-2 inhibitors decrease blood pressure and increase hematocrit . HoweverWith respect to the use of SGLT-2 inhibitors in kidney transplant patients, a meta-analysis that included eight studies with a total of 132 patients, one randomized controlled trial and seven case series, demonstrated that SGLT-2 inhibitors effectively lowered HbA1c when patients were treated for at least 12 months, and reduced body weight when treated for at least 6 months. Serum creatinine levels and urine protein-creatinine ratio were stable throughout the follow-up period. Moreover, canagliflozin showed efficacy in diminishing systolic blood pressure. Adverse effects of SGLT-2 inhibitors included urinary tract infection (43.8%), small ulcers in lower extremities (10%), cellulitis (10%), acute kidney injury (3.6%), and genital fungal infection (1.4%), but no acute rejection events were reported . In the The incretins glucagon-like peptide 1 (GLP-1) are gut-derived hormones that potentiate insulin secretion and contribute to glucose metabolism. As GLP-1 actions are reduced in type 2 diabetes mellitus, several GLP-1 receptor agonist formulations have been introduced for glucose lowering in this type of diabetes. Additionally, GLP-1 receptor agonists lead to reduced body weight, blood pressure, and lipid levels , and wheIn a study that included kidney transplant patients, exogenously delivered GLP-1 improved insulin secretion and glucose-induced glucagon suppression in a hyperglycemic state . With reThe ADA and European Association for the Study of Diabetes (EASD) Consensus Report recommended GLP-1 receptor agonists or SGLT-2 inhibitors for type 2 diabetics with established atherosclerotic cardiovascular disease or CKD, if their HbA1c levels were above 7% under therapy with metformin . More reWhile superficially it may seem that weight loss can only be good in patients with CKD and post-transplantation, the area remains quite challenging. Restrictive diets, the high prevalence of diabetes, the difficulty of maintaining an active lifestyle, weight loss goals, as well as the potential side effects of medications and bariatric surgery all compound the difficulty of managing this patient population. Despite this, newer medications such as SGLT-2 inhibitors and GLP-1 agonists may offer much needed novel therapeutic approaches to weight loss, and need to be better studied in the CKD, ESRD, and transplant populations.


N = 369); (B) >1 renal artery, 1 arterial anastomosis (N = 47); and (C) >1 renal artery, >1 arterial anastomosis (N = 35). Furthermore, the influence of localization of the arterial anastomosis (common iliac artery (CIA), versus non-CIA) was analyzed. Clinicopathological characteristics, outcome, and graft and patient survival of all groups were compared retrospectively. Results: With growing vascular complexity, the time of warm ischemia increased significantly . Furthermore, the duration of operation was prolonged, although this did not reach significance . There were no significant differences regarding surgical complications, post-transplant kidney function , or long-term graft survival. Regarding the localization of the arterial anastomosis, non-CIA was an independent prognostic factor for deep vein thrombosis in multivariate analysis . Conclusion: Multiple-donor renal arteries should not be considered a contraindication to deceased KT, as morbidity rates and long-term outcomes seem to be comparable with grafts with single arteries and less complex anastomoses.Aim: Complex arterial reconstruction in kidney transplantation (KT) using kidneys from deceased donors (DD) warrants additional study since little is known about the effects on the mid- and long-term outcome and graft survival. Methods: A total of 451 patients receiving deceased donor KT in our department between 1993 and 2017 were included in our study. Patients were divided into three groups according to the number of arteries and anastomosis: (A) 1 renal artery, 1 arterial anastomosis ( Kidney transplantation (KT) is the treatment of choice in patients with end-stage renal disease and it improves patient survival and recipients’ quality of life compared to chronic dialysis treatment ,2,3.During kidney graft implantation, vascular anastomosis is one of the most challenging aspects for the transplant surgeon, and post-operative vascular complications such as bleeding or thrombosis can require surgical repair or even nephrectomy . ComplexTherefore, this study aimed to investigate the impact of arterial reconstruction on outcome and graft survival in DD KT.Medical data from all adult patients (≥18 years of age) who underwent initial deceased donor kidney transplantation at the University Hospital of Leipzig between October 1993 and December 2017 were retrospectively analyzed. Our data source comprised a prospectively collected electronic database. Patients undergoing living kidney transplantations, multi-organ transplants, re-transplants, machine preservation of donor kidneys, and transplants with graft anastomosis to the aorta or inferior vena cava were excluded from the study. Living KTs were excluded from the study, as deceased donor organs cannot be compared with living donor organs regarding graft outcome and survival rates. Follow-up data were collected up to March 2020.Patients were divided into three groups according to the number of arteries and anastomosis: (A) 1 renal artery, 1 arterial anastomosis; (B) >1 renal artery, 1 arterial anastomosis; and (C) >1 renal artery, >1 arterial anastomosis.2), donor cause of death, duration of dialysis, and time on the waiting list. The criteria for expanded criteria donors (ECD) kidneys were donors over 60 years of age or donors between 50 and 59 years of age with at least two of the following three criteria: cerebrovascular death, arterial hypertension, or a donor serum creatinine level >1.5 mg/dL /1.73 m2 standard BSA = mL/min) [Outcome data included initial non-function (INF), episodes of acute rejection within 12 months after KT, delayed graft function (DGF), intra- and post-operative complications, date of graft failure, and patient death. INF was defined as dialysis dependence or creatinine clearance ≤20 mL/min at three months post-transplant. Acute rejection episodes were histologically proved. DGF was defined as the requirement of dialysis in the first week following transplantation . Using sa (BSA)) . To redu mL/min) ,12. PostThe kidney grafts were procured according to the guidelines provided by Eurotransplant (ET) and transplanted into the iliacal fossa. Kidneys were flushed in situ with cold HTK (histidin-tryptophan-ketoglutarat) solution and explanted. For static cold storage, grafts were immersed in HTK solution at 4 °C and stored in three separate bags, whereas the first bag was filled with preservation solution ,14. In gImmunosuppressive therapy comprised an induction therapy with the interleukin-2 receptor antagonist basiliximab or antithymocyte globulin, followed by triple maintenance immunosuppression comprising calcineurin inhibitors (tacrolimus or cyclosporine), and/or mTOR inhibitors (everolimus or sirolimus), antimetabolites (mycophenolate mofetil), and tapered steroids (prednisolone).t-test, the chi-squared test, analysis of variance (ANOVA), the Kruskal–Wallis test, and the Wilcoxon–Mann–Whitney test was used. Univariate and multivariate logistic regression analyses were used to evaluate the association between independent variables and binary outcomes of allograft function, and multivariate Cox proportional hazard analysis was applied to assess independent predictors of kidney graft failure. For multivariate analyses, we used a forward stepwise regression model including only clinically relevant variables and those presenting p ≤ 0.05 in univariate analysis. Survival rates were calculated using the Kaplan–Meier analysis, and the log-rank test was applied to test statistical significance. Graft survival was calculated as the time from initial transplant to graft failure , censoring for death with a functioning graft. Patient survival was defined as the time from transplant to patient death, censoring for patients still alive at the time of analysis. If a recipient was alive or lost to follow-up at the time of last contact, then survival time was censored at the time of last contact. SPSS software version 21.0  was used for statistical analysis. A p-value < 0.05 was considered statistically significant.For comparison between the groups, the appropriate statistical significance test, including Student’s A review of the literature on publications reporting results after renal transplantation with multiple renal arteries was performed using the Medline (Pubmed) database. The search algorithm included the following medical subject heading terms: kidney or renal transplant, multiple arteries, anastomosis, artery, and outcome. Articles written in languages other than English, articles without an abstract and/or full text, and those specific to the pediatric population were excluded. A manual search of the reference lists supplemented the electronic results. It yielded 53 potentially relevant original articles, of which 13 met the complete selection criteria  17,18,1,27,28,29N = 369), 16.4% two (N = 74), and 7.8% had three (N = 35) renal arteries. In 92.2% (N = 416) of the cases, a single arterial anastomosis was performed, in 6.7% (N = 30) two were performed, and in 1.1% (N = 5) three arterial anastomoses were performed. Donor, recipient, and transplant characteristics according to the different complexity of arterial anastomosis (groups A–C) are summarized in p = 0.006). Moreover, a longer operation time was associated with more complex arterial anastomoses, although this was not statistically significant .A total of 451 patients receiving primary deceased donor kidney transplantation (KT) were included in the study. The mean follow-up period was 7.6 ± 5.7 years. Among the overall study population, 81.8% of the kidney grafts had one , whereas permanent lack of graft function from the time of transplantation (primary non-function) was observed in six cases .In the overall study population, 27 kidneys lost their function in the first three months  , secondary bleeding and hematoma , and lymphoceles . The total number of vascular complications was relatively low . No differences in hospital stay  were noted.The most frequent post-operative complications were secondary wound healing (p = 0.322). The causes of death included multiple organ failure (N = 2), septic shock (N = 1), intracerebral hemorrhage (N = 1), and fatal heart attack (N = 1) in group A; decompensated heart failure (N = 1) and acute bleeding with cardiovascular arrest (N = 1) in group B; and decompensated heart failure (N = 1) in group C.Eight of the 451 patients (1.8%) died in the immediate post-operative course within the first 30 days after surgery. Overall, post-operative mortality was comparable between the groups , whereas no case of thrombosis was reported in group C. There was no significant difference between the two groups regarding post-transplant kidney function parameters .Univariate regression analyses of post-operative outcomes associated with the complexity of arterial anastomosis (groups A–C) and anastomosis localization are displayed in p = 0.044) and deep-vein thrombosis . Univariate risk analysis showed no correlation between cause of renal failure, warm ischemia time, the use of arterial patches, and post-operative outcome parameters  were thrombosis of the renal artery   failed to be an independent predictor of post-operative complications and graft function. However, multivariate analysis showed that the localization of arterial anastomoses is an independent prognostic factor for deep-vein thrombosis  .p = 0.733), respectively. Mean kidney graft survival decreased with the increasing complexity of arterial anastomoses, although these trends were not statistically significant among the groups . Overall long-term patient survival at one, three, five, and 10 years was 95%, 90%, 87%, and 74% in group A, 96%, 91%, 91%, and 83% in group B, and 94%, 91%, 88%, and 80% in group C (p = 0.633), respectively.The one-, three-, five-, and 10-year kidney graft survival rates were 96%, 89%, 85%, and 72% in group A, 91%, 91%, 85%, and 78% in group B, and 88%, 85%, 81%, and 81% in group C . Interestingly, arterial stenosis only occurred in cases with MRA on common aortic patches, not on reconstructed MRA patches [Most of the previously published reports showed higher rates of vascular complications in kidney grafts with multiple renal arteries (MRA) compared to single anastomosis ,27,28,29 patches . In our  patches . In our In the reviewed studies investigating KT after deceased donation, two reports showed delayed graft function (DGF) data with a slight insignificant increase in DGF in the MA groups ,26. DGF Long-term outcomes and especially graft survival rates seem to be comparable between kidney grafts with single and multiple arteries. However, most published studies investigated KT after living donation (LD) or mixed cohorts comprising both LD and DD KTs ,27,28,29There are some limiting factors of this study. First, one limitation of our study is the relatively low number of patients with multiple arteries and complex arterial anastomoses and its monocentric, retrospective non-randomized design. Second, the long investigation period makes further controlled and prospective studies necessary.In conclusion, based on our data, complex arterial reconstructions of multiple renal arteries are not a limiting factor in kidney transplants regarding early post-operative outcomes and long-term graft survival. However, the localization of the renal artery anastomosis was associated with deep-vein thrombosis, and anastomoses to the internal or external iliac recipient artery should be avoided whenever possible.


Hypertension can lead to different degrees complications of cardiovascular and cerebrovascular, and increase the risk of sudden death. Acupuncture has become a complementary alternative therapy for hypertension because of its antihypertensive and nontoxic side effects. However, there is still lack of evidence-based medicine evidence for an effective acupuncture antihypertensive prescription. The purpose of this study is to evaluate the effect of a special acupuncture prescription on hypertension with hyperactivity of liver yang.In this randomized controlled trial, we will recruit 56 hypertensive patients with hyperactivity of liver yang. Then the patients will be randomly divided into control group and experimental group. The control group will be treated with western medicine, and the experimental group will be treated with medicine combined with acupuncture. The intervention will last 4 weeks. The indices will be collected before acupuncture, after acupuncture, and 2 weeks after acupuncture. The primary outcome will be 24-hour ambulatory blood pressure. The secondary outcomes will be clinic blood pressure, anxiety and depression score, and the syndrome score of hyperactivity of liver yang. The auxiliary indicators will be blood pressure load values and salt sensitivity risk rate. The exploratory indicator will be acupoint diagnosis. The safety evaluation indicator will be incidence of adverse events.The results of this study will provide favorable evidence for the efficacy and safety of acupuncture in reducing blood pressure, and explore the positive reaction acupoints which related to hypertension. Most of the time, the treatment of hypertension is lifelong medication. The long-term use of antihypertensive drugs will bring damage of gastrointestinal, liver, and kidney function. In addition, antihypertensive drugs have the disadvantages of poor compliance and high cost of lifelong medication. Therefore, in recent years, in many countries’ hypertension treatment guidelines, it is mentioned to strengthen the intervention of non-drug therapy. In the review and analysis of clinical research report on acupuncture published by the World Health Organization, essential hypertension is definitely recommended as a disease for acupuncture treatment. This is obviously a confirmation of the antihypertensive effect of acupuncture. Acupuncture, as a characteristic therapy of traditional Chinese medicine (TCM), has the advantages of green and safety, and can adjust the body in multiple levels. With the international development of acupuncture, it has great potential and space in the prevention and treatment of global hypertension.Hypertension is one of the chronic diseases that seriously endanger human health. A study on hypertension epidemiology in 90 countries shows that the awareness rate of hypertension in adults is only 46.5%, the treatment rate is 6.9%, and the proportion of good blood pressure control is only 13.5%. Therefore, it is necessary to find a suitable prescription for acupuncture to reduce blood pressure, and strengthen the synergism and attenuation effects of acupuncture by combining with western medicine.The synergism and attenuation effects of acupuncture on hypertension is a research hotspot at present. Whether it can produce better therapeutic effect on hypertension is the focus of our research. Some literatures have compared the clinical trials of different acupuncture prescriptions in the treatment of hypertension, and found that the antihypertensive effect of acupuncture combined with medicine is better than that of Western medicine alone. And the acupuncture prescription following the principle of dialectical treatment has obvious antihypertensive effect, otherwise, the effect are not good.The purpose of this study is to evaluate the efficacy and safety of a special acupuncture prescription on hypertension with hyperactivity of liver yang (HLY), and to explore the positive reaction acupoints of patients with hypertension.22.1This is a single-center, single-blind, randomized, controlled, parallel group clinical trial. The selected patients will be divided into control group and experimental group according to the ratio of 1:1. The latter will receive acupuncture treatment for 4 weeks on the basis of the former. The data will be collected before acupuncture, after acupuncture, and 2 weeks after acupuncture. The process is shown in Figure 33.1The participants in this study will be recruited from Dongzhimen Hospital of Beijing University of Chinese Medicine and its surrounding communities.3.23.2.1 Without antihypertensive drugs, hypertension will diagnosed when systolic blood pressure (SBP) of clinic blood pressure (CBP) ≥140 mmHg and/or diastolic blood pressure (DBP) of CBP ≥90 mmHg are measured 3 times (not on the same day). The patients who had the history of hypertension and were taking antihypertensive drugs will also be diagnosed with hypertension. The diagnostic criteria of ambulatory blood pressure monitoring (ABPM) for hypertension are: 24 hour average SBP/DBP ≥130/80 mmHg; daytime SBP/DBP ≥135/85 mmHg; nighttime SBP/DBP ≥120/70 mmHg. The diagnostic criteria of home blood pressure monitoring (HBPM) ≥135/85 mmHg, which corresponded to 140/90 mmHg in CBP.The diagnosis criteria of essential hypertension will be in accordance with the 2018 revision of the guidelines for prevention and treatment of hypertension of China, revised by the China hypertension Revision Commission.According to whether participants has cardiovascular risk, including target organ damage, cardiovascular risk factors, diabetes, and clinical complications, they will divided into 4 levels: low risk (without risk factors), medium risk (with 1–2 risk factors), high risk (with ≥3 risk factors), very high risk .3.2.2 the guiding principles for clinical research of new Chinese medicine in the treatment of hypertension and the criteria for diagnosis and treatment of TCM syndromes (2017 edition), the TCM diagnostic criteria for HLY will be formulated. On the basis of the main symptoms, those who have ≥3 secondary symptoms at the same time combined with tongue and pulse conditions, can be diagnosed as HLY.According to the expert consensus on diagnosis and treatment of hypertension in TCM (2019 edition),To guarantee the consensus on inquiry method, judgment of syndrome type and record method, the clinical data will be collected by unified questionnaire and unified criteria. It will be reviewed by the deputy chief physician and above. If the judgment of syndrome type is inconsistent, 2 chief physicians of TCM will assist in the diagnosis.3.31.Age: 18 to 65 years, both male and female;2.Met the Western diagnostic criteria of essential hypertension. For patients without antihypertensive drugs, SBP: 140 to 179 mmHg and/or DBP: 90 to 109 mmHg. For patients with antihypertensive drugs, hypertension should be stabilized at a normal high value. The patients who took medicine used ≤2 antihypertensive drugs for >2 months.3.Confirmed TCM diagnosis of HLY in hypertension.4.Not receives acupuncture or Chinese herbal medicine treatment in recent 1 month.5.Good compliance with the observation and evaluation of researchers.6.Informed consent is signed by the patient himself or his immediate family members.3.41.Secondary hypertension, such as aldosteronism, pheochromocytoma, Cushing syndrome, gestational hypertension, obstructive sleep apnea hypopnea syndrome, and so on.2.Accompanied by other serious cardiovascular and cerebrovascular diseases, nephropathy, retinopathy, peripheral vascular diseases, diabetes, blood diseases, and so on.3.There were skin diseases and severe skin damage near the acupoints.4.Mental disorders, pregnant, and lactating women.5.Participating in other clinical trials.3.53.5.11.The patients who do not complete the treatment according to the regulations or the data are incomplete, which affect the later evaluation.2.Noncompliant patients, those who withdraw from the research by themselves.3.Unauthorized use of drugs and treatment methods other than those specified in this protocol.4.During the trial, patients with serious adverse reactions or complications. The patients are intolerant of acupuncture therapy, or should not continue to receive treatment.5.Patients lost to follow-up.3.5.21.When the patients falls off, we will contact by telephone, e-mail, and so on, as far as possible to ask for the reason. Record the time of the last treatment and complete the assessment items that can be completed.2.Patients who withdraw from the trial due to adverse reactions or ineffective treatment will take corresponding measures according to their actual situation.3.Intention analysis will be conducted after the end of the trial, then the reason and time of withdrawal will be recorded in detail. Those who had more than half course of treatment will be included in the statistical analysis of curative effect.3.61.Patients with serious adverse reactions, special physiological changes, and other unexpected events during the study period.2.Patients with severe complications, disease progression, and other critical illness during the study period.3.Patients who did not obey the treatment.44.1This study will adopt a single-center, randomized, single blind, simple positive drug control method. Simple random number method will be used for grouping. Input the expected sample size into the statistical software package PEMS3.1, and get the sequence number. Then make a random card and add an opaque envelope to seal it. When the qualified patients enter the trial, the envelopes will be opened according to the order of entry, and they will be grouped according to the information on the random card.4.2 The calculation result is 22.57, that is, the experimental group and the control group need about 23 patients, respectively. According to the shedding rate of 20%, a total of 56 patients will be recruited.The purpose of this study is to observe that the antihypertensive effect of acupuncture combined with medicine is not inferior to that of Western medicine alone. Therefore, the sample calculation is based on the sample content calculation formula of noninferiority test.4.3Due to the particularity of acupuncture clinical operation, this study will adopt a single-blind method, so only the efficacy evaluators and data statisticians will be blinded.4.4Before recruiting patients, this study had passed the ethical approval of the medical ethics committee of Dongzhimen Hospital of Beijing University of Chinese medicine . The registration was completed in China Clinical Trial Registration Center (Registration Number: ChiCTR2000037444). All patients will be fully informed about the trail and given enough time to decide whether to participate in the study. All patients will be asked to sign an informed consent form if they agree to participate in the study.55.1This group of patients will receive Western medicine treatment (each patient's specific medication should follow the advice of cardiovascular doctors), and will also receive acupuncture treatment at the same time. Record the type, dose, and frequency of drugs taken by each patient. The frequency of acupuncture will be once a day, 30 minutes each time, 5 times a week (2 days off), a total of 4 weeks.5.1.1Acupoint selection follows the semi standardized characteristics of acupuncture clinical research. Same main acupoints and reinforcing reducing manipulations will be used in this group, and the matching acupoints will be selected according to the principle of individualization.Main acupoints: Taichong (LR 3-double); Baihui (DU 20); Taixi (KI 3-double); sanyinjiao (SP 6-double); Zusanli (ST 36-double).Matching acupoints: headache: Fengchi (GB 20-double), Shuaigu (GB 20-double), Touwei (ST 8-double); insomnia: Sishencong (EX-HN), Benshen (GB 14-double), Shenting (DU 24), Shenmen (HT 7-double); excessive phlegm dampness syndrome: Yinlingquan (SP 9-double), Fenglong (ST 40-double); insufficiency of primordial QI: Qihai (RN 6), Guanyuan (RN 4).5.1.2 Acupuncture operation will be carried out according to the operation method of Acupuncture, a textbook of the 13th five-year plan of China. The manipulations will be carried out according to the operation standard of twirling reinforcing reducing manipulation which agreed by our research group. Andy brand acupuncture needle (0.30 × 40 mm × 100 pieces/box) will be used for acupuncture. Patients in supine or prone position, doctors choose acupoints according to the patient's personal situation. First of all, after local disinfection, then acupuncture to the appropriate depth. Make the acupoints De Qi . Then, with the right hand as the needling hand, 1 minute reinforcing manipulation at Taichong (LR 3-double) and 1 minute reducing manipulation at Sanyinjiao (SP6-double) will be performed. Finally, the needles will be kept for 30 minutes.It will be positioned according to the standard position of WHO in the Western Pacific Region.Baihui (DU 20), Taixi (KI 3-double), Zusanli (ST 36-double), and other matching acupoints will only retain needles with no manipulations. Twirling reinforcing reducing manipulations are as follows. Twirling reducing manipulation: the thumb exerts the heavy force to twist backward, and the light force to forward return, twirling range is 270 to 360 °/time, 60 times/minute, continuous rotation for 1 minute, retention for 29 minutes, a total of 30 minutes. Twirling reinforcing manipulation: the thumb exerts the heavy force to twist forward, and the light force to backward return. The twisting range is 270 to 360 °/time, 60 times/minute, continuous rotation for 1 minute, retention for 29 minutes, a total of 30 minutes.The acupuncture operators involved in this study are postgraduates majoring in acupuncture and moxibustion, and they have obtained the qualification certificate of licensed doctor for >2 years.5.2The patients in the control group will be treated with antihypertensive drugs of western medicine, without changing the original western medicine treatment . And the patients will be instructed to take medicine regularly.66.1 In this study, the 24 hours ambulatory blood pressure monitor (DMS-ABP) made by American Tim will be used for data collection. Ambulatory blood pressure will be measured in patients’ nondominant arm to reduce the impact of activity on blood pressure measurement. The detection time of each patient should be >23 hours. At the same time, the effective reading is >70%. There are at least 20 daytime blood pressure readings and 6 nighttime blood pressure readings.Ambulatory blood pressure monitoring: 24 hours ambulatory blood pressure is the “criterion standard” to evaluate the antihypertensive effect.Ambulatory blood pressure monitoring will be evaluated in the first week (baseline period), the fifth week (after acupuncture period), and the seventh week (after follow-up period).6.21.Clinic blood pressure: This index is used to assist the observation of blood pressure change trend of patients. The same doctor will use the same blood pressure meter in the same period on the same day. The blood pressure will be measured with Omron brand blood pressure meter (HEM-8711). After 5 minutes’ rest in a quiet environment, the blood pressure of the patient's right upper arm will be measured. Measure twice and take the average value. If the difference between the 2 times is >5 mmHg, the average value of 3 times shall be taken.2.Hospital Anxiety and Depression Scale (HAD): HAD is composed of anxiety scale and depression scale. The highest score of HAD is 42. The higher the score is, the worse the mental state of the patients is. The total score of 0 to 7 is normal, 8 to 10 is mild, 11 to 14 is moderate, and 15 to 21 is serious anxiety/depression. The patients’ mental and emotional health will be evaluated by the HADs.3. The evaluation symptoms included dizziness, headache, irritability, blush, hot eyes, thirst, bitter taste, constipation, reddish urine, dysphoria in chestpalms-soles, tinnitus, insomnia, and lumbar debility. The highest score is 42, and the lowest score is 0. The higher the score, the more serious the symptom.Syndrome integral of HLY: This index is used to observe the changes of syndrome of patients. Referring to the symptom grading scale, the symptom grading scale of HLY will be formulated. The symptom grading scale is from the diagnostic and curative effect standard of traditional Chinese medicine (2017 Edition).The secondary outcomes mentioned above will be evaluated in the first week (baseline period), the fifth week (after acupuncture period), and the seventh week (after follow-up period).6.31.Blood pressure load: blood pressure load is the percentage of times that SBP and DBP readings exceed the normal range respectively. The normal standard is 24- hour ambulatory blood pressure <130/80 mmHg, daytime blood pressure <135/85 mmHg, and nighttime blood pressure <120/70 mmHg. It is generally considered that normal load should be <5%.2. The specific assessment method: the blood pressure of the observed patients does not drop at night, that is, the patients with nondipper blood pressure. If their 24-hour heart rate is ≥70 beats/min, about 70% of them are salt sensitive in the saline infusion test, and define this type of patients as having high risk of salt sensitivity. Dipper blood pressure and 24-hour heart rate <70 beats/min are defined as low risk of salt sensitivity, whereas others are defined as medium risk of salt sensitivity.Risk rate of salt sensitivity: In 2011, Italian scholars proposed that the risk rate of salt sensitivity can be preliminarily determined by the nighttime blood pressure drop rate (monitored by 24-hour ambulatory blood pressure) combined with 24-hour average heart rate.The auxiliary outcomes mentioned above will be evaluated at the first week (baseline period) and the fifth week (after acupuncture period).6.4Acupoint diagnosis: all patients will be given acupoint diagnosis. Diagnostic acupoints: acupoints with 12 meridians below elbow and knee joint (1 cm around acupoints). In addition, there are some back shu points, including Ganshu (BL 18), Danshu (BL 19), Xinshu (BL 15), Pishu (BL 20), Weishu (BL 21), and Shenshu (BL 23) (1 cm around the points).Specific diagnosis methods : slide the thumb pulp within 1 cm of the acupoint, ① Feel the abnormal reaction of the skin and the superficial part of the acupoint with light strength; ② Detect the abnormal performance of the muscle with medium strength, including streak, tubercle, bulge, and hollow; ③ Detect the abnormal reaction of the deeper layer with slightly heavy strength; ④ Apply the force evenly, and review repeatedly, then record the results. The acupoints with positive reaction and their specific conditions will be recorded. Then the pain degree will be evaluated by the international commonly used visual analogue scale (VAS), and the VAS score will be recorded. The acupoint diagnosis will conducted be in the first week (baseline period) and the fifth week (after acupuncture period) of the eligible participants.6.56.5.1The experiment will observe the adverse events of the participants during the experiment . And fill in the adverse event report form . At the end of the treatment, the causes of each event will be analyzed and summarized carefully.6.5.2If there are adverse reactions in the process of acupuncture, it is necessary to deal with them timely and properly until the patient's condition is stable. Those with abnormal laboratory tests will be tracked until they return to normal. Researchers will need to analyze whether the adverse events are related to the trial interventions, and decide whether to discontinue the trial based on the severity of the adverse events. For those with serious adverse reactions, relevant departments will be consulted immediately. And we will report to the ethics committee in the first time (within 2 hours).7This study will control bias from the following aspects to improve the quality of research.1.The participants will come from hospitals and surrounding communities to avoid hospital selection bias.2.Acupuncture treatment, blood pressure measurement, and acupoint diagnosis will be operated by 3 doctors respectively (each item will operated by the same doctor), so as to avoid bias caused by doctors with different qualifications.3.To reduce the measurement bias, the blood pressure measuring instrument recommended in Chinese guidelines for the prevention and treatment of hypertension (revised version 2018) will be used.4.The data analysis team will be entrusted to analyze the data, and the research group will publish the real and complete results to eliminate the publication bias.8All information related with this trial will be recorded in CRFs by a trained and qualified investigator. No correction of completed CRFs is allowed once completed. The record of CRFs will be reviewed by the clinical inspector. To ensure the accuracy of the data, 2 investigators will input and proofread the data respectively. In addition, all papery documents and electronic versions of the CRF will be preserved in the secure research archives for 5 years after trial completing at the Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine and only can be viewed by the research team.9t test will used for intragroup and intergroup comparison respectively. For the measurement data of non-normal distribution, nonparametric test will be used. The blood pressure value will be analyzed by repeated measurement analysis of variance. In the correlation analysis of 2 theoretically related continuous variables, Pearson correlation coefficient model will be used if the data meet the normal distribution, and Spearman correlation coefficient model will be used if the data are nonnormal distribution. χ2 test will be used for counting data. All tests will be bilateral; P < .05 means the difference is statistically significant. In the correlation analysis, 0 < R≤0.2 means that there is no correlation between variables; 0.2<R≤0.4 means that there is a low correlation between variables; 0.4<R≤0.8 means that there is a moderate correlation between variables; 0.8 < R≤1 means that there is a high correlation between variables.SPSS 20.0 statistical software will be used for data statistics . The frequency percentage will be used to describe the demographic data. For the measurement data with normal distribution and homogeneous variance, mean ± standard deviation (\bar{x} (Latex code) ± s) will used to describe the data. Paired and independent sample 10 Therefore, it has important research significance. TCM believes that HLY belongs to a syndrome type of water failing to nourish wood, and deficiency in origin and excess in superficiality. Its pathogenesis is related to a series of pathological manifestations caused by the reverse ascending of Chong Channel in TCM. Therefore, Taichong (LR 3), Baihui (DU 20), Taixi (KI 3), Sanyinjiao (SP 6), and Zusanli (ST 36) are used as the main acupoints for adjustment. The purpose of these acupoints is to stabilize the reverse ascending of Chong Qi and guide the Qi downward. At the same time, these acupoints can also nourish yin to suppress yang, and regulate qi and blood. Finally, the goal of reducing blood pressure will be achieved. In addition, according to other symptoms and syndrome types of patients, matching acupoints will be selected to achieve better antihypertensive effect.The hypertension patients included in this study are HLY, which accounted for a high proportion (24.1%) of hypertension patients.–15 Therefore, according to the theory of reinforcing deficiency and reducing excess, reinforcing and reducing manipulations on the main acupoints can achieve better therapeutic effect. The operation time of manipulation is 1 minute, and the time setting is in line with the clinical operation. The indicators of the research will be evaluated at most 3 times, and the scale is not large, so it will be collected smoothly. In addition, salt sensitivity of hypertension is common in China. Because it is difficult to popularize invasive saline infusion test on a large scale, clinical evaluation is difficult. Although the effectiveness of the salt-sensitive risk assessment method used in this study needs to be verified, it has good feasibility and promotion value. Therefore, it is worthy of further study.Our research group has been engaged in the research of twirling reinforcing reducing manipulation for a long time.This experiment focused on 1 type of hypertension. The highlight of the experimental design is to fix the main acupoints according to the characteristics of HLY, and select the matching acupoints according to patient's conditions. Therefore, it will be more effective in reducing blood pressure and is in line with clinical operation.Lingshu · Hailun, it is said that “Twelve meridians belong to the viscera internally, and connect to the extremities and joints externally.” Therefore, the physiological and pathological conditions of the viscera will be reflected in the relevant acupoints. Many animal experiments have confirmed this. Because acupoint diagnosis takes more time, there are few studies in the current clinical trials. Acupoint diagnosis is to verify the correlation between acupoints and viscera. This result will also provide reference for the adjustment of acupoint prescription of hypertension.In addition, this design not only verifies the hypotensive effect of a special acupuncture prescription, but also explores the related theories of acupoints and viscera. This is also the unique feature of this clinical study. In Of course, this study also has some limitations. For example, the study cannot achieve double-blind, which may have some impacts on the results; the follow-up time of patients may be short, and so on.In summary, this study will be able to evaluate the effect of a special acupuncture prescription on hypertension with hyperactivity of liver Yang, and will provide experimental basis for the selection of acupoints for hypertension.Xudong Zhang and Jiaojuan Wu are the co-first authors. They contributed equally to this work. Jiping Zhao designed this study. Qingguo Liu guides the experiment. Xudong Zhang will perform acupuncture treatment. Jiaojuan Wu is responsible for acupoint diagnosis. Yanjun Xue is responsible for blood pressure measurement. Xiaoli Wu and Pengcheng Yu are responsible for recruitment. All authors have read and approved the final manuscript.Data curation: Yanjun Xue, Pengcheng Yu, Xiaoli Wu.Methodology: Jiaojuan Wu, Xudong Zhang.Project administration: Jiping Zhao, Qingguo Liu.


This study suggests that peak of sec‐surge could be a better predictor of LVH compared to parameters derived from regular nocturnal oscillometric SBP.Nocturnal blood pressure (BP) surge in seconds (sec‐surge), which is characterized as acute transient BP elevation over several tens of seconds, could be a predictor of target organ damage. However, it is not clear that the severity of sec‐surge is different between sec‐surges induced by sleep apnea (SA) (apnea/hypopnea detected by polysomnography (PSG) or oxygen desaturation) and those induced by non‐SA factors , and sec‐surge variables associate with left ventricular hypertrophy (LVH) independently of conventional BP variables. The authors assessed these points with 41 patients  who underwent full PSG, beat‐by‐beat (BbB) BP, and cuff‐oscillometric BP measurement during the night. All patients were included for the analysis comparing sec‐surge severity between inducing factors (SA and non‐SA factors). There were no significant differences in the number of sec‐surges/night between SA‐related sec‐surges and non‐SA‐related sec‐surges (19.5±26.0 vs. 16.4±29.8 events/night). There were also no significant differences in the peak of sec‐surges, defined as the maximum systolic BPs (SBPs) in each sec‐surge, between SA‐related sec‐surges and non‐SA‐related sec‐surges (148.2±18.5 vs. 149.3±19.2 mm Hg). Furthermore, as a result of multiple regression analysis ( Patients who met at least one of the following criteria were temporarily registered: (1) hypertensive patients, and (2) patients who had subjective symptoms of sleep apnea syndrome. Next, patients whose mean nocturnal SBP was ≥120 mm Hg, measured by ABPM or using a home BP monitor measuring BP automatically and intermittently, before 1 month of formal registration for the study were enrolled in this study. All registered patients underwent overnight full PSG, BP measurement using a BbB BP monitor worn on patient's left wrist and cuff‐oscillometric BP monitor worn on the patient's right arm for two nights within a month. After wearing these devices given them by study staff members, they were requested to sleep overnight at the sleep laboratory. A total of seven patients who had atrial fibrillation, missing data of PSG/BbB BP measurement in both nights, did not have adequate length of BbB BP records in both nights, or did not have sec‐surges in both nights were excluded from the study. In the end, 41 patients were included as study patients for assessing the difference in sec‐surge severity between sec‐surges induced by SA (apnea/hypopnea detected by polysomnography (PSG) or oxygen desaturation) and those induced by non‐SA factors . Eighteen patients who had inspection results of cardiac magnetic resonance imaging (MRI) within a year out of the 41 were included as study patients for assessing the association between sec‐surges and LVH. The detailed flow of study patients was shown in Figure The PSG was recorded by PSG‐1100 (Nihon‐Kohden) and analyzed by Polysmith (Nihon‐Kohden). The cardiac MRI was performed by OPTIMA MR450w Expert 1.5T . The measurement of left ventricular mass (LVM) was analyzed by cardiacVX  and Vitrea  following our recent study.2.2In the present study, overnight BbB BP was recorded by using the BbB BP monitoring device, based on the tonometry method2.3The office BP of the study patients was measured when they were recruited into this study. Conventional nocturnal BPs were measured using the arm‐cuff‐oscillometric BP monitor , which measures both intermittent BPs  and oxygen‐triggered BPs. Oxygen‐triggered BPs were measured when the oxygen saturation (continuously monitored by pulse oximetry) falls below a variable threshold.2.4The sec‐surges were detected from overnight BbB BP recordings by an automatic sec‐surge detection algorithmth percentile of BbB SBP  to avoid noises. The mean and maximum value of cuff‐oscillometric BPs used for BbB BP calibration  were also calculated.We defined the sec‐surge feature as shown in Figure 2.5To investigate the sec‐surge features between sleep stages and between the inducing factors of sec‐surges (SA‐related sec‐surges and non‐SA‐related sec‐surges), labeling of sleep stages and sleep apnea for each sec‐surge was conducted. Sleep stages, apnea, and hypopnea were automatically determined by the Polysmith. For further details of the labeling, see Expanded Methods in the data supplement.2.6p < .05 in all statistical analyses were considered statistically significant. All statistical analyses were performed with R version 3.6.0.BP variables and PSG‐derived variables were calculated for each night. The average values of the two nights were used in the analysis. Continuous variables were expressed as mean±SD, and categorical variables were summarized as frequencies and percentages. In the analysis of sec‐surge severity between inducing factors of sec‐surges, Student's t‐test was used to compare SA‐related sec‐surges and non‐SA‐related sec‐surges in each sleep stage, and to compare nocturnal BP variables in severe OSA patients (AHI ≥ 30) and non‐severe OSA patients (AHI < 30). In the analysis of the associations between sec‐surge and LVH, correlations between LVMI and BP variables both sec‐surge and conventional one were analyzed using Pearson's correlation coefficient. Furthermore, to investigate the contribution of sec‐surge variables, multiple regression analyses were performed using a sec‐surge variable and a conventional BP variable as independent variables. The partial regression coefficient β were compared after calculating z‐score. Values of 32, and non‐severe LVH.The clinical characteristics of the study patients are shown in Table 3.1p < .01, n = 31 and r = 0.473, p < .01, n = 31, respectively). Table There was no significant difference in the peak of sec‐surges between SA‐related sec‐surges and non‐SA‐related sec‐surges in the whole sleep period (148.2±18.5 vs. 149.3±19.2 mm Hg) and each sleep stage . The maximum of peak of sec‐surge and the mean of that were also significantly and strongly correlated with LVMI . The mean of peak of sec‐surge was correlated with the mean of oscillometric SBP for BbB BP calibration . Even though the sec‐surges were classified as SA‐related sec‐surges and non‐SA‐related sec‐surges, significant and strong correlations were observed between peak of sec‐surge and LVMI in both SA‐related and non‐SA‐related sec‐surges . The integrated values calculated in sec‐surge duration and downward duration had a marginally significant correlation with LVMI . Although hypoxia‐peak SBP measured by the oxygen‐triggered oscillometric method was also significantly correlated with LVMI , six out of the 18 patients did not have oxygen‐triggered BP measurements. There were no significant correlations between other conventional BP variables and LVMI.The BP measurements and correlations between LVMI and each BP variable were shown in Table p = .018) and −0.040 (p = .868), in the order of peak of sec‐surge and mean of nocturnal SBPs. The β in model 2 were 0.663 (p = .103) and −0.067 (p = .863), in the order of peak of sec‐surge and mean of nocturnal BbB SBPs. The β in model 3 were 0.723 (p = .003) and −0.325 (p = .130), in the order of peak of sec‐surge and SD of nocturnal SBPs. The β in model 4 were 0.604 (p = .010) and −0.041 (p = .843), in the order of peak of sec‐surge and SD of nocturnal BbB SBPs. The peak of sec‐surge was significant, except for model 2, and contributed more to LVMI than the other independent variables. The correlations between peak of sec‐surge and conventional BP variables are shown in Table p < .01, n = 41), there was no multicollinearity between the peak of sec‐surge and other conventional BP variables.As a result of four multiple regression models of LVMI using two independent variables , the peak of sec‐surges had a significant correlation with LVMI. The other variables in each model were: (1) mean of nocturnal SBPs, (2) mean of nocturnal BbB SBPs, (3) SD of nocturnal SBPs, and (4) SD of nocturnal BbB SBPs. The standardized β in model 1 were 0.626 . Moreover, our results showed that the peak of sec‐surge was significantly and strongly associated with LVMI compared with the mean or SD of nocturnal SBP. Furthermore, no significant difference in the severity of sec‐surge was found between sec‐surges induced by SA (apnea or hypopnea) and those induced by non‐SA factors (sympathetic nerve activity). These findings imply that the peak of sec‐surge is a better predictor of LVH than conventional BP parameters regardless of inducing factors of sec‐surges. Assessing sec‐surges could be important for nocturnal BP management.The peak of sec‐surge was ≥ 20 mm Hg higher than the mean of nocturnal SBP measured using the conventional oscillometric method. The intermittent BP measurement was insufficient to assess the risk of BP elevation. Whereas, the hypoxia‐peak SBP  was 147.6 mm Hg and comparable with the peak of sec‐surge detected using the BbB BP monitor. However, the oxygen‐triggered BP monitor does not always detect the peak of BP elevationp = .012, n = 18; and r = 0.607, p < .01, n = 18, respectively). We hypothesized that mean of peak of sec‐surge is suited to evaluate LVH because it may represent increased cardiac overload during the night. On the other hand, occurrence of CVE during the night may likely be triggered by the maximum of peak of sec‐surge.The peak of sec‐surge was strongly associated with LVMI independently of conventional mean nocturnal SBP measured using the oscillometric method every 30 min in the present study. To the best of our knowledge, no study has demonstrated the association between LVH and sec‐surges. Palatini and coworkers have demonstrated that general nocturnal BPV, defined as the SD of BP measured by ABPM every 15 or 30 min, is associated with the risk of CVEs using 7112 hypertensive patients in a prospective study.2) in 128 untreated hypertensive patients.Considering BbB BPV, no associations were observed between LVMI and nocturnal BbB BPV variables , and the peak of sec‐surge was better for assessing LVMI than these variables in this study. Several studies have reported that daytime 5–10 min of BbB BPV measured using a Finometer (volume compensation method using finger cuff) in the supine position is a potential predictor of stroke or target organ damage. Webb and coworkers have demonstrated that 5‐min BbB BPV progressed with increasing age, and had a similar predictive power of recurrent stroke and CVEs compared with that of day‐to‐day BPV in patients with cerebrovascular events.p = .285; n = 18), the mean of nocturnal BbB SBP was significantly associated with LVMI . The results implied that using a large sample of nocturnal BPs for calculating the BP level (∼14 570 measurements in this study) might assess LVH more accurately. Our previous Japan Morning Surge Home Blood Pressure (J‐HOP) study has demonstrated that the mean nocturnal SBP measured at 2:00 a.m., 3:00 a.m., and 4:00 a.m. is significantly associated with LVMI  in outpatients with one or more cardiovascular risks enrolled at multiple centers.p = .038; n = 12). However, the BP monitor only detects the sec‐surges induced by SA, and oxygen desaturation was actually not detected by the BP monitor in six out of 18 patients.Considering the level of nocturnal BP, although the mean of nocturnal SBP (measured using the cuff‐oscillometric method) was not significantly associated with LVMI . The peak of sec‐surges induced by any factors (SA and non‐SA) might be a better predictor of LVH, and these sec‐surges might be more accurately detected and assessed using the BbB BP monitoring device than other BP measurement methods.Surprisingly, no significant differences in the severity of sec‐surges  were found between SA‐related sec‐surges induced by apnea/hypopnea or oxygen desaturation and non‐SA‐related sec‐surges induced by sympathetic nerve activity in patients with OSA. It is known that baroreceptor reflex sensitivity is depressed in patients with OSA.All significant sec‐surge variables for assessing LVMI resulted from absolute BP values, although we calculated various variables including the duration or dp/dt of sec‐surges. These results suggest that absolute BP values more directly reflected cardiac overload than other BP variables, including the amplitude of sec‐surges. During sleep, LV preload is augmented by the increase in venous return from the lower body to the heart due to the supine position.p < .01, n = 18; and r = 0.614, p < .01, n = 18, respectively). Detecting higher BP value by BbB BP monitoring with fewer calibration might be important in clinical evaluation. Third, a validation of our BbB BP monitoring device was not currently performed. A validation method for continuous BP monitoring has not yet been established by the International Organization for Standardization. We are now considering the following points for a new validation method: (1) accuracy of the level of BbB BP values are assessed using the accuracy of a BP monitor for calibration, and (2) accuracy of the amount of BPV induced by Valsalva maneuver is assessed by comparing it with a validated continuous BP monitoring device. Our recent study has demonstrated that the error between BbB BPs measured by our BbB BP monitoring device and those measured by a conventional BbB BP monitor  was −0.3 ± 4.7 mm Hg in SBP, and 0.7 ± 3.4 mm Hg in DBP, respectively.The present study has some limitations. First, this study was conducted on a small sample composed of patients with OSA and focused on only nocturnal BP variables for the evaluation. Although sec‐surge variables were not directly compared with daytime one in this study, recent studies have demonstrated the nocturnal BP measured by ABPM is more associated with CVE than daytime BP. Sec‐surge may be a better predictor for CVE risk evaluation. Furthermore, despite the small sample size, we demonstrated a strong association between LVMI and the peak of sec‐surges owing to a large number of BbB BP measurements for BP evaluation. To verify the findings of this study, other studies including patients without SA and larger‐scale clinical trials are required. Second, the BbB BP calibration was triggered many times (approximately 23.3 times) during the night when BP changed by some factors such as repeated sec‐surge. In short, the calibration SBP might detect a part of phenomenon of the sec‐surge. The correlation coefficient between the peak of sec‐surge and the calibration SBP was 0.870, and both variables were strongly correlated with LVMI  and those induced by non‐SA factors (sympathetic nerve activity). Sec‐surges brought about by nocturnal BP assessment using the BbB BP monitor have a potential of worth monitoring to the management of nocturnal BP for preventing LVH, regardless of the inducing factors of sec‐surges. Further studies of nocturnal sec‐surges or short‐term BPV will be needed to understand the mechanisms and implications because current knowledge about them is not widely studied. In addition, to facilitate future clinical study, the development of the BbB BP monitor with better usability and durability for overnight measurement is quite important. Patients with resistant hypertension tend to have nocturnal hypertension. In the present study, the sec‐surges occurred frequently in the night, and the peak of them were missed by the conventional cuff‐oscillometric measurement. The assessment and management of sec‐surges will potentially facilitate the understanding of the mechanisms of resistant hypertension.K Kario received research grants from Omron Healthcare, and is a consultant for Omron Healthcare. A Kokubo works for Omron Healthcare Co. Ltd and belongs to Jichi medical university as a graduate student. M Kuwabara and T Shiga work for Omron Healthcare Co. Ltd and are visiting researchers at the Jichi medical university.K. Kario supervised the conduct of the study and data analysis, and had the primary responsibility of writing this paper. A. Kokubo analyzed the data and wrote the Introduction, Methods, Results, and Discussion sections. M. Kuwabara, N. Tomitani, and S. Yamashita contributed to the analysis and reviewed the manuscript. Y. Ota wrote the Methods section. T. Shiga supervised the conduct of the study. A. Kokubo, M. Kuwabara, Y. Ota, and S. Yamashita collected the data. All authors discussed the results and contributed to the final manuscript.Supporting materialClick here for additional data file.


Kidney dysfunction is common in patients with heart failure (HF) and has been associated with poor outcomes. This study aimed to determine the prevalence, correlates, and prognosis of kidney dysfunction in patients with HF in Cameroon, an understudied population.2. Prognostic outcomes included death and prolonged hospital stay (> 7 days). We also performed a sensitivity analysis excluding racial considerations.We conducted a cross-sectional study in consecutive patients hospitalized with HF between June 2016 and November 2017 in the Buea Regional Hospital, Cameroon. Kidney dysfunction was defined as an estimated glomerular filtration rate < 60 ml/min/1.73mn = 34) were males. Half of patients (n = 37) had kidney dysfunction. Correlates of kidney dysfunction included previous diagnosis of HF  and left ventricular hypertrophy . Thirty-six (48.9%) had prolonged hospital stay, and seven (9.5%) patients died in hospital. Kidney dysfunction was not associated with in-hospital death  nor prolonged hospital stay . In sensitivity analysis , factors associated with Kidney dysfunction in HF were; anemia , chronic heart failure , heart rate on admission < 90 bpm , left atrial dilation , and hypertensive heart disease . Kidney dysfunction in HF was associated with hospital stay > 7 days .Seventy four patients (86.1% of those eligible) were included. Their median age was 60 (interquartile range: 44–72) years and 46.0% (Moderate-to-severe kidney dysfunction was seen in half of the patients hospitalized with HF in our setting, and this was associated with a previous diagnosis of HF and left ventricular hypertrophy. Kidney dysfunction might not be the main driver of poor HF outcomes in this population. In sensitivity analysis, this was associated with anemia, chronic heart failure, heart rate on admission less than 90 bpm, left atrial dilatation, and hypertensive heart disease. Kidney dysfunction was associated with hospital stay > 7 days.The online version contains supplementary material available at 10.1186/s12882-021-02641-2. Heart failure and chronic kidney diseases (CKDs) are common conditions in sub-Saharan Africa (SSA), where they account for about 35% of all deaths –3. Heart2) can be seen in more than 30% of patients with heart failure ) and females (72.8 [SD 40.0]), Patients spent between 3 and 21 days in the hospital, with a median of 7.5 (IQR 6–11) days. Thirty-six  patients had prolonged hospital stay (> 7 days). Kidney dysfunction was not significantly associated with prolonged hospital stay after adjusting for sex and age .In-hospital death occurred in seven  patients, including two with hyper-filtration, three with mild kidney dysfunction, and two with moderate kidney dysfunction. No patient with severe kidney dysfunction or those with normal kidney function died. Kidney dysfunction was not associated with in-hospital death . Those with kidney hyper-filtration (compared with those without) had a 4-fold higher in-hospital death . This 4-fold higher odds for in-hospital death persisted after adjusting for sex and age ..2. This was significantly lower than when the race was considered . The number of patients with an eGFR < 60 was 45  thus, a re-classification of 8 (10.8%) patients to lower eGFR class . The eGFR was normal in 12 (16.2%), mildly reduced in 16 (21.6%), moderately reduced in 35 (47.3%), severely reduced in 4 (5.4%), and failure in 6 (8.1%). Hyper-filtration was seen in 1 (1.4%) patient. Factors associated with kidney dysfunction (Table Sp = 0.036), chronic heart failure , heart rate at admission < 90 bpm , left atrial dilation , and hypertensive heart disease . Kidney dysfunction in HF was associated with hospital stay > 7 days  and not with in-hospital death .After re-calculating the eGFR and excluding racial consideration, the median eGFR was 46.8 (IQR: 35–73.3) ml/min/1.73mThis study aimed to investigate the frequency, associated factors, and outcomes of kidney dysfunction in patients hospitalized for HF in a semi-urban setting in Cameroon. We found that moderate-to-severe kidney dysfunction (assessed with the MDRD equation considering black race) was seen in half of the patients hospitalized with HF and this was associated with a previous diagnosis of HF and left ventricular hypertrophy. In the sensitivity analysis , kidney dysfunction was seen in over 60 % of patients admitted with HF and this was associated with anemia, left atrial dilatation, and hypertensive heart disease. Kidney dysfunction might not be associated with in-hospital death but with prolonged hospital stay> 7 days.Sani et al. reported a prevalence of 30.6% of kidney dysfunction on admission despite comparable aetiologies of HF with our study (predominant hypertensive heart disease). This could be due to the older age of our patients (60 vs 52 years), as kidney function declines with age [Hillege et al. reported a prevalence of 36% in an older population of patients with HF with predominantly ischemic heart disease [Kaze et al. [Hamadou et al. [Sani et al. [Data on the prevalence and correlates of kidney dysfunction in patients with HF in Cameroon are scarce . The prewith age . In the  disease . In a me disease . In a gre et al.  reportedu et al.  reportedi et al. . This suFactors traditionally associated with CKD in the general population are age, hypertension, diabetes, and obesity , 20, 21.Kidney dysfunction is associated with excess mid- to-long-term mortality in patients with HF . In thisThis study has some limitations. The accuracy of our estimates is limited by the relatively small sample size of the study, as shown by wide confidence intervals. The low number of patients in regression analyses might have precluded the detection of some significant associations. Furthermore, we did not collect data on proteinuria, an important marker of kidney dysfunction. In the absence of available kidney function before the index admission, it was not possible to differentiate CKD from acute kidney injury. Also, it was not possible to tell if the patients with high eGFR were true cases of glomerular hyperfiltration or due to sarcopenia with resultant low serum creatinine levels. There was no follow-up data to assess for medium and long-term outcomes. Despite these limitations, to the best of our knowledge, this study is the first to investigate the epidemiology of kidney dysfunction in patients with HF in a non-urban setting in Cameroon.Moderate-to-severe kidney dysfunction (assessed with the MDRD equation and considering the black race) was seen in half of the patients hospitalized with HF in this setting, and this was associated with a previous diagnosis of heart failure and left ventricular hypertrophy on echocardiography. Kidney dysfunction was not associated with in-hospital death or hospital stay > 7 days with the index hospitalization. We also found that patients with high eGFR were more likely to die during admission. Excluding racial consideration in the estimate , mild-to-moderate kidney dysfunction was seen in 60 % of patients admitted with HF, and this was associated with anemia, chronic heart failure, heart rate at admission less than 90 bpm, left atrial dilatation, and hypertensive heart disease. Kidney dysfunction was associated with hospital stay > 7 days.There is a need for further studies with a larger cohort of patients with appropriate follow-up to better characterize the association of renal dysfunction with heart failure outcome in our context.Additional file 1.