Airway eosinophilic inflammation is a characteristic of asthmatic patients and of a sub group of COPD subjects. Blood eosinophils are deemed as a good surrogate marker of sputum eosinophilic inflammation; however, controversial data have been published particularly in COPD. The aim of our study was to compare blood and sputum eosinophils in COPD and asthmatic patients in “real life”.Sputum was induced in stable patients with COPD or asthma with hypertonic saline solution and blood eosinophils were evaluated. Frequency of comorbidities was recorded. Correlations were performed stratifying patients by disease and comorbidities.p = 0.004), but the entity of correlation was lower compared with asthmatic subjects . When blood eosinophils were expressed as counts the correlation was slightly lower than when expressed as percentages in COPD  and in asthmatic patients . In COPD patients older than 73 years or with blood eosinophils higher than the median value (210.6 eos/μl), or co-diagnosed with hypertension, ischemic heart disease or atrial fibrillation no correlation between blood and sputum eosinophils was found.146 patients, 57 with COPD and 89 with asthma were evaluated. Blood and sputum eosinophils expressed as percentages were correlated in COPD (rho = 0.40; However, the effect of ischemic heart disease and atrial fibrillation could be driven by hypertension since most of these patients have this comorbidity.Blood eosinophils correlated with sputum eosinophils to a lesser degree in COPD than in asthmatic patients. Older age, high blood eosinophils and hypertension affected the correlation between blood and sputum eosinophils, more studies are needed to evaluate the role of other cardiac comobidities. In the last decades, characterization of airway inflammation highlighted the presence of different phenotypes not only in asthmatic but also in COPD patients , 2. The In asthmatic patients, the correlation is reliable, even if influenced by comorbidities  . In COPDThe aim of our study was to assess the correlation between blood and sputum eosinophils in COPD patients in “real life” and to compare this correlation with that found in asthmatic patients. Effect of age and comorbidities on blood and sputum eosinophils correlation was considered. To the best of our knowledge, this is the first study evaluating this correlation simultaneously in these groups of patients. Preliminary data were presented as abstract .We evaluated COPD and asthmatic patients who underwent induced sputum to assess airway inflammation and blood eosinophil count in our Institute from November 2016 to August 2018.1 (forced expiratory volume in the first second) post bronchodilator test and classified with the GOLD step from 1 to 4. No patients with step 4 underwent sputum induction. In addition, we clinically stratified COPD patients in a scale from A to D taking into account dyspnoea and number of exacerbations [COPD was diagnosed according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria . Lung imrbations .All patients had COPD without history of asthma or other allergic diseases. Asthma was diagnosed according to current Global Initiative for Asthma (GINA) guidelines .None of the patients had infections of the upper respiratory tract or exacerbations in the previous 2 months of the enrolment. This study conformed to the declaration of Helsinki and was approved by the IRB of Istituti Clinici Scientifici Maugeri (number 2209 CE).1 was monitored before and after each inhalation to either prevent or detect possible bronchoconstriction . After collection, the sputum sample was processed within 2 hours, according to the International Guidelines standardized method with dithiothreitol [Sputum was induced by inhalation of hypertonic saline aerosol. Briefly, 10 min after salbutamol inhalation (200 μg), hypertonic saline (4.5%), nebulized by an ultrasonic nebulizer , was inhaled over four different time periods and then the patient was invited to cough and sputum was collected. FEVthreitol , and thethreitol .Bloodwas collected in K2EDTA tubes . Peripheral blood eosinophils were determined using UniCelDxH 800 haematologyanalyser  for cell differentiation.P-value less than 0.05 was considered statistically significant. Stata 15 statistical software was used for every statistical computation.An ad hoc electronic database was created to collect all study variables. Qualitative data were summarized with absolute and relative frequencies. Mean and standard deviation (SD) or median and interquartile range (IQR) were used for quantitative variables with a parametric and non-parametric distribution, respectively. Chi-squared or Fisher exact test was used to detect any statistical differences for qualitative variables. Student’s t and Mann-Whitney tests were used for quantitative variables following their parametric and non-parametric distribution, respectively. Spearman’s correlation was used to assess the relationship between eosinophils in the peripheral blood and in sputa. P < 0.0001, P = 0.03 and P = 0.03, respectively).We evaluated 146 patients, 57 with COPD  and 89 with asthma (mainly moderate/severe). The characteristics of the enrolled subjects are shown in Table No statistically significant differences were found between asthma and COPD in the frequency of: OSAS, obesity and diabetes. Diabetes, neoplasia, and bronchiectasis showed a low prevalence both in COPD and asthmatic patients and not considered for further evaluations.p = 0.004), but less if compared with asthmatic subjects , Fig. Blood and sputum eosinophils expressed as percentages were correlated in COPD  and in asthmatic patients , Fig. When we expressed blood eosinophils as counts the correlation was slightly lower than that expressed as percentages in COPD . In COPD patients, only when blood eosinophils were lower than the median value (210.6 eos/μl), blood and sputum eosinophils slightly correlated. In asthmatic patients, the correlation was consistently present and better when blood eosinophil count was higher than the median value, Table There was no correlation between blood and sputum eosinophils in COPD patients co-diagnosed with ischemic heart disease, atrial fibrillation or hypertension, Table p = 0.24).Sex did not influence the correlation between blood and sputum eosinophils in any of the patients considered. No correlation between age and blood eosinophils was found in COPD and asthmatic patients, however, in COPD patients ≥73 years (median age) percentages of blood and sputum eosinophils were not correlated , while a tendency to a higher prevalence of atrial fibrillation was found in patients older than 73 years (p = 0.05).No difference in the prevalence of ischemic heart disease and hypertension was found in COPD patients younger and older than 73 years . In COPD patients, co-diagnosis with hypertension and/or atrial fibrillation was not associated with an increase of blood eosinophils.In COPD patients with ischemic heart disease there was a tendency towards increased blood eosinophils compared to patients without this comorbidity  but the difference was not statistically significant . In the asthmatic patients the correlation was higher in the group who reported ≥1 exacerbations .When subjects were divided according to the reported exacerbations in the year before the evaluation, in COPD patients the correlation was quite similar . ICS treatment did not affect correlation between blood and sputum eosinophils in asthmatic patients .A few COPD patients were treated with ICS , had high blood eosinophils  or in subjects co-diagnosed with ischemic heart disease, atrial fibrillation or hypertension. However, since ischemic heart disease and atrial fibrillation are often present with hypertension, we cannot conclude on the role of these comorbidities. Diabetes can be another comorbidity, which could affect the correlation between blood and sputum eosinophils, but its frequency was too low in the evaluated subjects. Most of the COPD patients enrolled in this study were not treated with ICS, whereas in the asthmatic group, the treatment with ICS did not affect the correlation between blood and sputum eosinophils.Blood eosinophils expressed both as percentage and count have been recently used as surrogate marker of airway inflammation in asthma and in COPD. While in asthmatic patients this correlation, even if not strong, is convincing, in COPD patients more scepticism has been raised. We know that the strength of correlation between blood and sputum eosinophils varies in different studies both in asthma and in COPD, but to the best of our knowledge, none of them evaluated the correlation in the two groups of patients in the same study.Blood eosinophils in COPD patients should be detected for therapeutic choices: to select patients to be treated with combination of ICS/bronchodilators is needed to reduce the risk of pneumonia in patients without an eosinophilic inflammation, and to evaluate possible therapies with monoclonal antibodies against IL-5 or its receptor, decreasing T2 inflammation. Increased blood eosinophils could represent a treatable trait in COPD patients, but it is not clear if this increase only reflects airway eosinophilia or more likely a mixed systemic and peripheral inflammation.Concrete evidence that the correlation between blood and airway eosinophils in COPD was weak or even absent came from the study of Turato et al. where eosinophils in tissue biopsies did not reflect the amount of blood eosinophils . BiopsieHartjes et al. in COPD patients not treated with ICS found a weak correlation between blood eosinophils and sputum, biopsies and BAL eosinophils . HoweverSchleich et al. found that in stable COPD patients with different treatments, part without ICS and part with ICS or oral corticosteroids, the best cut-off which reflects sputum eosinophils ≥3% was 215 eosinophils/μl  or 2.3% blood eosinophils  . In our Kolsum et al.  showed tEosinophils are produced by bone marrow and migrate to tissues attracted by different cytokines and chemokines. They can present different phenotypes sometimes protective and sometimes detrimental.Changes in tissue metabolic state, stem cell activity, morphogenesis and regeneration are processes where eosinophils can be involved . EosinopThe presence of different subtypes of eosinophils with different roles and characterized by different membrane molecules demonstrated the heterogeneity of these cells, which were previously only described as steady state or activated cells . MesneilCOPD patients frequently have one or more comorbidities. COPD patients with hypertension are highly prevalent in our study and in these subjects, blood and sputum eosinophils are less or not correlated compared with those without this comorbidity.Blood eosinophils, particularly in COPD patients, could increase because of systemic inflammation, cardiac heart failure or they could reflect an attempt to regulate perivascular adipose tissue and hypertension.Recently it has been demonstrated that eosinophils play a pivotal role in metabolic homeostasis , 17 and High serum triglyceride, low serum high-density lipoprotein cholesterol and chronic kidney disease were associated with high absolute eosinophil count , 20.In asthmatic patients with hypertension, the correlation between blood and sputum eosinophils was not affected, probably because the trigger that attracts cells might overcome the systemic increase of eosinophils due to other causes.Blood eosinophils exert not only a protective but also an inflammatory role. Sweetnam PM et al. found that increased blood eosinophil count is a risk factor for coronary heart disease  and TanaRecently a new unexpected role for eosinophils in haemostasis and thrombosis in response to vascular injury has been described . It mighThe effect of comorbidities on blood eosinophils and on the correlation between blood and airway eosinophils has scarcely been evaluated. DiSantostefano RL et al., found in a cohort of COPD patients that blood eosinophils increased in older male subjects with contemporarily severe asthma . In our In non-smoking COPD patients any percentage of blood eosinophils is predictive of a response to ICS in terms of reduction of exacerbation , while tBlood and sputum eosinophils in COPD patients did not correlate as well as in asthmatic patients, probably due to blood eosinophils triggered in blood from bone marrow by different causes other than airway inflammation. An accurate clinical and biological characterization of COPD patients could help in understanding the role of blood eosinophils in COPD patients and using them as useful biomarker.


Objective: To prospectively examine the long-term safety of a cardiovascular health dietary supplement by assessing a comprehensive set of safety measures.Design: Single-arm, open-label study.Location: National University of Natural Medicine, Portland, OR.Subjects: Thirty adults with screening blood pressure readings consistent with prehypertension or stage I hypertension.Intervention: One caplet per day of a dietary supplement for 6 months. The investigated herbal–mineral supplement contains several ingredients, most notably Rauwolfia serpentina.Outcome measures: Primary measures included b-type natriuretic peptide (NT-proBNP), aspartate aminotransferase (AST), alanine aminotransferase (ALT), estimated glomerular filtration rate (eGFR), electrolytes, and the Patient Health Questionnaire (PHQ-9). Exploratory measures included physical vital signs, cholesterol levels, high-sensitivity cardiac troponin-I, cystatin C, endothelin, interleukin (IL)-6, IL-17a, tumor necrosis factor-α, high-sensitivity C-reactive protein, blood counts, and the Patient Reported Outcome Measure Information System (PROMIS) Sleep Disturbance Short Form 8b.Results: NT-proBNP, AST, ALT, eGFR, sodium, calcium, magnesium, PHQ-9 score, and the majority of exploratory measures did not change. However, serum potassium increased (p < 0.05), systolic blood pressure decreased (p < 0.0001), and diastolic blood pressure decreased (p < 0.0001). There were no serious adverse events, but 30% of participants withdrew citing potential side effects, most commonly nasal congestion or fatigue; most participants who reported nasal congestion also reported concomitant seasonal allergies. Adherence to the supplement was 90.9%.Conclusions: The findings of this study suggest that the investigated dietary supplement is safe for long-term use in adults with prehypertension and stage I hypertension. Additional results of this study, particularly the increase in serum potassium and decreases in systolic and diastolic blood pressure, are promising and suggest that future research on this dietary supplement, or its ingredients, should further explore effects on blood pressure and biologic mechanisms of action, which may involve potassium-sparing and diuretic effects. This is particularly relevant for naturopathic physicians and other complementary medicine providers, who frequently discuss the safety, quality, and efficacy of dietary supplements during clinical encounters.10 On subgroup analysis, use of the formula was associated with greater reductions in blood pressure, compared with those who had not been given the supplement (unpublished data). Herbs in the formula, including Rauwolfia serpentina, Rosa vinca, and Convolvulus pluricaulis, each have a long history of use in Ayurvedic management of patients with hypertension.11–13 Also in the formula, Rosa centifolia is commonly used in Ayurvedic formulas for inflammatory conditions and Tribulus terrestris, Terminalia arjuna, and Boerhaavia diffusa each increase diuresis.14–17 Expanding on the aforementioned observational findings, the authors designed the present study to (1) prospectively evaluate the Ayurvedic herbal–mineral formula based on a comprehensive set of objective safety and tolerability measures; (2) assess patient-reported outcomes during extended use of the supplement; and (3) describe adherence among adults with pre- and stage I hypertension.The authors previously reported on the naturopathic treatment of hypertension, in which a specific Ayurvedic herbal–mineral formula was recommended to 50.6% of the patients.a priori as changes in (1) sodium, potassium, calcium, magnesium, aspartate aminotransferase (AST), alanine aminotransferase (ALT), estimated glomerular filtration rate (eGFR), b-type natriuretic peptide (NT-proBNP); and (2) Patient Health Questionnaire (PHQ-9)-measured mood scores. Participants were first screened for eligibility by phone and then confirmed with an in-person clinical screening visit. Once enrolled, participants returned for a baseline visit, a 3-month midpoint visit, and a 6-month closure visit. Participants were contacted by phone between study visits. All study-related operations were conducted at the National University of Natural Medicine (NUNM). This study was approved by the Institutional Review Board at NUNM and registered at ClincalTrials.gov (NCT02452749).A single-arm, open-label clinical trial designed to assess safety and tolerability by prospectively assessing changes in clinical laboratory biomarkers, validated questionnaires for depression and sleep, clinical AEs, and vital signs was implemented. Primary measures were defined 18 Target enrollment was n = 30.Adults ages 18–75 years with blood pressure meeting JNC 7 criteria for prehypertension or stage I hypertension (120–139 mmHg systolic and/or 80–99 mmHg diastolic) were recruited from the Portland, OR, metropolitan area.B. diffusa, C. pluricaulis, R. serpentina, R. centifolia, R. vinca, T. arjuna, T. terrestris, or coral powder within the previous 2 months; or participation in another interventional research study within the previous month.Participants with the following were excluded: resting heart rate <50 beats per minute (bpm) or <45 bpm in athletes; serum sodium, potassium, or calcium levels outside of laboratory reference ranges; elevated AST or ALT; eGFR ≤60 mL/min; PHQ-9 ≥ 10; initiation of, or changes to, prescription blood pressure-lowering medications or thyroid medications within the previous month; use of β blockers, α blockers, digoxin, levodopa, antidepressant medications, antipsychotic medications, sedatives, tranquilizers, Participants were excluded if they had a history of cardiovascular disease, heart surgery, cardiac arrhythmia, pacemaker placement, abnormal electrocardiogram, abnormal echocardiogram, kidney disease, chronic liver disease, gallbladder disease, bowel disease, ulcers, alcoholism, obstructive sleep apnea, Parkinson's disease, depression, pheochromocytoma, or malignancy (within the previous 5 years); reported consumption of more than 14 alcoholic beverages per week, smoking or tobacco use, illicit or recreational drug use. Lactating or pregnant women, or women planning pregnancy during the study period, were excluded. Also, those with a known intolerance or allergy to ingredients in the study supplement.Recruitment approaches included newspaper advertisements, online advertisements, and flyers. In addition, electronic health records of consenting patients of the NUNM Health Center were queried. Potentially eligible individuals were mailed an invitation letter and recruitment flyer on a rolling basis.®, was a supplement manufactured and supplied by Ayush Herbs, Inc.  in 60 caplet bottles. Participants were asked to take 1 caplet nightly before bed. The supplement contains the following ingredients in each caplet: R. centifolia, B. diffusa, and Dendrogyra cylindrus  as a proprietary blend (350 mg), magnesium aspartate (200 mg), C. pluricaulis (100 mg), T. arjuna (100 mg), T. terrestris (100 mg), low-reserpine R. serpentina (50 mg), and R. vinca (25 mg). The manufacturers grow the herbs in the formula on farms that they own and process them in their plant in Nagrota Bagwan, Himachal Pradesh, India. The supplement is manufactured in the United States in a Good Manufacturing Practice-certified facility. The finished supplement was analyzed for reserpine content via high-performance liquid chromatography and levels were below the lower limit of detection . Lead analysis showed that levels were <0.2 ppm .The intervention, CarditoneFasting blood samples were obtained by venipuncture by a certified phlebotomist. Vital signs were measured by trained clinical research coordinators. Blood pressure and resting heart rate were measured using an Omron digital blood pressure monitor (HBP-1300) after the participant was seated for at least 5 minutes with their back supported, feet flat on the floor, and their arm supported at heart level. Three consecutive readings were taken (at least 1 minute apart) and then averaged. All questionnaires were completed by direct interview. To assess adherence, unused study supplement was returned for pill counts at the midpoint and endpoint of the trial.Serum samples from the screening visit were sent to Quest Diagnostics  by courier the day of collection and analyzed for sodium, potassium, calcium, AST, ALT, and eGFR to confirm eligibility; however, screening laboratory values were not used in any analyses. At subsequent visits, serum, plasma, and whole blood were shipped to Veridia Diagnostics  on the day of collection and analyzed for sodium, potassium, calcium, magnesium, NT-proBNP, AST, ALT, eGFR, total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, high-sensitivity cardiac troponin-I, endothelin, cystatin C, high-sensitivity C-reactive protein, interleukin (IL)-6, IL-17a, tumor necrosis factor-α, white and red blood cell (RBC) count, platelet count, hemoglobin, and hematocrit.20 All other AEs were designated “nonserious.”AEs were monitored by specific interviews during scheduled 3- and 6-month visits and by phone calls between visits. Participants were encouraged to report any AE between study visits or phone calls by contacting a clinical research coordinator or the principal investigators. A 91-item standardized monitoring questionnaire, developed according to the National Cancer Institute's Common Terminology Criteria for Adverse Events v4.0, was administered at each trial visit. Administering the form requires querying symptoms in eight systems: eyes/ears/nose/throat, gastrointestinal, neurologic/musculoskeletal, psychologic/general, cardiopulmonary, skin, genitourinary, and constitutional systems. Symptoms are graded from 0 to 5 . Furthermore, AEs were classified as serious or nonserious based on FDA and Federal Food Drug and Cosmetic Act definitions. AEs were considered “serious” if a participant's outcome had included the following: a life-threatening experience, inpatient hospitalization, disability or incapacity, death, a congenital anomaly or birth defect, or a medical or surgical intervention to prevent one of these outcomes.21 An increase of >5 points was defined as a categorical change in mood, and thus was specifically evaluated at the 3- and 6-month visits. Changes in sleep quality were assessed with the Patient Reported Outcome Measure Information System (PROMIS) Sleep Disturbance Short Form 8b, which was scored as previously described.23The 9-item Patient Health Questionnaire (PHQ-9) was used to assess changes in mood. The PHQ-9 was scored as previously described.d that is computed as the change in means divided by baseline standard deviation; standardized differences are referred to as Cohen's d in the a priori defined safety and tolerability criteria at the midpoint and trial end visits was calculated. These safety and tolerability criteria were as follows: NT-proBNP >400 pg/mL; sodium, potassium, calcium, or magnesium ≥25% higher or 25% lower than the laboratory reference range; AST or ALT >2 times the upper laboratory reference range; eGFR decrease of ≥15 mL/min from baseline; increase in PHQ-9 score by ≥5 points ; systolic hypotension (<90 mmHg); diastolic hypotension (<60 mmHg); systolic blood pressure increase of ≥20 mmHg compared with baseline; diastolic blood pressure increase of ≥10 mmHg compared with baseline; resting heart rate <50 bpm (or <45 bpm in athletes); grade 3, 4, or 5 AEs (monitored via the 91-item symptom monitoring form); or participant elected to withdraw from the study citing AEs. Statistical analyses were performed using SPSS v.20 software .Continuous measures are presented as mean and standard deviation at each time point. Changes from baseline to 3 months and from baseline to 6 months were summarized using Glass's Delta, a version of Cohen's Baseline demographic parameters are described in p < 0.05). Changes in NT-proBNP, sodium, calcium, magnesium, AST, ALT, and eGFR were nonsignificant. Primary outcome measures plus additional safety and tolerability criteria were also examined as a composite , nasal congestion , feeling tired/fatigued , and headache .No serious AEs were reported by any participant during the study. Nine participants (30%) elected to withdraw before completion citing nonserious AEs as the reason . AEs repp < 0.0001). Several blood measures also changed significantly, including cystatin C, RBC count, hemoglobin, and hematocrit (p < 0.05). However, mean values for these biomarkers remained within normal laboratory reference ranges at all time points. There were no significant changes in high-sensitivity cardiac troponin-I, endothelin, cholesterol, inflammatory markers, white blood cell and platelet counts, sleep questionnaire total score, or heart rate.Significant changes in exploratory measures were more frequent than in primary measures . DecreasA pill count of unused study supplement indicated that adherence throughout the study was 90.9% ± 11.6%.This trial rigorously collected long-term safety and tolerability data on a dietary supplement using a semipragmatic model. The supplement evaluated has been sold in the United States for 25 years and is recommended by naturopathic and complementary medicine providers for cardiovascular health. Although many of the findings were unremarkable, several findings stand out as clinically meaningful, including a lack of serious AEs and a lack of meaningful change in many biomarkers, including NT-proBNP, three of four electrolytes, liver enzymes, and eGFR. The lack of change in these measures suggests safety and a lack of harm to major organ systems, including the kidney, liver, and myocardium. Significant decreases in systolic and diastolic blood pressure were also clinically meaningful. The modest but significant increase in serum potassium was also clinically interesting and potentially related to modulation of blood pressure.10 These results support previously observed findings that suggested that use of the formula was associated with clinically meaningful blood pressure reductions when the formula was used as part of a comprehensive naturopathic treatment plan to address hypertension. Regarding potential mechanisms of action of the formula studied, R. serpentina is rich in alkaloids that exhibit multiple pharmacologic actions, including a vasodilatory effect and alteration of the balance between the sympathetic and parasympathetic nervous systems.24R. vinca contains alkaloids that act as α-adrenergic receptor antagonists.12T. terrestris, T. arjuna, and B. diffusa each increases diuresis.15–17T. terrestris and B. diffusa also each inhibit angiotensin-converting enzyme (ACE) activity.25The decreases in blood pressure were anticipated based on historic use of the supplement, prior research findings, and previously reported mechanisms of action of the ingredients.T. arjuna and T. terrestris have each been shown to increase potassium, along with diuresis, in animal models.16 Furthermore, the increase in serum potassium could have been related to potential inhibition of ACE activity by T. terrestris and B. diffusa.25 It is well documented that agents that inhibit ACE have the downstream effect of reducing renal potassium excretion.26 However, this study was not designed to assess ACE activity.The observed increase in potassium was unexpected, since modulation of serum potassium was not a previously known clinical effect of the formula. However, the increase in potassium is consistent with previously reported preclinical data on ingredients in the formula; estimate of glomerular filtration rate, cystatin C is independent from serum creatinine, age, gender, race, and muscle mass.28 Since cystatin C is highly sensitive to change in glomerular filtration rate, the slight increase in serum cystatin C is plausibly related to increased urine output (diuresis), if the supplement did indeed increase diuresis.28 However, this study was not designed to assess urine output.Interestingly, mean cystatin C increased throughout the study, yet remained within the normal laboratory reference range. Cystatin C is a biomarker of glomerular filtration and unlike eGFR, which is an each highly correlated with both systolic and diastolic blood pressure.29–32 Hematocrit in particular is the prevailing determinant of blood viscosity and as a result plays a role in long-term modulation of blood pressure.33 It is plausible that the slight decreases in RBC count, hemoglobin, and hematocrit observed after 6 months are related to the decreases in systolic and diastolic blood pressure demonstrated in the first 3 months of the study.This analysis also demonstrated small but significant decreases in RBC count, hemoglobin, and hematocrit over the course of the study. Epidemiologic data collected from racially diverse populations in multiple studies demonstrated that RBC count, hemoglobin, and hematocrit are 34 Nasal congestion is a well-known effects of R. serpentina.11 A long-term study on the effect of R. serpentina extract in hypertensive individuals published in 1956 reported nasal congestion in 30% of participants.35 In the present study, 20% of participants reported nasal congestion. All but one individual who reported nasal congestion also reported preexisting seasonal allergies, suggesting that seasonal allergies may be a contraindication for some individuals. R. serpentina is also known to cause fatigue and T. arjuna has been reported to cause headache.36Although there were no serious AEs, 30% of the study sample elected to withdraw due to nonserious AEs. The nonserious AEs reported by 10% or more of the entire study population were not surprising given previously published clinical data. The mild and typically transient light-headedness reported was most likely related to the observed change in systolic and diastolic blood pressure. Many agents, particularly antihypertensives, can cause dizziness.8 Carefully designed single-group studies can suffice depending on the response of participants.8 A clinically relevant limitation of the study was evaluating one dosage of the dietary supplement. The authors investigated a dosage of one caplet per day, but health care providers who recommend the supplement will sometimes suggest a dosage regimen of up to four caplets per day, based on the clinical presentation of each patient. The high rate of withdrawal from the study was also an important limitation, especially in a study with a relatively small number of participants. The high rate of withdrawal was partly a reflection of the study design, which collected data from participants over a 6-month period, a lengthy time frame for a dietary supplement study.This study has both strengths and limitations. Strengths include successful implementation of a robust experimental design, devised to collect long-term and comprehensive data on an herbal–mineral formula not previously evaluated in a prospective clinical study. An additional strength was excellent adherence by the participants as demonstrated by pill count data. While not including a control group may be perceived as a limitation, an early-phase study does not always require an untreated group according to Aickin, considering that the real purpose of early-phase research is to inform and influence future research effort.A randomized, placebo-controlled trial for the treatment of hypertension is justified to confirm and expand on the clinically meaningful decreases in systolic and diastolic blood pressure observed in the present study. It is plausible that the changes in potassium and blood pressure are related, and thus, future research should explore if the mechanisms involve potassium-sparing and diuretic effects. In the meantime, the results presented here greatly inform the clinical community about what to expect from the use of this dietary supplement in practice, including rates of clinically relevant AEs, reasons for potential limitations in adherence, the expected magnitude of blood pressure decreases at a typical starting dosage, and cautions of potential interactions with other agents, including prescription potassium-sparing diuretics.The findings of this study suggest that the investigated dietary supplement is safe for long-term use in adults with prehypertension and stage I hypertension. Additional results of this study, particularly the decreases in systolic and diastolic blood pressure, and the potentially related increase in serum potassium, can also serve to inform future clinical research endeavors that explore efficacy and mechanisms of action of the investigated dietary supplement or its ingredients. A follow-up study, that includes a control arm and tests additional dosages of the supplement, is justified to expand on the findings of this study.


High blood pressure is one of the most common reasons why patients seek assistance in daily clinical practice. Screening for hypertension is fundamental and, because hypertension is identified only when blood pressure is measured, accurate measurements are key to the diagnosis and management of this disease. The European Society of Hypertension International Protocol revision 2010 (ESH-IP2) was developed to assess the validity of automatic blood pressure measuring devices that are increasingly being used to replace mercury sphygmomanometers.We sought to determine whether the iHealth Track blood pressure monitor meets ESH-IP2 requirements for self-measurement of blood pressure and heart rate at the brachial level and is appropriate for use in the general population.This study was a descriptive investigation. ESH-IP2 requires a total number of 33 participants. For each measure, the difference between observer and device blood pressure and heart rate values is calculated. In all, 99 pairs of blood pressure differences are classified into 3 categories , and 99 pairs of heart rate differences are classified into 3 categories . We followed these protocol procedures in a convenience sample of 33 participants.iHealth Track fulfilled ESH-IP2 requirements and passed the validation process successfully. We observed an absolute difference within 5 mm Hg in 75 of 99 comparisons for systolic blood pressure, 78 of 99 comparisons for diastolic blood pressure, and 89 of 99 comparisons for heart rate. The mean differences between the test and standard readings were 4.19 (SD 4.48) mm Hg for systolic blood pressure, 3.74 (SD 4.55) mm Hg for diastolic blood pressure, and 1.95 (SD 3.27) beats/min for heart rate. With regard to part 2 of ESH-IP2, we observed a minimum of 2 of 3 measurements within a 5-mm Hg difference in 29 of 33 participants for systolic blood pressure and 26 of 33 for diastolic blood pressure, and a minimum of 2 of 3 measurements within a 3-beat/min difference in 30 of 33 participants for heart rate.iHealth Track readings differed from the standard by less than 5, 10, and 15 mm Hg, fulfilling ESH-IP2 requirements. Consequently, this device is suitable for use in the general population. High blood pressure (BP) is one of the most common reasons why patients seek assistance in daily clinical practice -7. In adScreening for hypertension is therefore fundamental, and many interventions are available, both pharmacologic and nonpharmacologic, to control such pathology and its consequences ,5,6. BecMercury sphygmomanometers are being used less and less due to prohibitions against the use of mercury. Automatic BP devices are therefore replacing mercury sphygmomanometers -15.To assess the validity of these automatic BP devices, 3 different protocols are used: that of the Association for the Advancement of Medical Instrumentation (AAMI) , that ofThe purpose of this study was to validate an automatic monitor that measures BP, iHealth Track, in the general population, following ESH-IP2 .We hypothesized that the iHealth Track for home BP monitoring would show validated measures of BP and heart rate (HR), and would meet the requirements of ESH-IP2 in the general population.This study was a descriptive investigation to validate the iHealth Track device for the measurement of BP in the general population according to ESH-IP2  and the The Clinical Research Ethics Committee of Hospital Clínico San Carlos in Madrid, Spain, approved this study (number 18/504-O_P).This study complies with the ethical principles of the Declaration of Helsinki , includiAll participants were informed about the study and gave written informed consent to participate.The reference device used in the study was the Omron M3 IntelliSense , which was validated according to the ESH-IP2 . It consThe device to be validated was the iHealth Track automatic device , which records brachial BP with the oscillometric method, with a range of pressure of 0 to 300 mm Hg (measuring accuracy ±3 mm Hg) and an HR range of 40 to 180 beats/min (measurement accuracy ±5%).The systolic BP (SBP), diastolic BP (DBP), and HR are displayed on a liquid crystal display screen. The device has enough memory for 99 measurements. In addition, this unit can be used with Apple Bluetooth 4.0 devices and certain Android Bluetooth 4.0 mobile phones, by means of an app called Health MyVitals, which means that it allows for storage of BP and HR data in wireless devices connected to an iHealth Track and tracks data graphically and visually.BPA: entry BP and HR, with the standard device (Omron M3 IntelliSense).BPB: device detection of BP and HR with the test instrument . This measurement is used to determine the correct functioning of the test instrument with the participant and is discarded from further analysis.BP1: with the standard device.BP2: with the test instrument.BP3: with the standard device.BP4: with the test instrument.BP5: with the standard device.BP6: with the test instrument.BP7: with the standard device.The unit weighs approximately 348 g (batteries and sleeve included). It required 4 AAA batteries with an approximate capacity of 250 measurements. The included standard cuff fits the circumferences of the arm in a range of 22 to 42 cm.We recruited a convenience sample of participants in Plasencia, Spain, from a family medical practice known to one of us.According to the protocol review , we inclThe validation team consisted of a single researcher with experience in the measurement of BP.The measurement room was at a comfortable temperature and without any factors that could influence the measurements, including noise and distractions ,19.Each participant reported his or her sex and date of birth. We registered weight, height, and body mass index  and measured the arm circumference to ensure that the cuff size was adequate. Subsequently, the participant relaxed for 10 minutes and 9 consecutive BP measurements were taken on the same arm, with the left arm at heart level, according to ESH-IP2 ,19. MeasDuring measurement, participants remained calm, quiet, sitting, and not moving, with the back straight, keeping the feet on the floor in a parallel position, without crossing the legs. They rested the arm on a flat surface, with the palm of the hand upward and the elbow slightly flexed so that their arm was at the height of the heart. The interval between BP measurements was 30 to 60 seconds .All measurements were made in the same room.t test for independent samples. Statistical significance was set at P<.05.We performed statistical analyses using IBM SPSS Statistics, version 19 (IBM Corporation). The results are expressed as mean (SD). According to the normality tests of the Shapiro-Wilk test, we analyzed nonparametric data by the Wilcoxon-Mann-Whitney test and parametric data by means of the Student We based the accuracy of a device, according to ESH-IP2, on comparisons between the test device  and the reference device (Omron M3). For each participant, we first compared the device measurements BP2, BP4, and BP6 with the standard measurements BP1, BP3, and BP5, respectively, and then with the standard measurements BP3, BP5, and BP7, respectively. We classified the differences between these 2 devices separately for both SBP and DBP according to whether their values were within 5, 10, or 15 mm Hg  and, forWe analyzed and expressed results according to ESH-IP2 requirements to determine whether the device passed or failed the validation protocol. Part 1 and part 2 of the validation process concern the number of differences in the requested ranges for individual measurements (99 measurements) and for individual participants (33 participants), respectively .We used Bland-Altman plots to represent the relationship of the SBP difference (device reference) and mean SBP (device and reference); DBP difference (device reference) and mean DBP (device and reference); and HR difference (device reference) and mean HR (device and reference).We screened a total of 33 participants. There were 13 men and 20 women. These analyses showed an absolute difference within 5 mm Hg in 75 of 99 pairs of differences for SBP and in 78 of 99 pairs for DBP (vs at least 73 for SBP and 65 for DBP following ESH-IP2 requirements). We observed an absolute difference within 10 mm Hg in 93 of 99 comparisons for SBP and in 89 of 99 comparisons for DBP (vs at least 87 for SBP and 81 for DBP following ESH-IP2 requirements). Additionally, 94 of 99 comparisons exhibited an absolute difference within 15 mm Hg for SBP an DBP (vs at least 96 for SBP and 93 for DBP following ESH-IP2 requirements). Therefore, we successfully completed part 1 of the device validation for BP.For part 2 of ESH-IP2, 29 of 33 individuals had a minimum of 2 of 3 comparisons within a 5-mm Hg difference for SBP, and 26 of 33 participants met this requirement for DBP (vs at least 24 of 33 participants for SBP and DBP following ESH-IP2 requirements). On the other hand, 3 comparisons exceeded the 5 mm Hg requirement for SBP and DBP in 3 of 33 participants (vs a maximum of 3 participants for SBP and DBP following ESH-IP2 requirements). Because these 2 conditions were validated, we successfully completed part 2 of the device validation for BP.Thus, part 3 of the iHealth Track device validation also was passed, because parts 1 and 2 were both validated for SBP and DBP.These analyses showed that 89 of 99 comparisons had an absolute difference within 3 beats/min, 91 of 99 comparisons had an absolute difference within 5 beats/min, and 93 of 99 differences had an absolute difference within 8 beats/min. Therefore, we successfully completed part 1 of the device validation for HR.For part 2 of ESH-IP2, 30 of 33 individuals had a minimum of 2 of 3 comparisons within a 3-beats/min difference for HR. On the other hand, none of the 33 participants had 3 differences exceeding 3 beats/min. Because these 2 conditions were validated, we successfully completed part 2 of the device validation for HR.Thus, part 3 of the iHealth Track device validation was passed, because parts 1 and 2 were both validated for HR.With these results, the iHealth Track device meets ESH-IP2 validation criteria for both BP (SBP and DBP) and HR for use in the general population.These results coincide with the Bland-Altman plots showing the differences in measurements between the iHealth Track device and the Omron M3 for SBP , DBP Fi, and HR The results obtained from this research are important because they are the first to show that the iHealth Track device successfully passed both parts of the validation process according to the ESH-IP2 review in the general population . HoweverRegarding the validation protocols, the presence of several protocols for this function -19 is prIn this study, we used the ESH protocol, first published in 2002  and reviFirst, ESH-IP2 does not specify the number of validation studies needed to validate the instrument, although a few findings suggest that a device should be validated in no fewer than 2 different centers separately -24. In tSecond, the specific conditions required for the participants recruited in the study exclude children and young people, thus omitting data on the hypertensive population between 18 and 25 years of age.Third, although we calculated the sample size, consecutive sampling bias should be considered, and a simple randomization sampling process could be more adequate for future studies.Fourth, ESH-IP2 mentions no explicit criteria for a validation process in specific populations, and we highly recommended that this be taken into consideration in its next revision.Fifth, although sphygmomanometers measure SBP, DBP, and HR, no version of the international protocol of the ESH considers validating HR. Hence, we have added such a validation based on the protocol criteria in BP and establishing, in this case, the required differences based on the scale of values found after HR measurements, being even more demanding than the ESH.The results of this study are relevant because they show that an automatic wireless device that measures BP and HR and that can also be linked to new technologies meets the requirements of ESH-IP2.We highly recommended that the accuracy of iHealth Track be assessed in other specific populations, such as pregnant women, older people, patients with arrhythmia, and so on, using other types of sampling. Also, it would be convenient to extend the validation equipment in order to reduce intraobserver error.


ROC curve analysis revealed that hsCRP is a sensitive and specific predictor of EAA and increased PWV values. Concluding, vitamin D deficiency and increased hsCRP and LDL values are very common, and high oxidized LDL is related to pulse pressure amplification in patients with elevated blood pressure. Vitamin D level and high-sensitivity C-reactive protein and LDL provide valuable information in middle-aged hypertensive and HNBP patients related to arterial stiffness and early arterial aging, but only hsCRP is a sensitive predictor of EAA and PWV.Arterial stiffness and arterial age provide valuable prognostic cardiovascular information. The present study aimed at assessing the levels of vitamin D, high-sensitivity C-reactive protein (hsCRP), low-density lipoprotein cholesterol (LDL), and oxidized LDL (oxLDL) in a group of middle-aged hypertensive patients and their relationship with pulse wave velocity (PWV), central blood pressure, and early arterial aging (EAA), respectively. A total of 56 patients, aged 48 ± 6 years, 57% males, with hypertension and high normal blood pressure (HNBP), were investigated using a Mobile-O-Graph, to assess central and peripheral blood pressure, PWV, and arterial age. Additionally, hsCRP, LDL, oxLDL, and 25-hydroxy vitamin D3 were assessed. PWV, 25-hydroxy vitamin D3, hsCRP, oxLDL, and LDL levels were 7.26 ± 0.69 m/s, 25.99 ± 11.17 microg/l, 0.48 ± 0.44 mg/dl, 261.37 ± 421 ng/ml, and 145.73 ± 39.53 mg/dl, respectively. Significant correlations were obtained between oxLDL and pulse pressure amplification (rS = −0.347,  Cardiovascular disorders are leading causes of death worldwide, and Romania was considered a high-cardiovascular-risk country according to the guidelines of the European Society of Cardiology . Early dVitamin D is essential not just for musculoskeletal health, considering that low 25-hydroxy vitamin D levels were frequently associated with an increased risk of cardiovascular events, including stroke and heart failure –9. C-reaConsidering the importance of prophylactic measures in hypertension, the present study aimed at assessing the levels of several laboratory biomarkers such as vitamin D, high-sensitivity C-reactive protein, LDL, and oxidized LDL (oxLDL) and their impact on pulse wave velocity, central blood pressure, and early arterial aging (EAA), respectively, in a group of middle-aged patients with hypertension and high normal blood pressure.A total of 56 consecutive hypertensive and HNBP patients, recruited from the Military Hospital Timisoara, were investigated during the period of July 2016–March 2017. All patients underwent investigation using a Mobil-O-Graph, and biochemical measurements were performed on the same day. Data about cardiovascular risk factors, diagnosis, and therapy were collected from medical records.Patients aged between 18 and 55 years, with essential hypertension, both treated as well as uncontrolled patients, and high normal blood pressure, were included. Essential hypertension and high normal blood pressure were diagnosed according to the European criteria . CardiovThe investigations conformed to the principles outlined in the Declaration of Helsinki and were approved by the “Victor Babes” University. Written informed consent was obtained from each study participant, and the objectives and procedures of the study were explained to each patient included in the study.Blood was drawn after an overnight fast. Serum levels of 25-hydroxy-cholecalciferol, high-sensitivity C-reactive protein, LDL, and oxidized LDL were measured. LDL was assessed using a photometric method, a Siemens Advia 1800 analyzer, and Siemens LDL cholesterol reagents. An ELISA method and Immundiagnostik reagents were used for oxidized LDL. 25-Hydroxy-cholecalciferol and high-sensitivity C-reactive protein were assessed using liquid chromatography and immunophelometry, respectively. The thresholds used for defining normal/abnormal values for the various laboratory variables were provided by the laboratory.Pulse wave velocity (PWV), augmentation index and pressure , arterial (vascular) age, and central and peripheral blood pressure were assessed using a Mobil-O-Graph , a noninvasive, validated device.The measurements were made after 10 minutes of rest, in supine position, using different cuff sizes, and considering the arm circumference. The participants were not allowed to smoke, eat, or drink coffee or alcohol 4 hours before the recording and speak or move during the measurements.Mobil-O-Graph enables brachial blood pressure measurement, followed by the reinflation of the cuff and recording of pulse waves, with a high-fidelity pressure sensor . After mAI was defined as the ratio of AP to aortic pulse pressure, indicating the augmentation component of aortic SBP due to the premature arrival of the reflected wave . PWV wasThe significance of the variables was also described in previous studies . PWV andCategorical data are given as numbers and percentages; continuous data are given as means ± standard deviation. Bravais-Pearson's, Kendall's, and Spearman's correlations and ROC curve analysis were used as statistical methods. Nonparametric correlations were used especially for assessing the correlation between a dichotomous variable and a continuous variable. Analyses were performed using IBM SPSS Base Edition.The subjects included in the study were middle-aged (48 ± 6 years), and most of them were male (57%). The baseline characteristics of the study population are included in Vitamin D deficiency and insufficiency, defined as serum levels < 20 microg/l and <30 microg/l, respectively, were very common in the study population, as well as increased hsCRP and LDL values . VitaminCorrelations were calculated for all variables mentioned in the study objectives, both in a continuous fashion and after categorization. However, no significant correlations were obtained between vitamin D level and pulse wave and blood pressure variables. High-sensitivity C-reactive protein was significantly correlated with early arterial aging, PWV, and pulse pressure amplification . LDL choROC curve analysis revealed hsCRP as a sensitive and specific test for EAA and pPWV Figures  and 3. TVitamin D, LDL, and oxidized LDL were not revealed as sensitive markers for EAA or PWV according to ROC curve analysis .Further testing revealed important negative predictive values for low vitamin D, oxidized LDL, and hsCRP levels in predicting pathological PWV values and for hsCRP in predicting EAA . OxidizeThe present study reports that low vitamin D levels and increased hsCRP and LDL values are very common in middle-aged hypertensive and HNBP patients; correlations were also found between pulse wave velocity and early arterial aging with high-sensitivity C-reactive protein and LDL cholesterol levels, respectively. However, only hsCRP was found as a sensitive predictor of early arterial aging.Conflicting results have been previously published regarding the relationship between vitamin D level, vitamin D supplementation, and arterial stiffness , 17. Sev25-Hydroxy vitamin D and not 1,25-dihydroxy vitamin D was assessed in the present study because 25-hydroxy vitamin D is a nutritional parameter of vitamin D status, the primary circulating and storage form of vitamin D, and a reliable, available marker of low vitamin D levels able to bind to vitamin D receptors , 35.p = 0.049; rS = 0.266, p = 0.048). High-sensitivity C-reactive protein, a marker of low-grade inflammation, was also associated with deep white matter lesions, ischemic stroke, and heart failure [Several mechanisms link inflammation and arterial stiffness, considering the effect of inflammation on the arterial endothelium, nitric oxide (NO), and smooth muscle cells and considering its ability to change the composition of the extracellular matrix, to breakdown elastin, and to enable the calcification of the vessel wall . hsCRP w failure , 43. On  failure .Non-HDL cholesterol was reported as a good predictor of the risk of increased arterial stiffness in postmenopausal women in an urban Brazilian population . Kim et p = 0.028). A high specificity and negative predictive value were obtained for oxidized LDL in predicting pathological PWV.Oxidized LDL was associated with pulse wave velocity in patients with renal failure  and in hPulse pressure amplification, the ratio between central and peripheral pulse pressure, is related to an increase of pulse pressure (PP) amplitude as pressure waves propagate distally in the vessel network and is a measure of arterial elasticity , 51. ChaThe most important study limitations include the cross-sectional study design, which does not provide any data about the cause-effect relationship, the relatively small sample size, and not considering the duration of daily sun exposure, which is important for vitamin D synthesis. Further larger studies are needed to demonstrate if vitamin D level, hsCRP, LDL, and oxidized LDL play important roles in the development of increased arterial stiffness and early arterial aging in hypertensive patients and to reveal their relationship with cardiovascular events, such as stroke and heart failure in hypertensive patients. A power analysis, using PASS 2019, was conducted before the study to determine the sample size needed for the present study, and we do not expect changes in the results by increasing the sample size. A minimum sample size required for Bravais-Pearson's and Spearman's correlations was 35 participants . The required sample size for an area under the curve (AUC) of 0.7 and power and alpha of 0.75 and 0.15, respectively, was 52. One reading was made for each study participant for PWV, AI, and AP using the Mobil-O-Graph, which might be considered as another study limitation; however, earlier measurements provided by the same device demonstrated good reproducibility. According to Our study is the first one comparing the predictive value of vitamin D, LDL, oxidized LDL, and hsCRP for arterial stiffness and early arterial aging, demonstrating a high sensitivity only for hsCRP, and revealing, for the first time, as far as we know, a correlation between pulse pressure amplification and oxidized LDL level. The findings of the present study have clinical implications, considering the prognostic importance of increased arterial stiffness and early arterial aging for cardiovascular risk. hsCRP, LDL, and oxidized LDL can provide valuable information related especially to large vessels, arterial age, and cardiovascular risk in treated hypertensive patients.Hypertension is a state of low vitamin D level, oxidative stress, and low-grade inflammation. Further larger follow-up studies are needed in hypertensive patients to confirm the findings of the present study and to correlate the collagen content of the arterial wall with vitamin D level, high-sensitivity C-reactive protein, LDL, and oxidized LDL level, in order to confirm their role as cardiovascular active substances.Concluding, low vitamin D levels and increased hsCRP and LDL values are very common in middle-aged hypertensive and high normal blood pressure patients, and they provide, along with oxidized LDL, valuable information about vascular function. However, only high-sensitivity C-reactive protein level is a sensitive predictor of increased arterial stiffness and early arterial aging.


This review focuses on the pathogenic association between gut microbiota and kidney diseases (the gut–kidney axis), covering CKD, IgA nephropathy, nephrolithiasis, hypertension, acute kidney injury, hemodialysis and peritoneal dialysis in clinic. Targeted interventions including probiotic, prebiotic and symbiotic measures are discussed for their potential of re-establishing symbiosis, and more effective strategies for the treatment of kidney diseases patients are suggested. The novel insights into the dysbiosis of the gut microbiota in kidney diseases are helpful to develop novel therapeutic strategies for preventing or attenuating kidney diseases and complications.Dysbiosis represents changes in composition and structure of the gut microbiome community (microbiome), which may dictate the physiological phenotype . Recent technological advances and efforts in metagenomic and metabolomic analyses have led to a dramatical growth in our understanding of microbiome, but still, the mechanisms underlying gut microbiome–host interactions in healthy or diseased state remain elusive and their elucidation is in infancy. Disruption of the normal gut microbiota may lead to intestinal dysbiosis, intestinal barrier dysfunction, and bacterial translocation. Excessive uremic toxins are produced as a result of gut microbiota alteration, including indoxyl sulphate,  The microbiota in healthy human intestines is a complex community of more than 100 trillion microbial cells among which are more than 1000 different species . The altThis review focuses on the pathogenic association between gut microbiota and kidney diseases (the gut–kidney axis), touching on CKD, hemodialysis, peritoneal dialysis, immunoglobulin A nephropathy (IgAN), nephrolithiasis, hypertension and acute kidney injury (AKI) patients. As we reflect on the relevant studies and summarize the accumulating findings, we come to a notation that prebiotics and probiotics as well as their combination are important adjuvant therapies for CKD treatment. Dysbiotic gut microbiota provides a potential therapeutic target for preventing or harnessing complications.Establishment of advanced next-generation sequencing technologies, including metagenomics and 16S ribosomal RNA (rRNA) sequence analysis has facilitated the analysis of a much larger number of gut microorganisms. Both approaches have their own unique advantages. Metagenomic sequencing is aimed at determining “what they can do” by random sequencing all extracted DNA in the sample . FunctioMetabolomics was defined as “the quantitative measurement of the dynamic multiparametric metabolic response of living organisms to pathophysiological stimulation or genetic modifications” –21. As aOverall, the infancy in both gut microbiome and metabolome data calls for the need to further our understanding mechanisms and phenotypes in links between gut microbiota and kidney diseases through multi-omics research.p-cresyl sulphate, indole-3 acetic acid, TMAO, and phenylacetylglutamine; these are found to associate with cardiovascular diseases, mortality in CKD, and other end-organ toxicity.Uremic toxins are traditionally categorized based on the physicochemical characteristics affecting their clearance during dialysis. These contained low water-soluble molecules (molecular weight < 500 Da), larger middle molecules (molecular weight > 500 Da), and protein-bound molecules. Uremic toxins also can be classified based on their site of origin: endogenous , exogenous (diet) or microbial. Currently, known gut-derived uremic toxins include indoxyl sulphate, Escherichia coli; after intestinal absorption, indole is sulphated to indoxyl sulphate in the liver. Indoxyl sulphate is normally excreted in urine; it cannot be efficiently cleaned by conventional hemodialysis because of its high binding affinity for albumin [Indoxyl sulphate and indole-3 acetic acid are produced by dietary tryptophan metabolism , 33. Try albumin .p-Cresol/p-cresyl sulphate is produced from phenylalanine and tyrosine catabolism by anaerobic gut bacteria. p-Cresol is conjugated by intestinal microbes to p-cresyl sulphate and p-cresyl glucuronide. p-Cresyl sulphate is a toxin due to its high circulated concentration and biochemical impact in the body [p-Cresol is conjugated also in the liver as well as it can compete with xenobiotics that have either similar structure or moiety in their skeletal structure, which in turn can affect their corresponding pharmacokinetic/pharmacodynamic profiles (including toxicity/adverse effects) [the body . p-Cresoeffects) .l-carnitine or phosphatidylcholine that release trimethylamine [p-cresyl sulphate, TMAO can be efficiently removed by dialysis.TMAO is a gut-derived toxic metabolite from bacterial metabolism of quaternary amines that include betaine, hylamine . TrimethLactobacillus and Bifidobacterium) has been described [Phenylacetylglutamine is another colonic microbial product, produced from phenylalanine fermentation. Microbes metabolize phenylalanine to phenylacetic acid, which undergoes glutamine conjugation to form phenylacetylglutamine. Like TMAO, it is dialyzable. The uremic state has been demonstrated to induce changes in gut microbiota. Despite no significant differences in total amount of microorganisms, an erosion of the aerobic bacteria by the anaerobic bacteria  and 100 times higher Enterobacteria and Enterococci species  were determined in CKD patients [Enterococci and Enterobacteria species, was higher in patients with ESRD than in healthy controls [Lachnospiraceae, Enterobacteriaceae and certain Ruminococcaceae, and decrease in some Prevotellaceae, Bacteroidaceae and particular Lactobacillus and Bifidobacterium species [Prevotella was prevalent in healthy controls whereas Bacteroides was enriched in ESRD patients. The butyrate producing bacteria, including Roseburia, Faecalibacterium, Clostridium, Coprococcus, and Prevotella, were reduced in ESRD patients [Increasing evidence suggests that the gut microbiome was altered in patients with CKD. Approximately, 190 microbial operational taxonomic units (OTU) were significantly different in abundance when the gut microbiome of patients with end-stage renal disease (ESRD) was compared with healthy controls . The lowpatients . The quacontrols . Dysbioscontrols , 55. Gut species . The abspatients .p-cresyl sulphate were associated with increased inflammatory biomarkers in stage 3–4 CKD patients, such as glutathione peroxidase and interleukin-6 [Alteromonadaceae, Clostridiaceae, Cellulomonadaceae, Dermabacteraceae, Halomonadaceae, Enterobacteriaceae, Methylococcaceae, Moraxellaceae, Micrococcaceae, Polyangiaceae, Xanthomonadaceae, and Pseudomonadaceae), 5 possessed uricase , and 3 possessed indole and p-cresyl-forming enzymes  [Prevotellaceae and Lactobacillaceae, the two families that possess SCFA (butyrate) forming enzymes, were amongst the four microbial families that were depleted in ESRD patients [Our studies further indicated that the dysregulations of oxidative stress and inflammation were associated with the perturbations of serum amino acid, lipid, purine and lipid metabolisms in CKD , 59, whileukin-6 . Anotherriaceae) . Prevotepatients .Based on metabolomics, our previous studies demonstrated that the perturbations of amino acid, lipid, purine metabolisms in serum –70 as weProteobacteria (primarily Gammaproteobacteria), Actinobacteria and Firmicutes  [p-cresyl sulphate [Bacteroidetes was significantly increased while Proteobacteria was significantly decreased in hemodialysis patients compared with healthy individuals [By replacing kidney excretory function, dialysis is intended to eliminate the symptom complex known as the uremic syndrome. Hemodialysis has made survival possible for more than a million people throughout the world who have ESRD with limited or no kidney function , 77. Thrstridia) . Howeverstridia) . Interlesulphate . The redsulphate . The gutsulphate . Bacteroividuals . Additioividuals .Firmicutes and Actinobacteria, especially Bifidobacterium catenulatum, Bifidobacterium bifidum, Bifidobacterium longum, Lactobacillus plantarum and Lactobacillus paracasei in peritoneal dialysis patients [Bifidobacterium and Lactobacillus species [Lactobacillus and Bifidobacterium in peritoneal dialysis patients were associated with several adverse effects. Pediatric peritoneal dialysis patients showed a relative lower abundance of gut bacteria within the Firmicutes and Actinobacteria, whereas the Proteobacteria were significantly increased [Proteobacteria (iron oxidizing bacteria) was associated with the oral iron supplementation in peritoneal dialysis patients. Additionally, peritoneal dialysis patients enhanced intestinal absorption of glucose from the peritoneal dialysis dialysate that promoted glucose fermentable bacteria Enterobacteriaceae [Enterobacteriaceae was responsible for peritonitis development in peritoneal dialysis patients, since Enterobacteriaceae family accounted for up to 12% of all peritonitis episodes in these patients [One study described a decrease in gut patients . In gene species . Therefoncreased . The inceriaceae . Considepatients .p-cresol level. The potential link between bacterial lipopolysaccharides and hypogalactosylation of IgA existed. Bacterial lipopolysaccharide could stimulate a systemic inflammatory response and lipopolysaccharides was involved in the hyperproduction and hypogalactosylation of IgA1, the important pathogenesis involved in IgAN [Since immunoglobulin A (IgA) is widely found in gut mucosal immune system, dysbiosis of gut microbiota plays a role in the pathogenesis of IgAN . Chronic in IgAN .Oxalobacter formigenes has attracted attention in medicine [Oxalobacter formigenes, as an oxalate degrader bacterium in the intestinal tract, showed health benefits through the homeostasis of oxalic acid [Oxalobacter formigenes, which reduced the oxalate concentration that was available for absorption at constant rates in the intestine. Oxalobacter formigenes could lower oxalate excretion in urine and protect against formation of calcium oxalate kidney stones [Bacteroides spp. was more abundant in kidney stone formers where Prevotella spp. was more abundant in the healthy controls [Nephrolithiasis is a complex disease that could be caused by genetic and different environmental factors. Kidney stones are small deposits that build up in the kidneys, made of calcium, phosphate and other components of foods. Hyperoxaluria is an important risk factor for the appearance of nephrolithiasis, since 75% of kidney stones contain calcium oxalate . Since hmedicine . The Oxalic acid . An invey stones , 92. Besy stones . Bacterocontrols .Klebsiella was subsequently identified in faeces and could convert melamine to cyanuric acid directly. Rats colonized by Klebsiella terrigena displayed exacerbated melamine-induced nephrotoxicity [In addition, cyanuric acid was produced from melamine in gut by microbial transformation and it served as an integral component of the kidney stones responsible for melamine-induced renal toxicity in rats . Klebsietoxicity . CurrentFirmicutes and Bacteroidetes, is associated with increased blood pressure in several models of hypertension [l-carnitine, and further can be metabolized into TMAO and expedited atherosclerosis in mice [Patients with elevated systolic blood pressure and CKD revealed altered bacterial composition and decreased bacterial richness . The aburtension . It has rtension . Another in mice .Recently, several studies indicated that intestinal microbiota can regulate AKI. One possible mechanism was the renoprotective action of SCFAs against ischaemia–reperfusion injury in models. SCFAs with anti-inflammatory properties were produced by gut microbiota . TreatmeLactobacilli, Streptococci and Bifidobacteria species, that could alter gut microbiota and affect the inflammatory state to produce a less pathogenic microflora and thus lowered generation of uremic toxins. A pilot multinational trial in patients with CKD stages 3 and 4 showed significantly decreased blood urea and improved life quality after treatment with the Renadyl formulation of Lactobacillus acidophilus, Streptococcus thermophilus and Bifidobacterium longum over 6 months [p-cresyl sulphate and gut microbiome alterations [3 and NH4OH and promoted intestinal wall inflammation [The use of probiotics and prebiotics are common therapeutics. Probiotics are living organisms ingested through food or supplements that could promote the health of the host. Probiotics are composed of living bacteria, such as 6 months . However6 months . The few6 months . To addrerations . Therefoammation , 104.Bifidobacteria [Bifidobacteria and Lactobacilli species at the expense of other groups of bacteria in the gut [p-cresol and indoxyl sulphate are lowered by the oral intake of p-inulin in hemodialysis patients [p-cresyl sulphate in hemodialysis patients [Prebiotics are non-digestible carbohydrates that selectively stimulate the growth and activity of beneficial gut bacteria in colon, such as bacteria . Prebiot the gut . Prebiot the gut . Serum ppatients . Howeverpatients . The sempatients . Resistapatients , 109.p-cresol without improvement of gastrointestinal symptoms in 30 stage 3–4 CKD patients for 4 weeks [p-cresyl sulphate but not in indoxyl sulphate and a favorable change in stool microbiome in 37 stage 4–5 CKD patients [Lactobacillus casei strain Shirota and Bifidobacterium breve strain Yakult plus galacto-oligosaccharides showed a significant decrease of serum p-cresol and improvement of stools quantity and quality in nine hemodialysis patients for 2 weeks [Synbiotics is the combination of prebiotic and probiotic treatments. Treatment with Probinul neutro, synbiotic treatment, showed decreased total plasma  4 weeks . The SINpatients . Treatme 2 weeks . More re 2 weeks .p-cresyl sulphate, and TMAO, and cause oxidative stress injury to the kidney, cardiovascular and endocrine systems. Recently, the study of the gut–kidney axis has opened up novel therapeutic avenues for the management of inflammation, kidney injury and uremia to prevent adverse outcomes in CKD patients. Multiple promising interventions were exerted to reverse gut microbiota imbalance and slow the progression of kidney diseases. The probiotics or their byproducts have been employed to develop innovative signaling-targeted interventions which outperform traditional drugs with obvious side effects. Selecting specific probiotic species with well-known metabolic functions could alleviate various disease states. For example, Streptococcus thermophiles can be used to reduce urea from uremia. Future attention and examination of these interventions are required to bring the knowledge of the microbiota into practical benefits of CKD patients. However, interventions need to be further examined in large trials before they can become a primary therapy for patients with kidney diseases.Increasing evidence has demonstrated that a bidirectional relationship existed between host and gut microbiome in patients with various kidney diseases. There is an urgent need for more studies to further characterize the gut microbiome in kidney diseases and explore the relationship between different kidney diseases and the gut microbiome. Intestinal inflammation and epithelial barrier breakdown accelerate systemic translocation of the bacterial-derived uremic toxins including indoxyl sulphate, The metagenomics and metabolomics have been used to investigate the function of key low-molecular-weight endogenous metabolites derived from the gut microbiome in kidney diseases. Understanding the metabolic capabilities of gut microbiota is very important in elucidating their functions on health and disease. Although 16S rRNA sequencing analysis was employed to conveniently survey the composition and structure of gut microbiome, the information on their metabolite effects were limited by the incomplete knowledge in bacterial genomic databases. Metagenomic sequencing mines more knowledge of the existent genes, but the functions of most of these genes remain unknown. KEGG and MetaCyc are the most comprehensive databases for linking orthologous gene groups to reactions and metabolites. To achieve more effective combination of microbiome and metabolome for understanding gut microbial metabolisms in the kidney disease context, advanced multi-omic integration methods need to be developed. To further our understanding of the functional potential of host-associated gut microbiota, we can fill the gaps of the aforementioned databases through genome sequencing, untargeted biochemistry, and functional studies. Thus, even with these enormous challenges, increasing studies have found key microbes and their enzymes/metabolites as potential targets of medical interventions in the context of kidney diseases. With improved understanding of the metabolic interplay between the microbiome and the host, novel prebiotics and probiotics can be explored, and personalized treatment of CKD that utilize knowledge of gut microbiome and their interactions with the host will become feasible.


Pulmonary vascular permeability correlated positively with HR (r = 0.31) and negatively with cardiac index (r = −0.49), end-diastolic volume (r = −0.48), and GEF (r = −0.40), suggesting that capillary leak contributes to hypovolemia and systolic dysfunction. In conclusion, TPTD data suggest that in HCPS patients, increased permeability leads to PE, hypovolemia, and circulatory impairment.Hantavirus cardiopulmonary syndrome (HCPS) is characterized by capillary leak, pulmonary edema (PE), and shock, which leads to death in up to 40% of patients. Treatment is supportive, including mechanical ventilation (MV) and extracorporeal membrane oxygenation (ECMO). Hemodynamic monitoring is critical to titrate therapy and to decide ECMO support. Transpulmonary thermodilution (TPTD) provides hemodynamic and PE data that have not been systematically used to understand HCPS pathophysiology. We identified 11 HCPS patients monitored with TPTD: eight on MV, three required ECMO. We analyzed 133 measurements to describe the hemodynamic pattern and its association with PE. The main findings were reduced stroke volume, global ejection fraction (GEF), and preload parameters associated with increased extravascular lung water and pulmonary vascular permeability compatible with hypovolemia, myocardial dysfunction, and increased permeability PE. Lung water correlated positively with heart rate (HR,  Hantaviridae family, are rodent-born segmented negative strand RNA viruses [Orthohantaviruses, members of the  viruses ,2. Two m viruses .Andes orthohantavirus (ANDV) is the Orthohantavirus endemic to Chile and Argentina and its main reservoir is the long-tailed pygmy rice rat (Oligoryzomys longicaudatus) [audatus) . Humans audatus) ,6. Additaudatus) ,8,9,10. The incubation period of ANDV varies from 7 to 49 days ,12, follAlthough the characteristic pathological feature of HCPS is the increased capillary permeability in lungs and depression of cardiac function, the detailed mechanism for such pathological changes remains unclear . Hantavi2 despite maximal support and at least one of the following conditions found to be associated with a 100% mortality rate: serum lactate greater than 4.0 mmol/L , a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2:FiO2) less than 60, or cardiopulmonary deterioration, such as arrhythmia or cardiac arrest [HCPS is one of the deadliest infectious diseases, with fatality rates of 35–40% ,25,26,27c arrest . These cc arrest . This dec arrest . Since ec arrest ,30. Extrc arrest ,32.Andes orthonavirus (ANDV). Additionally, we explored possible associations between PE and hemodynamic variables.Considering that pulmonary capillary leak and circulatory dysfunction characterize HCPS, TPTD appears to be a highly suitable method to assess them through the course of the disease. To date, a systematic description of TPTD measurements in HCPS patients has not been performed. The aim of this study is to describe the TPTD hemodynamic pattern in patients with HCPS admitted to a Chilean referral hospital due to th 2011). For this study, only patients admitted to the adult intensive care unit (ICU) of Clínica Alemana from 2011 to 2018 were considered.This was an observational retrospective analytical study. The cohort was part of a prospectively obtained database by the Hantavirus Program from the Instituto de Ciencias e Innovación en Medicina de la Facultad de Medicina, Clínica Alemana—Universidad del Desarrollo, approved by our local IRB and ethics committee , detecting ANDV-specific immunoglobulin M or detecting ANDV RNA by reverse-transcription polymerase chain reaction. Even though ELISA and PCR cross-reactivity between orthohantaviruses is well described, a substantial number of viruses have been sequenced in Chile and all have been ANDV .Demographic, clinical, laboratory, and hospital mortality data were collected using a standardized case record form, and deidentified data was entered into a dedicated database.In Clínica Alemana, all patients with a diagnosis of hantavirus diseases are admitted to the ICU, considering its unpredictable and potentially fatal course. Our protocol was to monitor all patients with hantavirus diseases presenting respiratory and/or circulatory failure by TPTD.The TPTD technique is based on the injection of a cold saline bolus close to the right atrium through a central venous catheter and recording the temperature change with time on the arterial side of the circulation, usually through a femoral artery catheter . Aside f(1) The maximal volume of blood in the four heart chambers or global end-diastolic volume (GEDV);(2) The whole blood volume in the chest or intrathoracic blood volume (ITBV), which includes the GEDV and the pulmonary blood volume (PBV);(3) The volume of fluid in the pulmonary interstitium and alveolar spaces where the thermal indicator can dissipate from the pulmonary capillaries or extravascular lung water (EVLW).These variables can be combined to yield the following ones:(1) The stroke volume (SV) is the ratio between CO and heart rate (HR);(2) The global ejection fraction (GEF) is the ratio between SV and a fourth of the GEDV (considering the four cardiac chambers);(3) The cardiac function index (CFI) is the ratio between CO and GEDV;(4) The pulmonary vascular permeability index (PVPI) is the ratio between EVLW and PBV.Cardiac output, SV, GEDV, and ITBV are anthropometrically normalized using the body surface area to yield the cardiac index (CI), stroke index (SI), GEDV index (GEDVi), and the ITBV index (ITBVi), respectively. Extravascular lung water is normalized to predicted body weight to yield the EVLW index (EVLWi) .Other hemodynamic variables stem from systemic arterial pressure wave contour analysis: stroke volume variation (SVV) is the percentage change between maximal and minimal SV along 30 s, normalized by its mean value. In patients under controlled invasive mechanical ventilation (IMV) it represents cardiac preload dependency and may be used to predict the chance of increasing CO after a fluid challenge . The maxTM system . This monitor computes all the parameters derived from the TPTD and arterial pressure waveform analysis described above. TPTD was performed in triplicate according to manufacturer’s recommendations, discarding measurements where CO differed more than 10% from the other two. Mean values of each variable were considered for analysis. On VA-ECMO the working principles of TPTD are violated, making it unreliable. Thus, only measurements performed before VA-ECMO connection were considered in these patients.All the patients in this study were monitored using the PiCCO-“Classic hemodynamic”: HR, mean systemic arterial pressure (MAP), central venous pressure (CVP), CI, SI, and systemic vascular resistance index (SVRi), which is the ratio between the difference of MAP and CVP, and CI times 80;-Myocardial contractility: GEF, CFI, and dPmax;-Volumetric preload: ITBVi and GEDVi;-Fluid responsiveness predictor: SVV;-Pulmonary edema: EVLWi and PVPI.Variables obtained from TPTD can be categorized as follows:All these variables were available for each patient studied.All the data from all the thermodilutions performed in every patient were recorded. Values are expressed as mean ± standard deviation (SD).p-value < 0.05. Statistical analysis was performed using the IBM SPSS statistical package, version 20 .An initial descriptive analysis of the patients considered was performed. All the TPTD variables obtained from all patients were descriptively analyzed. To explore possible associations between PE and hemodynamic variables, linear regressions were performed between these variables and Pearson’s coefficients were obtained. To assess the behavior of hemodynamic variables according to PE severity, we dichotomized thermodilutions according to EVLWi; < 15 mL/Kg or EVLWi ≥ 15 mL/kg and compared them using the t-test or Mann–Whitney non-parametric test according to the distributions of the sample. Normality of data distribution was assessed using Kolmogorov–Smirnov’s test. Significance was defined as Eleven patients with confirmed HCPS monitored with TPTD were identified; all required vasopressors, five patients required IMV, three required VA-ECMO support after a failed trial of IMV and hemodynamic optimization, and three required non-invasive mechanical ventilation. All the patients survived and are still alive. Demographic, clinical, and laboratory characteristic of these patients are shown in A total of 133 TPTD were recorded. The median (IQR) number of measurements per patient was 11 ,13,14,15Correlations between PE and hemodynamic variables are summarized in A dichotomic analysis of TPTD measurements according to EVLWi showed that when PE is severe (EVLWi ≥ 15 mL/kg), HR and CVP are higher, while MAP, GEF, and CFI are lower .Additionally, we presented the time course of HR, SI, EVLWi, and PVPI in a representative patient that required VA-ECMO (Patient 2) and in a representative patient that did not require VA-ECMO support (Patient 4) . It is eTo the best of our knowledge, this is the first study that systematically describes the hemodynamic pattern, and quantifies pulmonary edema and lung permeability using transpulmonary thermodilution in a cohort of patients with HCPS requiring vasopressors. Only one previous case report suggested the usefulness of TPTD in HCPS . The maiOur findings perfectly agree with those of the only previous systematic description of HCPS hemodynamics and lung permeability assessment, by Hallin et al. in 1996, although through quite different techniques. Using the pulmonary artery catheter, chest X-rays, and the ratio of tracheal fluid to plasma protein and albumin concentration, they documented PE with low pulmonary artery occlusion pressure and high PE fluid to the plasma protein concentration ratio in the context of circulatory shock with hypovolemia at presentation in patients with HCPS due to the sin nombre virus . Once fl2O) and the three who did not insinuates a higher CVP and lower volumetric preload and SI in the first group, suggesting some hemodynamic impact of IMV. Nevertheless, EVLWi was similarly high and PVPI was higher in the IMV group, suggesting a greater impact of the HCPS on permeability in these patients. Furthermore, the different trend of HR, SI, EVLWi, and PVPI between the two patients on IMV depicted on Controlled mechanical ventilation, particularly with positive end-expiratory pressure (PEEP), can produce complex genuine or artifactual hemodynamic effects. The most important genuine effects are a reduction in venous return and preload, coupled with an increase in afterload to the right heart that may result in reduced SV and CO . ImportaA novel observation of our report is the association of PE and increased permeability to circulatory failure with elements of both hypovolemia and myocardial depression. The association of capillary leak and hypovolemia is self-explanatory, though in contrast to “old world” orthohantaviruses, in “new world” orthohantaviruses the leak is most prominent in the lung vasculature. The association of capillary leak and myocardial depression is more intriguing. Myocardial edema is a relatively newly recognized entity and it has been shown that heart function can be significantly compromised with only small increases in myocardial interstitial fluid . One hisOn an individual patient basis, it is interesting to see that stroke index behaves as the mirror image of pulmonary permeability, lung edema, and compensatory tachycardia along the course of the disease . The couThe weaknesses of our study are its retrospective nature, the small number of patients, and the high variability in the number of measurements between patients. Its strengths are the large number of measurements collected for analysis and the inclusion of patients with different severities in terms of supportive therapy requirements.In conclusion, transpulmonary thermodilution provides a bedside characterization of the hemodynamic profile in HCPS consistent with the pathophysiology of the disease and older descriptions using different diagnostic tools. Increased permeability pulmonary edema may be pathophysiologically linked to hypovolemia and eventually to myocardial depression. This TPTD pattern with evidence of reduced preload, myocardial contractility, and increased permeability PE, though highly suggestive of HCPS in the proper epidemiological context, cannot be considered specific, as sepsis can produce all three of them. In fact, ARDS is characterized by increased permeability PE ,32 and s


Risk stratification for patients with nonvariceal upper gastrointestinal (NVUGI) bleeding is crucial for successful prognosis and treatment. Recently, the AIMS65 score has been used to predict mortality risk and rebleeding. The purpose of this study was to compare the performance of the AIMS65 score with the Glasgow-Blatchford score (GBS), Rockall score, and pre-endoscopic Rockall score in Korea.We retrospectively studied 512 patients with NVUGI bleeding who were treated at a university hospital between 2013 and 2016. The AIMS65, GBS, Rockall score, and pre-endoscopic Rockall score were used to stratify patients based on their bleeding risk. The primary outcome was in-hospital mortality. The secondary outcomes were composite clinical outcomes of mortality, rebleeding, and intensive care unit (ICU) admission. Each scoring system was compared using the receiver-operating curve (ROC).P = 0.07). The AUC value of the AIMS65 was not significantly different from the other scoring systems in prediction of rebleeding, endoscopic intervention, or ICU admission.A total of 17 patients (3.3%) died and rebleeding developed in 65 patients (12.7%). Eighty-six patients (16.8%) required ICU admission. The AIMS65 (area under the curve (AUC) 0.84, 95% confidence interval, 0.81–0.88)) seemed to be superior to the GBS , the Rockall score , or the pre-endoscopic Rockall score  in predicting in-hospital mortality, but there was not a statistically significant difference between the groups (The AIMS65 score in NVUGI bleeding patients was comparable to the GBS or Rockall scoring systems when predicting the mortality, rebleeding, or ICU admission. Because AIMS65 is a much easier, readily calculated scoring system compared to the others, we would recommend using the AIMS65 in daily practice. Upper gastrointestinal (UGI) bleeding is a medical emergency with an incidence of mortality of 5–10% , 3. It iThere are some scoring systems have been developed to predict bleeding outcomes for patients with UGI bleeding. The Rockall score (RS) and the Glasgow-Blatchford risk score (GBS) are the most widely-used scoring systems in clinical practice , 5. ThesRecently, much interest has been shown in pre-endoscopic risk scores for UGI bleeding. The pre-endoscopy Rockall score (PRS) excludes the endoscopic findings that are needed for the RS; because of this, using the PRS to make clinical predictions, has been controversial , 9. The The causes of UGI bleeding differ among countries. The prevalence of variceal bleeding is higher in Korea than in Western countries . LimitedThe aim of this study was to compare the predictive value of the AIMS65 with the GBS, PRS, and RS scores for a large scale of NVUGI bleeding patients in Korea.From January 2013 to June 2016, patients for the UGI bleeding who visited the emergency medical center of the Sanggye Paik Hospital, Seoul, South Korea were reviewed retrospectively in this study. UGI bleeding was confirmed by the hospital staff based on the presence of hematemesis or melena. All patients underwent emergency upper endoscopy within 24 h. Patients with esophageal or gastric variceal bleeding were excluded. Cases of iatrogenic post-procedural bleedings after endoscopic resection for gastric tumors were also excluded. The data of the patients were collected in the electronic medical record. Patients were excluded if the data required for calculation of relevant risk stratification scores were unavailable. The data were reviewed by two endoscopy specialists (M.S.K. and J.C.) for all cases.Patients received the same treatment according to emergency bleeding protocols. All patients received intravenous proton pump inhibitor infusion before upper endoscopy. Upper endoscopy was performed by endoscopy specialists within the first 24 h. Endoscopic therapies were applied as following conditions: (1) peptic ulcers with actively bleeding (type Ia), oozing hemorrhage (type Ib), or a nonbleeding visible vessel (type IIa); (2) Dieulafoy’s lesion (3) angiodyplasia (4) and any lesions with active bleeding. Adherent blood clot (type IIb), flat spot (type IIc), clean base ulcer (type III), or lesions with no active bleeding stigmata including acute gastric mucosal lesion or Mallory-Weiss tear were initially treated medication without endoscopic therapy.Endoscopic therapies included injection of epinephrine, hemostatic forcep electrocoagulation, argon plasma coagulation, or application of endoscopic clips. In cases of failed endoscopic hemostasis, transarterial embolization was preferred over surgery. When rebleeding occurred after successful endoscopic therapy, endoscopic therapy was initially preferred. Surgery as salvage therapy was performed when embolization was unsuccessful.Transfusion was required if hemoglobin was below 8 g/dL. ICU admission was considered in the following conditions: if the patients have any symptoms of confusion or altered mentality; presence of hemodynamic instability ; or severe comorbid illness including heart failure, chronic renal failure, liver cirrhosis, or chronic lung disease. Decision of ICU admission was made finally by ICU unit attending physicians.The following data were collected through electronic medical record review: age, sex, symptoms of visiting emergency centers , vital sign , the Glasgow Coma Scale, mental status, medications that contribute to bleeding . Laboratory findings , and endoscopic findings were also collected. The AIMS65 score, RS, PRS, and GBS were obtained based on the data. Components of the each scoring system were described in Table P values were divided by 4 for the comparison with an alpha level of 0.05), the corrected P values were 0.0125 for the combination group versus. Data were analyzed using SPSS Statistics for Windows . AUCs were compared with the DeLong method by using MedCalc program .The performance of each scoring system was evaluated with a receiver operating characteristic (ROC) curve, calculation of area under the curve (AUC) with 95% confidence intervals. In a ROC curve the true positive rate (sensitivity) is plotted in function of the false positive rate (100-specificity) for different cut-off points of a parameter. Each point on the ROC curve represents a sensitivity/specificity pair corresponding to a particular decision threshold. The cut-off value of each scoring system is determined by the ROC curve with the most specificity and sensitivity. The risk prediction scoring system was divided into two groups, high-risk group and low-risk group. For each scoring systems, a cutoff point was calculated that maximized the sum of sensitivity and specificity in predicting the primary and secondary outcomes. Fischer’s exact test was used for categorical variables. All confidence intervals are described as two-sided binomial 95% confidence intervals. The cut-off value 0.05 considered to be the threshold for statistical significance. In a Bonferroni correction to adjust for the multiple comparisons in the scoring systems (in which the n = 11), endoscopic mucosal resection (n = 2), endoscopic sphincterotomy (n = 3)), and 20 patients were lost to follow-up  years old, and 71.9% patients were men. Among patients, 397 (69.7%) patients had comorbidities and 327 (36%) were taking anti-platelet agents or anti-coagulant medications on admission. The most common symptom of visiting the emergency center was melena (27.5%). The common causes of bleeding were gastric ulcer (32.8%), duodenal ulcer (20.5%), Mallory-Weiss tear (13.1%), and acute gastric mucosal lesion (12.9%) (Table n = 5), complications due to cirrhosis (n = 5), sepsis due to pneumonia (n = 4), renal failure (n = 2), and cerebral infarction (n = 1). In the cases of 5 deaths due to uncontrolled bleeding, two patients underwent angiographic embolization and two patients underwent angiography followed by surgery. One patient died of active duodenal ulcer bleeding and hypovolemic shock during endoscopic therapy.Seventeen of the 512 patients (3.3%) died. Their median age was 70.24 (range 43–93) years old. The causes of death were uncontrolled bleeding (P = 0.07)  for AIMS65 0, 1/201 (0.5%) for AIMS65 1, 6/104 (5.8%) for AIMS65 2, 6/36 (16.7%) for AIMS65 3, 3/9 (33.3%) for AIMS65 4, 0/1 for AIMS65 5. The AUC values of each test were: AIMS65 = 0.84 , 0.81–0.88), PRS = 0.74 , RS = 0.75 , and GBS = 0.72 . With regard to AUC value, there was a trend suggesting that the AIMS65 scoring system (0.84) seemed more accurate than the GBS system (0.72) for predicting mortality  were diagnosed with serious clinical outcomes . For these composite serious clinical outcomes, the AUC values of AIMS65, PRS, RS, and GBS were 0.68 , 0.70 , 0.66 , and 0.65 , respectively. AUC values of each scoring system did not differ significantly in terms of composite serious clinical outcomes.P = 0.01 and P = 0.04), but not statistically different than that of AIMS65 .Rebleeding occurred in 65 patients (12.7%). Rebleeding occurred in patients with elderly, or chronic kidney disease. The AUC values for predicted rebleeding were as follows: AIMS65 = 0.58 , PRS = 0.58 , RS = 0.63 , and GBS = 0.55 . In pairwise comparisons between the scores for rebleeding, the AUC value of RS was superior to that of PRS and GBS  were admitted to the ICU. The AUC values for predicted admission were: AIMS65 = 0.73 , PRS = 0.70 , RS = 0.70 , and GBS = 0.71 . All four scoring systems similarly predicted the need for ICU admission.Transfusion was required in 264 patients (62.3%) and the median transfusion was 2 units . The AUC values for the need of transfusion were: AIMS65 = 0.69 , PRS = 0.70 , RS = 0.74 , and GBS = 0.87 . GBS was superior to other scoring systems in predicting transfusion requirement.Endoscopic intervention was required in 301 patients (58.8%). The AUC values for the prediction of the need of endoscopic intervention were: AIMS65 = 0.57 , PRS = 0.56 , RS = 0.56 , and GBS = 0.61  (Table p < 0.001) to 88.2% , which was similar to other scoring systems, ranging from 71.3  to 78.6 , respectively. Cut-off as a value separating risk levels (high vs. low risk) for death was above 2 points on the AIMS65 and 8 points on the GBS, and 1 point on the AIMS65 and 11 points on the GBS for rebleeding. The cut-off values for ICU admission were 2 points on the AIMS65, 10 points on the GBS, 4 points on the PRS, and 5 points on the RS . Each scoring system to predict mortality was less accurate than previously reported, because death events were rare [The AIMS65 score in NVUGI bleeding patients was comparable to the GBS or Rockall scoring systems when predicting mortality, rebleeding, ICU admission, and endoscopic intervention in Korean patients. The AIMS65 score, however, is much easier to calculate using variables routinely available in the emergency clinical situation, and has the advantage that it can be performed by the busy clinician before an endoscopy. Therefore, we recommend AIMS65 for prediction of severity of GI bleeding in daily practice. Before the AIMS65 becomes a standard of care for the risk stratification of UGI bleeding cases, further multicenter prospective studies will be required.