Eighty-three adult patients, who had been physician diagnosed with at least asthma, cough variant asthma and/or atopic cough, were divided into asthma and non-asthma groups. They recorded daily cough symptoms during 4 January–30 June 2011 study period while daily samples of total suspended particles were simultaneously collected by use of glass fiber filters and the particulate PAH content determined by high performance liquid chromatography coupled with a fluorescence detector. Ambient concentrations of NO2 and SO2 were obtained from a local monitoring site. Logistic regression models using generalized estimating equations were used to determine population-averaged estimates of association between cough prevalence and ambient pollutant exposures for the two groups. Fully adjusted odds ratios from single pollutant models were 1.083 : 1.029, 1.140) and 1.097  per 0.57 ng/m3 for lag2 PAH exposure, while only for asthma group had significant associations with NO2 and SO2 exposures for both lag2 and lag02. Similar associations were observed in multipollutant models. This finding suggests that ambient PAH, NO2, and SO2 exposure even at low levels is related to cough prevalence in adult chronic cough patients and may be considered as aggravating factor during clinical management of the condition.Information on potential cough triggers including environmental irritants is vital for successful management of chronic cough in patients. We investigated the relationship between ambient levels of particulate polycyclic aromatic hydrocarbons (PAH), nitrogen dioxide (NO The estimated prevalence of chronic cough is said to be affecting close to 10% of the general population ,3. It is2.5 and PM10. Recent data suggests stimulation of Transient Receptor Potential Ankyrin 1 (TRPA1) plays an important role in mediating cough response, and several environmental irritants that are present in air pollution, vehicle exhaust, and cigarette smoke have been demonstrated to be potential agonists of the receptor fluoranthene, benzo[k]fluoranthene, and benzo[a]pyrene were measured. The sum of these individual PAH was used as proxy for total particulate PAH concentration. These were measured as part of total suspended particles (TSP) on a 24-h (noon–noon) basis from 4 January–30 June 2011 at Kanazawa University, Japan . TSP was collected on boronsilicate glass fiber filter coated with fluorocarbon  using a high volume air sampler  at a flow rate of 1000 L·min2, SO2 (for same study period) obtained from Kodatsuno monitoring site  while temperature and humidity from Kanazawa Local Meteorological Office—Japan Meteorological Agency  in Kanazawa city in Kanazawa city [Details of PAH extraction and quantification method has been previously described ,26. Hourawa city  were useAnalysis was performed as preplanned and restricted to only participants whose cough symptom and smoking status information had been recorded. Also, daily concentrations of pollutants of interest were available. Spearman correlation coefficients were computed to examine the association between pollutants of interest and weather parameters (temperature and humidity). Additionally, for each participant daily cough symptom was created using maximum value from afternoon to afternoon period and also average value for the entire study period calculated. The two values were then used to create a new overall day cough symptom value in order to correspond to 24-h exposure monitoring that was performed on noon-to-noon basis. The outcome variable cough prevalence (irrespective of its occurrence on the previous day) in the logistic models was defined as follows: no cough if either the difference was negative or same between the two values; cough if there was a positive difference . Mann-WhWe used marginal approach generalized estimating equations (GEE) for panel data ,27,28,29p < 0.05 for all analyses.Model regression parameters are presented as symptom odds ratios with 95 percent CI per IQR change in pollutants of interest because they are from separate measurements. All statistical analyses were performed using SPSS software program for MS Windows, version 19.0  and plots made using R software . Significance was set at p < 0.001,  and potential time dependent confounders . To the best of our knowledge, this is among the few longitudinal studies to report a relationship between ambient PAH in addition to the routinely monitored pollutants and cough prevalence in asthma, CVA and/or AC patients.2 exposure [While previous observational studies have assessed the relationship between ambient exposure to criteria pollutants on respiratory health among susceptible adults, there have been relatively few studies on cough symptoms associated with low level ambient PAH in addition to criteria pollutants. Thus, the associations of such exposures with cough prevalence among adults with known airway disease are not well known. A longitudinal study among susceptible  patients showed links between reduced lung function in asthmatics and NOexposure . Anotherexposure . Evidencexposure .10, NO2 and SO2 was associated with reduced lung function in adults [The current findings on PAH exposure as an independent pollutant confirm our recent result indicating that ambient particulate PAH is related to cough symptoms in adult patients with known airway disease . Althougn adults . In the 2 and SO2 exposure were related to cough prevalence as independent pollutants among the asthma group. However, there were confounding effects when these pollutants were fitted in multipollutant models that might have resulted from moderate correlations between them. On the other hand, no significant association was found in the non-asthma group that might be due to lack of statistical power to detect the effects or different responses in asthma and non-asthma group. Previous studies on NO2 observed no or inconsistent associations [2 exposure reported marginal association with asthma exacerbation in children [We also observed NOciations ,14, whilciations ,34. Elsechildren . Also, achildren ,35.2 and SO2) leading to increased cough responses in adult patients with known respiratory conditions. Although low levels of ambient pollutant may have little impact on healthy persons, those with preexisting respiratory conditions might experience exaggerated responses. Among the predictor variables, disease group had a significant correlation with cough prevalence, suggesting the influence of airway disease. Chronic cough is known to result from host-environment interactions, with environmental factors such as chemicals, scents, cold air and exercise cited as common triggers of cough in chronic cough patients [Based on the current results, ambient PAH may act independently as well as synergistically with criteria pollutants  that allowed evaluation of the relationship between organic compounds not routinely monitored with cough symptoms alongside NO control .Some study limitations need to be considered. First, the small sample size of non-asthma group consisting of some diagnosed with both CVA and AC might have reduced the statistical power, though an association was found in relation to PAH exposure. Second, there was the masking of adverse effects due to the fact that participants continued to take their prescribed medication during the study. However, no changes in prescription of medication were effected that could be interpreted, as no significant influence of medication use was present in the current study. Third, daily pollutants were collected from central sites, and hence the possibility of misclassification of exposure especially for participants who resided at greater distances from the central monitoring sites. However, in the present study ambient exposures irrespective of source were of interest.2, SO2 is associated with increases in cough prevalence among adult chronic cough patients, with the largest associations seen in lag2 and lag02 exposures. Between the two groups, non-asthma patients are more likely to have increased cough prevalence that is related to ambient PAH exposure, while asthma patients may experience increases related to ambient pollutants in general. Our results add to the growing evidence that ambient pollutants, including organic chemical compounds not routinely monitored even at low levels, remain a matter of concern that needs to be considered as aggravating factors in adult patients with chronic cough.In conclusion, our results suggest that ambient PAH, NO


Whilst the prevalence of low blood pressure in preterm infants seems to have fallen over the last number of years, the problem is still frequently encountered in the neonatal intensive care unit and many babies continue to receive intervention. Great variability in practice persists, with a significant number of extremely low gestational age newborns in some institutions receiving some form of intervention, and in other units substantially less. A great degree of this variability relates to the actual criteria used to define hypotension, with some using blood pressure values alone to direct therapy and others using a combination of clinical, biochemical and echocardiography findings. The choice of intervention remains unresolved with the majority of centres continuing to administer volume followed by dopamine as a first line inotrope/vasopressor agent. Despite over 40 years of use there is little evidence that dopamine is of benefit both in the short term and long-term. Long-term follow up is available in only two randomised trials, which included a total of 99 babies. An under recognized problem relates to the administration of inotrope infusions in very preterm infants. There are no pediatric specific inotrope formulations available and so risks of errors in preparation and administration remain. This manuscript outlines these challenges and proposes some potential solutions. This compares to less than 30% receiving volume and 6% receiving an inotrope in another centre [vs. 6%). Differing practices must account for a large proportion of this variability. A recent survey highlighted the lack of protocols in many institutions [The decision to intervene in preterm infants with low blood pressure remains unresolved and as a result significant variability in practice remains ,2. The ritutions . The mosA consistent finding from many surveys of practice is that in the majority of cases intervention is driven by blood pressure values ,4,5,6,7.“It is a source of regret that measurement of flow is much more difficult than measurement of pressure. This has led to an undue interest in blood pressure measurements.” This statement by Austrian physician Adolf Jarisch Jr, almost 100 years ago, still holds true today for the clinician at the bedside. Historically, for reasons mentioned above, clinicians have continued to be guided by blood pressure values. However, the relationship between flow and pressure is complex, especially when one factors in the dynamic changes that are taking place during the first 24 hours of life. A number of authors have highlighted the poor relationship between flow and blood pressure in preterm infants in the first few days of life ,12,13. TNumerous studies have highlighted an adverse relationship between low blood pressure and adverse outcome. We explored this relationship previously and highlighted some of the concerns around this relationship . We idenOther authors have also questioned the relationship between low blood pressure and adverse long term outcome. Logan and colleagues evaluated three indicators of hypotension: (1) lowest mean arterial pressure (MAP) in the lowest quartile for gestational age; (2) treatment with a vasopressor; and (3) blood pressure lability, defined as the upper quartile of the difference between each infant’s lowest and highest MAP. They found no association between any of these definitions and adverse outcome defined as white matter abnormality on cranial ultrasound or a diagnosis of CP at 24 months . In a siOthers have suggested that it is the treatment that may be a factor in adverse outcome ,22,23,24et al recently described three clinical windows at the bedside in the overall assessment of circulatory shock, namely the skin, kidney and brain [Circulatory well-being is generally assessed clinically at the bedside . Howevernd brain . Clinicind brain . Howevernd brain . Each ofnd brain ,26,27. Dnd brain . Other and brain ,30,31, nnd brain ,33,34 annd brain  and nonind brain ,37,38.Optimising transition: A great deal of interest and a number of clinical trials have reported the effects of placental transfusion on outcome in preterm infants.et al. [versus ICC [A recent systematic review by Rabe et al.  found a et al. . Oh alsoet al. . A recenet al. . Systolirsus ICC . Whilst rsus ICC . Some rersus ICC . Howeverrsus ICC  found noOptimising Respiratory Support: A recent review article by Polgaise and colleagues highlights the complex cardiorespiratory changes that occur over the first few minutes of life as newborns adapt to extrauterine existence,  and the Algorithms outlining the treatment of low blood pressure and surveys of practice are characterized by a very similar approach, volume administration initially followed by dopamine. However, there is little evidence to support this approach.Volume administration, typically 10 mls/kg of normal saline, is the initial intervention by most clinicians to hypotension in the preterm infant . Howeverversus placebo in patients with low blood pressure or low flow states. There are a number of studies of dopamine versus placebo but these are in infants who are not hypotensive [versus another inotrope in patients with hypotension or low flow states; dobutamine, eight trials [One way to assess the efficacy of catecholamines is to assess these agents based on the goals of one’s intervention or so called “goal directed therapy”. For example when a clinician decides to start an inotrope is the aim to increase the blood pressure, or is it to improve end organ blood flow, thus preventing brain injury and improving long-term outcome? These can be thought of as immediate, short term, and long term outcomes of the intervention. The primary aim at present is increasing blood pressure, for all the reasons stated previously. Dopamine is the commonest inotrope used in this population of infants and has been in use in the newborn infant for approximately 40 years. However, there are no studies comparing dopamine otensive ,59,60. Tt trials ,66,67,68t trials ,70 and mt trials . All of t trials ,72. The t trials . Despitet trials . There it trials . Epinepht trials , but agat trials .Milrinone, a phosphodiesterase inhibitor is commonly used in pediatric intensive care units, typically following cardiac surgery. It improves contractility and reduces pulmonary vascular resistance. However, due to changes in developmental regulation of PDE subtypes after delivery, milrinone might not be an effective inotrope in the immediate transitional period . There aCorticosteroids do increase blood pressure in preterm infants. They are now more commonly prescribed for hypotension than for bronchopulmonary dysplasia in premature newborn infants . There aThere are a number of important factors that need to be considered when delivering an inotrope infusion in very preterm infants, factors that are not as relevant in the paediatric/adult population. The first relates to the drug formulation; firstly there are no neonatal specific formulations, a finding that is consistent with the overall lack of newborn specific formulations , and secPractical administration challenges relate to issues such as the total daily fluid volume administered in the preterm infant; it may be as low as 30–40 mls in total for a preterm infant weighing 500 grams. As a result every effort is made to ensure optimal administration of parenteral nutrition, and consequently additional infusions volumes need to be low, resulting in low infusion rates e.g., as low as 0.1 mL/h. This brings challenges in relation to optimal drug delivery time especially when taking into consideration dead space issues of the vascular catheter and the additional tubing that may be in place. There can be long lag times before the agent actually reaches the babies bloodstream, an infusion running at 0.1 mL/h may need 90 min to cover a dead space of 0.15 mls (start-up times). This phenomena is often under recognized and can result in both a delay in delivery and unpredictable effects.There are a number of other important factors that need to be considered that can influence the delivery of an agent. It is best to think of these from the syringe driver through to the vascular access device. These include the vertical displacement of the syringe pump, the syringe itself, the tubing, the vascular access device being used and finally the concomitant infusions that may be running. Upward displacement results in a reduction in the internal pressure of the tubing and ultimately an increase in the flow rate, resulting in a bolus delivery. The lower the infusion rate, the greater the bolus delivery. Conversely, a downward displacement will result in an increase in the IP and a reduction in the flow rate. A number of studies on animals have highlighted these findings ,100,101.Studies on syringe size and design have shown that the time to reach steady-state flow, time to occlusion alarm, and the time without flow, increase with syringe size and lower preprogrammed flow rates. Increased syringe size will result in increased bolus volume caused by vertical displacement. The tubing compliance will also influence the time to occlusion alarm. A low compliance tubing will result in an earlier alarm than a high compliance tubing system. It is essential that clinicians are familiar with dead space volume issues of their own vascular device; either the umbilical venous catheter or PICC line. As is often the case in newborn care vascular access is limited and multiple infusions are often run in a single catheter. The carrier flow rate is important as low total flow results in a slower time to reach a steady state compared to high flow rates. Perhaps the most important aspect is that clinicians and healthcare professionals become educated in the concept of flow variability and the factors that may influence this variability. Efforts should be made to ensure low occlusion pressures are used, highest possible/practical flow rates are utilized, low compliant tubing and minimize vertical displacement of the syringe pump relative to the patient .In the last few years a number of studies in the area of cardiovascular support in preterm infants have commenced. Two of these studies have ceased recruiting, namely the HIPHOP trial from Italy and the NICHD hypotension trial . Both sthttp://www.hip-trial.com) is now enrolling and is attempting to determine whether a standard approach to management of hypotension with volume and dopamine, versus a more observational approach with placebo (permissive approach), will result in improved short and long-term outcomes for preterm infants less than 28 weeks [http://neocirculation.eu/) will determine if dobutamine therapy results in an improvement in outcome in preterm infants with low flow as evidenced by low superior vena cava flow determined by echo. The TOHOP study is currently enrolling patients with low blood pressure and is attempting to evaluate the role of near infrared spectroscopy as an adjunct in the management of low blood pressure, focusing on an objective assessment of end organ blood flow. These studies will hopefully provide the clinician with evidence to direct therapy in preterm infants in the first few days of life.Whilst I have highlighted a number of the challenges in this area, it is encouraging to see a number of clinical trials ongoing. The European Commission has funded two of these studies in an attempt to determine the efficacy of dopamine and dobutamine in the management of cardiovascular compromise. The HIP trial (28 weeks . The Neoversus 25%), prompting the need for a much larger study.A recent randomized trial utilising near infrared spectroscopy with an associated treatment algorithm in preterm infants less than 28 weeks is a novel approach to managing preterm infants in the first few days of life. Patients were randomized to either visible monitoring with the treatment algorithm, or standard care. If cerebral saturations were above 85% or less than 55% in the monitored group then a list of options were available to the clinician. This is a paradigm shift in newborn care, focusing on the end organ. The primary outcome was a reduction in the time spent “outside the normal range”. The monitored group spent a significantly shorter percentage of hours outside this range. Whilst there were no statistically significant differences in secondary endpoints, fewer patients died in the monitored group compared to the non-monitored (16% Many preterm infants continue to receive treatment for low blood pressure. The main treatment criterion used is having a mean blood pressure less than gestational age, and the main treatment approach is volume administration followed by dopamine. The evidence is lacking for both the definition and this current management approach. This review article has highlighted that a number of key issues remain unresolved. What should direct intervention? Who should be treated? Does treatment improve long-term outcome? It is encouraging to see a number of clinical trials currently underway in an attempt to finally address these important issues. Whilst we will have to wait for a number of years until these trials are completed, the judicious use of inotropes in this population is warranted.


Chronic Heart Failure (CHF) is highly prevalent and is associated with high morbidity and mortality rates. It has been well established that excessive intake of sodium chloride  induced hypertension in some populations. Although salt seems to induce cardiovascular diseases through elevation of blood pressure, it has also been indicated that salt can induce cardiovascular diseases independently from blood pressure elevation.The present study aimed to evaluate the association between salt consumption and inflammation in CHF patients.This study was conducted on 86 patients between 18 and 65 years old who were diagnosed with New York Heart Association (NYHA) functional class I and II heart failure. Salt intake was calculated by using 24 hour urine sodium excretion. Besides, the association between inflammation and daily salt intake was evaluated regarding C - reactive protein (CPR), High sensitive CRP (HsCPR), Erythrocyte Sedimentation Rate (ESR), and ferritin and fibrinogen levels using Pearson correlation analysis.Our results showed a statistically significant difference between the low (n = 41) and high (n = 45) salt intake groups in terms of serum HsCRP levels (5.21 ± 2.62 vs. 6.36 ± 2.64) (P < 0.048). Additionally, a significant correlation was observed between the amount of salt consumption and HsCRP levels. In this study, daily salt consumption of the enrolled patients was 8.53 gram/day. The medications and even the blood pressures were similar in the two groups, but daily pill count, prevalence of hypertension, and coronary heart disease were higher in the high salt intake group; however, the differences were not statistically significant (P = 0.065). Also, no significant difference was observed between the groups concerning the inflammation markers, such as CRP, ESR, ferritin, and fibrinogen.Neurohumoral and inflammatory factors are thought to contribute to high mortality and morbidity rates in CHF. Yet, inflammatory markers may early diagnose CHF and predict the prognosis. Excessive salt intake also worsens the inflammation as well as volume control. Chronic Heart Failure (CHF) is highly prevalent in the general population and is associated with high morbidity and mortality rates. The prevalence of CHF has been reported to be about 1 - 2% in the general population .It has been well established that excessive intake of sodium chloride  induced hypertension in some populations. Although salt seems to induce cardiovascular diseases through the elevation of blood pressure, it has also been known that salt can induce cardiovascular diseases independently from blood pressure elevation .Nutritional factors in heart failure may be related to the pathophysiology of the disease, including inflammation. However, the association between salt consumption and inflammation has not been evaluated in the patients with CHF. Being a major contributing factor to high mortality rates in CHF, inflammation may be enhanced by high salt intake.Therefore, the present study aims to evaluate the relationship between salt intake and inflammation in the patients with CHF.This study was conducted on 95 patients between 18 and 65 years old who were diagnosed with New York Heart Association (NYHA) functional class I and II heart failure .Echocardiography was performed before blood samples were collected for serum analysis. Salt intake was computed using 24 hour urinary sodium extraction. Serum levels of High sensitive C - reactive protein (HsCRP), C - reactive protein (CRP), fibrinogen, ferritin, Brain Natriuretic Peptide (BNP), aldosterone, and homocysteine were measured, as well.The Statistical Package for the Social Sciences (SPSS) 12.0  was used for all the statistical analyses. The data are presented as mean ± standard deviation for continuous variables, and as percentages for the categorical ones. The scale data between the groups were analyzed using unpaired Student’s T test. In addition, Pearson correlation coefficient was used to analyze the correlations. Besides, one-way ANOVA was used to make comparisons between sodium/creatinin groups.This study was conducted on 86 patients . The patients' demographic characteristics, comorbidities, and medications have been listed in The patients were divided into three groups according to their 24 hour urine sodium/creatinine ratio . The 24 hour urine sodium/creatinine ratios were 76.05 ± 12.83, 143.07 ± 28.03, and 252.93 ± 43.49 in groups I, II, and III, respectively. Besides, serum HSCRP levels were higher in group III compared to groups I and II and the difference was statistically significant .In order to evaluate the association between inflammation and daily salt intake, the patients were compared in terms of CRP, HsCRP, ESR, ferritin, and fibrinogen. The results indicated a significant difference among the study groups regarding urinary sodium/creatinine ratio and serum HSCRP levels .Serum uric acid levels were measured as 5.54 ± 1.55, 5.8 ± 1.77, and 7.81 ± 0.86 in groups I, II, and III, respectively. Additionally, higher serum uric acid levels were detected in group III and the difference was statistically significant.The findings of the present study showed that 24 hour urinary sodium/creatinine ratio was highly correlated to serum HSCRP levels. Also, high sodium intake was associated with higher serum uric acid levels.In the last decade, some improvements were made in understanding the pathophysiology and treatment of CHF. High mortality and morbidity rates in these patients imply that unexplained mechanisms may also play a role. It has been well known that compensatory mechanisms of CHF involve renal, neurohumoral, and renin-angiotensinaldosterone system. Also, it has been hypothesized that persisted immune system activation and inflammation may have crucial importance. Recent studies have focused on the negative effects of inflammation and circulating cytokines on cardiac inotropy and remodeling in course of CHF. In an animal model of dilated cardiomyopathy, it was shown that circulating inflammatory cytokines were increased -10. In SStudies have also been conducted on the effectiveness of treatments. In PRAISE trial, amlodipine lowered IL-6 but not TNF-alpha and high dose enalapril lowered IL-6 levels. Additionally, ß adrenergic stimulation increased IL-1 and TNF-alpha levels, while ß blockade lowered these inflammatory cytokines. Moreover, statin therapy lowered CRP levels .In general, neurohumoral activation, aldosterone synthesis, and triggers of these two take place in pathophysiological fundamentals of CHF. Aldosterone that is significantly influenced by salt intake plays a role in pathophysiological mechanisms of both CHF and hypertension. Our study results showed no significant difference among the study groups regarding serum aldosterone levels. Also, no statistically significant difference was observed among the groups in terms of demographic characteristics and co-morbidities. Dietary salt intake affects vascular endothelial independently from blood pressure. A study demonstrated that excessive salt intake in normotensive rats resulted in higher expression of endothelial TGF-beta .In National Health and Nutrition Examination Survey (NHANES III), the patients with non-ischemic CHF were evaluated in terms of CRP and fibrinogen levels. According to the results, fibrinogen levels were higher in the CHF patients and also displayed a racial difference. In addition, the highest levels of fibrinogen were detected in non-Hispanic whites .Microalbuminuria is a useful prognostic marker in evaluation of both diabetic and non-diabetic patients for renal and cardiovascular risk profiling -18. MicrBNP is a protein which consists of 32 amino acids. It is primarily secreted as preproBNP after volume and pressure increases in the ventricles and is converted enzymatically into N-terminal proBNP (NT-proBNP) and BNP. Both NT-proBNP and BNP are used for diagnosis of congestive heart failure , 25. BNPHsCRP is produced from the liver in case of systemic inflammation and is assumed as a new risk factor for atherosclerosis. Coronary atherosclerosis is manifested by CHF. Alonso-Martinez et al. studied the relationship between NYHA CHF stages and Left Ventricle Ejection Fraction (LVEF) in hospitalized CHF patients. HsCRP levels were found to be reversely correlated to functional capacity and LVEF. Also, higher HsCRP levels were found to predict mortality and rehospitalization .In National Health and Nutrition Examination Survey (NHANES III), fibrinogen and HsCRP levels were found to be higher in the patients with non-ischemic CHF compared to those without CHF . Howic eOur study results showed that salt intake was correlated to HsCRP levels. This implies that increased salt intake may play a role in the neurohumoral and the physiopathological pathways of CHF besides increasing the volume load. Thus, it may be hypothesized that salt restriction may improve the inflammatory process besides improvements in the volume load and hypertension.Recent studies have supported the effectiveness of inflammatory markers and cytokines in CHF physiopathology by negative inotropic impact and remodeling.The present study also revealed no relationship between salt intake and other inflammation markers, except for HsCRP. The positive correlation between salt intake and HsCRP makes us think that salt intake may contribute to inflammatory damage in CHF. Yet, the effect of salt restriction on the inflammation status needs to be further investigated.The main limitation of the present study was the absence of a control group. Another limitation of the study was the number of the patients involved in this study. Also, evaluation of salt intake and inflammation by using the stages of CHF was not performed; early and late stages of CHF may show a different association in terms of salt intake and inflammation.


Background. The aim of the present study was to determine the prevalence of orthostatic hypertension (OHT) in elderly patients with type 2 diabetes and its relation to metabolic and echocardiographic parameters. Methods. This was an analytical cross-sectional study in 97 patients normotensive or hypertensive. OHT was defined as a ≥10 mmHg increase in systolic blood pressure after four minutes in the standing position. Results. The prevalence of OHT was 20.6%. The mean body mass index was significantly higher in patients with OHT than in those without it . There were no statistically significant differences between the two groups for other metabolic parameters. Among the 68 patients who had an echocardiographic examination 27% of those with OHT had an increase in their left atrial volume index (LAVi) compared with 75% of those who did not have OHT (P = 0.004). The mean LAVi of patients with OHT was significantly lower than that of those without OHT . Conclusion. We found a high prevalence of orthostatic hypertension and a lower left atrial volume indexed in the patients with orthostatic hypertension. Autonomic cardiac neuropathy is associated with significant morbidity and mortality in diabetics, the risk being greater in those with hypertension . Some reThe prevalence and clinical significance of orthostatic hypertension in diabetic patients are as yet not well understood, unlike postural hypotension, which is a common feature of advanced autonomic neuropathy in type 2 diabetes mellitus (T2DM) , 4.The difficulty in determining the actual prevalence of orthostatic hypertension is due to several factors, such as the varying definitions used and differences between the populations that have been studied to date. There are studies that define orthostatic hypertension as a rise in systolic blood pressure (SBP) of 5 mmHg . Still oP < 0.05) and stroke  [In hypertensive patients, the prevalence and clinical significance of orthostatic hypertension also remain largely undetermined , 7. A reP < 0.01, for normotensive patients, and 12.6 versus 11.1%, nonsignificant for hypertensive patients) [P < 0.001) and systolic blood pressure in the supine position (P = 0.023) were correlated with orthostatic hypertension in a statistically significant manner, with the risk for this condition increasing in adults from the age of 40 yr [In a study of 277 Japanese males with DM2, including 90 hypertensive patients and 128 nondiabetic males matched by age, excluding users of antihypertensive medications, the prevalence of orthostatic hypertension, in normotensive and hypertensive diabetics, was significantly higher than in the controls  . A populIn view of the lack of published data on the prevalence of orthostatic hypertension in elderly patients with diabetes, this study was designed to determine the prevalence of orthostatic hypertension and its possible relation to metabolic factors and echocardiographic parameters in a population referred for treatment to an outpatient endocrine clinic.Approximately 4,800 patients spontaneously sought the outpatient endocrinology clinic at Agamenon Magalhães Hospital within six months of data collection. Assuming a 12% prevalence of orthostatic hypotension in normotensive and hypertensive diabetics, a sample of 375 patients with an error rate of 2.5% was calculated. However only 97 patients 60 years and older were evaluated, all of whom were diagnosed with type 2 diabetes mellitus. The patients were normotensive or hypertensive, receiving either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and/or a calcium channel blocker. The exclusion criteria were as follows: patients with type 1 diabetes mellitus; those reporting the chronic use of diuretics, beta blockers or alpha blockers for treatment of hypertension; heart failure patients with systolic ejection fraction ≤35%, or functional class III or IV as established by the New York Heart Association; patients with atrial fibrillation; patients suffering from terminal chronic renal disease undergoing hemodialysis; patients with cancer at any site except the skin (nonmelanoma); those with rheumatic diseases (rheumatoid arthritis or arthrosis of the hands and feet); patients with limitations in the supine position; and those with Parkinson's disease or tremors of the extremities.The patients answered a questionnaire after signing the informed consent form. The questionnaire consisted of age, sex, physical examination with measurement of weight, height, waist circumference, and hip circumference, physical examination of the feet , medications used, diagnosis of arterial hypertension, and time since diagnosis of diabetes mellitus. They were also evaluated for the presence of comorbidities, based on their previous diagnosis of cardiovascular disease due to acute myocardial infarction or coronary artery bypass graft (with bypass surgery or stenting) coronary angiography with stenosis of at least ≥50%, ischemic stroke, ≥50% stenosis of the carotid, or previous peripheral arterial disease.Patients underwent a thorough physical examination, including measurement of systolic blood pressure (SBP) and diastolic blood pressure (DBP) with an automatic device , weight, height, body mass index (BMI), waist circumference, and hip circumference.Blood pressure was measured with the patient seated and again after four minutes in the standing position, using an automatic device . Two measurements were taken consecutively in seated and standing with the arm supported at heart level in both positions, the mean of the two being considered for purposes of assessment.Blood samples were collected after 12 hours of fasting to determine serum levels of glucose, glycated hemoglobin, total cholesterol and fractions (LDL-cholesterol and HDL-cholesterol), triglycerides, and creatinine.Urine samples were collected for creatinine and protein determination.Laboratory tests were performed using an autoanalyzer, Johnson & Johnson, USA, and for HbA1C, Fugion, USA.Patients underwent echocardiography , conducted by an examiner blinded to which patients had orthostatic hypertension. Measurements were made for left atrial volume and left ventricular mass.Orthostatic hypertension was defined as a ≥10 mmHg increase in systolic blood pressure after 4 minutes in the standing position, compared with the sitting position.2. LAVi greater than 28 mL/m2 was considered to be altered. The left ventricle mass index (LVMi) was measured, which is the mass of the left ventricle divided by the body surface area. The normal female value was from 43 to 95 g/m2, slightly abnormal between 96 and 108 g/m2, moderately abnormal between 109 and 121 g/m2, and critically abnormal ≥122 g/m2. For male it ranged from 49 to 115 g/m2, slightly abnormal between 116 and 131 g/m2, moderately abnormal between 132 and 148 g/m2, and critically abnormal ≥149 g/m2.According to the recommendations of the Committee of the American Society of Echocardiography (ASE) 2005  the leftThe study was approved by the Agamenon Magalhães Hospital Ethics in Research Committee (registration CAAE-.0114.0.236.000-11).t-test was used for numeric variables, Pearson's chi-square test for association of two categorical variables, or Fisher's exact test when it was not possible to use the chi-square test, and the Student's t-test demonstrated both equal and unequal variances. Verification of the hypothesis of equality of variances was performed using Levene's F-test and the correlation analysis using the F-test (ANOVA). Considering the confidence interval of 95%, the index of significance was set at P < 0.05. The software used was version 17 of the SPSS.In the statistical analysis the paired Student's 2 (2)  . No statistically significant association was seen between orthostatic hypertension and abnormal physical examination of the feet. Of the orthostatic hypertension patients, 17 (22.7%) had a diagnosis of systemic arterial hypertension (P = 0.551) (P = 0.004). The mean iLAV of patients with OHT was significantly lower than those without it . We examined the interaction of BMI with the iLAV and found that the correlation persisted  , of whom 30.9% (30 patients) were males. The mean time since the diagnosis of diabetes was 12.23 years (±8.34 years). Mean glycated hemoglobin was 7.9% (±1.71%). 59 (60.8%) patients were taking statins and 33 (34%) patients used insulin. Of the 97 patients, 7 (7.2%) had an ulcer on foot, 34 (24.7%) had negative monofilament test, 35 (36.1%) had a change (decreased or absent) in vibration sensitivity, 39 (40.2%) had changes (decreased or absent) in thermal sensitivity, and 11 had changes (decreased or absent) of tactile sensitivity. The majority of patients in this study had hypertension , were overweight or obese , with a mean BMI of 27.95 kg/m2 . The pre2  with mos= 0.111) . BMI was= 0.551) . Of the = 0.452) .Available data shows a strong association between obesity and hypertension. In the Framingham study, the relative risk of hypertension in overweight men and women was 1.46 and 1.75, respectively, after adjusting for age .Data on OHT are not well characterized in the literature and its real clinical significance is unknown, although some studies carried out in recent years have suggested that orthostatic hypertension may be a new cardiovascular risk factor .Orthostatic hypertension can vary from a simple incidental finding during a physical examination to a significant increase in blood pressure, resulting in baroreflex deregulation . HoweverInitial studies involving orthostatic hypertension showed that individuals with this condition had a greater decrease in cardiac output in the upright position, with an increase in venous blood flow in the lower extremities, and higher levels of plasma norepinephrine after standing up , 13. TheIn the present study orthostatic hypertension was found to be present in 20.6% of the elderly diabetic patients. In the literature the prevalence of orthostatic hypertension varies greatly, depending on the definition used and the population studied. In a study of Japanese men with diabetes, the prevalence of orthostatic hypertension was 12.8% in normotensive patients and 12.6% in hypertensives ones, using an increase in SBP of the 20 mmHg or more after 3 minutes in the supine position to define orthostatic hypertension . RegardiIn our study, with a population consisting of patients aged 60 years and more, we found no association between orthostatic hypertension and increase in age. However, there are some reports in the literature in which older people have a higher occurrence of orthostatic hypertension . LikewisIn a multivariate analysis, high BMI and not being treated with insulin were independent factor associated with OHT.The literature consulted indicates an increased occurrence of orthostatic hypertension in elderly patients with hypertension . HoweverIncreased left atrial volume is often reported with age and with a variety of cardiovascular disorders , as in hA study on orthostatic changes in blood pressure and target organ damage showed no significant correlation between left ventricle mass index and the occurrence of orthostatic hypertension , no suchOur study had three main limitations: the small size of the sample; the fact that 29 patients did not undergo echocardiography exam because it had to be done on a different day from the clinical examination of the patient; and the lack of a control group.We found a high prevalence of orthostatic hypertension in elderly patients with type 2 diabetes. High BMI and not being treated with insulin were independent factors associated with OHT. A left atrial volume indexed was found significantly lower suggesting that OHT may not be a harmful phenomenon.


Current guidelines for prevention and treatment of cardiovascular disease (CVD) emphasise the importance of a healthy lifestyle. There is now sufficient evidence that a multitude of lifestyle factors play an important role in the occurrence of CVD. Most of these factors relate to lifestyle and are thus modifiable, such as tobacco smoking, lack of physical activity, dietary habits, elevated blood pressure, type 2 diabetes, and dyslipidaemias. Consequently there has to be continuous attention to lifestyle modification, both in primary and secondary prevention . With reShort bouts of high-intensity exercise can reverse some early cardiac changes in patients with type 2 diabetes . It was Sitting is bad for children indicating that children who sit too much may face adult-sized health consequences . After aFidgeting  may counteract the negative effects of prolonged sitting. A recent study about fidgeting found that fidgeting may actually counteract the negative effects of sitting behind a desk all day . The autSeniors who work longer are healthier than those who are retired . ResearcVitamin C may improve blood vessel tone in sedentary adults who are overweight or obese, as presented at the American Physiological Society’s annual meeting. Overweight and obese people who take a high dose of supplementary vitamin C daily may acquire cardiovascular benefits related to physical exercise. Subjects who took 500 mg of vitamin C daily had equal improvement in blood vessel tone as those who took up a three-month regimen of brisk walking five to seven times a week.Trans fatty acids (TFA) may not be harmful indicating that not all TFA are equal, and that several TFA might even be good . The autDrinking coffee does not increase risk of atrial fibrillation . AnalysiCarbonated drink consumption may be associated with higher risk of acute myocardial infarction outside of a hospital as presented at the 2015 European Society of Cardiology (ESC) Congress in London. The more money people spend on carbonated beverages the more likely they are to suffer heart attacks outside of a hospital. Meanwhile, expenditures on other beverages such as green tea, black tea, coffee, cocoa, fruit or vegetable juice, fermented milk beverage, milk and mineral water were not significantly related to out-of-hospital cardiac arrests.Honey, cane sugar, high-fructose corn sweetener have similar impacts on health. A study by the United States Department of Agriculture did find that the health effects of high-fructose corn sweetener and honey were essentially the same. It was found that daily doses of honey, cane sugar and high-fructose corn sweetener had equal impacts on blood sugar, insulin, body weight, cholesterol and blood pressure.A daily glass of red wine may help improve metabolic health in people with type-2 diabetes . It was Individuals who were exposed to second-hand smoke when they were children or when they were in the womb may have a higher risk of developing atrial fibrillation later in life. The findings were based on Data obtained from the Health eHeart Study, analysing 4976 participants, of whom 593 (11.9 %) showed atrial fibrillation .Psychological distress in childhood may be associated with higher risk of heart disease and diabetes later in life . InvestiA high-stress job may be linked to an increased risk for an ischaemic stroke . The autContrary to stress, it was recently reported that cardiac patients with a positive outlook (‘sunny disposition’) are more likely to exercise, continue with their medications and to take other steps to protect against further cardiovascular complications. These findings were based on surveys and physical examinations of over 1000 adults with coronary artery disease .Sexual activity does not trigger heart attacks or strokes . In totaAcupuncture may potentially benefit people with mildly or moderately elevated blood pressure . InvestiFour monthly text messages might stimulate health improvements for cardiac patients . ReceiviInteractive health tracking may help lower blood pressure in patients with hypertension, as presented at the American Heart Association Council on Hypertension Scientific Sessions 2015. Routine use of an interactive website or app that tracked health data and stimulated regular exercise and other healthy behaviours—structured as a game—was associated with significantly lower blood pressure among hypertensive participants. It was found that almost 50 % of study participants with high blood pressure (≥ 140/90 mmHg) at the start of the study showed a significant reduction in systolic blood pressure.In summary, a healthy lifestyle remains a challenging world. The above-described new findings on lifestyle modification published during the past 6 months may have prominent effects on the occurrence of CVD. Nevertheless, cornerstones of lifestyle remain exercise, dietary influences, and smoking habits. European guidelines (version 2012) and systems such as HeartSCORE have been developed to assist physicians in advising patients , 18. YetThe present study by Achttien et al.  clearly


The aim of this paper is to investigate whether urosepsis is related to irrigation pressure of ureteroscopy (URS) and evaluate the prognostic value of adrenomedullin (ADM) and atrial and brain natriuretic peptides (ANP and BNP) in URS-induced uroseptic patients. From July 2008 to October 2013, we enrolled 332 patients with untreated unilateral ureteral obstruction (UUO). The UUO group included three subgroups of, respectively, 118, 132, and 82 patients who underwent URS under intermittent stable irrigation pressure of, respectively, 80, 120, and 160 mmHg. The plasma concentrations of ADM, ANP, and BNP were measured in all subjects. URS was performed for all UUO patients; the values of the three peptides were measured again after URS. Irrigation pressure and stone size were independent risk factors of urosepsis. After URS, the plasma concentrations of ADM, ANP, and BNP were significantly higher in uroseptic patients. Moreover, the concentrations were significantly higher depending on the disease severity. Plasma concentrations of the three peptides were correlated with plasma ET concentration in the uroseptic patients. The areas under receiver operating characteristic (ROC) curve of ADM, ANP, and BNP for predicting urosepsis were 0.811, 0.728, and 0.764, respectively. In conclusion, ADM, along with ANP and BNP, is valuable for prognosis in urosepsis secondary to URS which is associated with irrigation pressure. Urosepsis is defined as sepsis caused by infection of the urogenital tract and is a systemic response to infection . FrequenAdrenomedullin (ADM) was first isolated from human pheochromocytoma . It has Atrial and brain natriuretic peptides  are polypeptide hormones comprising the cardiac-derived natriuretic peptide system which are involved in the long-term regulation of sodium and water balance, blood volume, and arterial pressure –13. IncrTo measure the plasma concentrations of ADM, ANP, and BNP and evaluate their prognostic value in uroseptic patients induced by URS, we measured the values of the three peptides in untreated patients with unilateral ureteral obstruction (UUO) secondary to ureteral stones and compared the results with those of healthy control subjects. Additionally, we measured the values of the three peptides after URS for UUO patients.This retrospective, case-control study was conducted in Renmin Hospital of Wuhan University between July 2008 and October 2013 in accordance with our institutional standards and under the appropriate license of the Ethics Committee of Renmin Hospital, as well as in adherence to national regulations. The study groups consisted of 90 healthy control subjects  and 332 patients with untreated UUO . In order to investigate whether urosepsis is related to irrigation pressure of ureteroscopy (URS), all UUO patients underwent URS with intermittent stable irrigation pressure of 80 mmHg , 120 mmHg , and 160 mmHg , respectively. All patients agreed to participate in this study and provided written informed consent. The operation was performed by only one experienced surgeon. The irrigation pressure was randomly selected and the patients and surgeon were blind to it according to the double blind method. All patient information was anonymized and deidentified prior to analysis. Routine laboratory studies and image examinations were conducted before URS. The inclusion criteria for UUO subjects were as follows: simple unilateral ureteral stone, without urinary tract infections by urinalysis (the presence of 10 urine leukocytes/HPF and no microorganisms), without any symptoms of urogenital tract infections, without antimicrobial prophylaxis before the procedure. Ureteroscopy was performed using a Wolf rigid ureteroscope. UUO was definitely diagnosed on the basis of intravenous pyelonephrography or computed tomography. All patients undergoing laser lithotripsy had a double-J stent and a Foley catheter placed at the end of the procedure. The indwelling Foley catheter was drawn within 72 hours. All uroseptic patients were symptomatic or signs of potential sepsis were present within 24 hours after URS. They fulfilled the systemic inflammatory response syndrome (SIRS) criteria defined by the American College of Chest Physicians/Society of Critical Care Medicine [Venous blood samples were drawn from an antecubital vein within 24 hours for nonseptic subjects or septic patients before vasopressor treatment and were transferred to ice-chilled tubes containing Trasylol (500 KIU/mL) and ethylenediaminetetraacetic acid . They were then centrifuged at 3,000 rpm for 15 min at 4°C and the plasma was immediately frozen and stored in polypropylene tubes at −80°C until radioimmunoassay (RIA).Baseline clinical data were recorded as follows: endotoxin (ET) using the Pyrochrome test kit , white blood cell counts (WBC) using a Sysmex SE-9000 analyzer , C-reactive protein (CRP) using an immunoturbidimetric assay , lactate (LAC) using enzymatic method , and procalcitonin (PCT) using an immunoassay analyzer .The plasma ADM levels were measured with specific RIA for human ADM . The intra- and interassay coefficients of variation were 3.8% to 7.9% and 4.5% to 8.8%, respectively. All assays were performed in duplicate. ADM concentrations were expressed as ng/L.The plasma ANP concentrations were measured with a specific immunoradiometric assay for human ANP . The intra- and interassay coefficients of variation were 4.7% to 9.8% and 5.9% to 11.6%, respectively. The plasma BNP concentrations were measured by a method similar to that for ANP, developed by the same company (Shiono RIA BNP kit). The intra- and interassay coefficients of variation were 5.8% to 10.7% and 6.5% to 12.5%, respectively. All assays were performed in duplicate. The concentrations of ANP and BNP were expressed as ng/L.t-test or Mann-Whitney U test. Multiple comparisons were evaluated with analysis of variance followed by Student-Newman-Keuls or Kruskal-Wallis method. The significance of differences between paired variables was determined by paired t-test or Wilcoxon test. Categorical variables were assessed by the chi-square test or Fisher's exact test. Stepwise multiple linear regression analysis was used to evaluate the most important factor for ADM, ANP, and BNP. The correlation between two variables was done by linear regression analysis and further confirmed by Spearman's rank test. Receiver operating characteristic (ROC) curves were used to predict urosepsis and determine the cutoff values. Kaplan-Meier curves were plotted according to the identified cutoff values of ADM, ANP, and BNP and further confirmed by log-rank test. A 2-sided p value less than 0.05 was considered to indicate statistical significance.All continuous data were expressed as mean ± SD and analyzed with SPSS software, version 19.0 . Comparisons between two variables were performed with unpaired p < 0.05). However, there were no significant differences in age, sex distribution, Scr, and Ccr among the three uroseptic groups (data not shown).After URS, the uroseptic rates of the three UUO subgroups were 8.5% (10/118), 18.2% (24/132), and 30.5% (25/82), respectively, which were significantly higher and higher in proportion to the irrigation pressure  and irrigation pressure  were the most important independent factors of urosepsis, when age, sex, stone side, stone site, stone size, and irrigation pressure were taken into account.We analyzed the risk factors of urosepsis by stepwise multiple logistic regression analysis which revealed that stone size (p < 0.05). However, Scr and Ccr remained unchanged after URS.p < 0.05). There was no significant difference in mean ADM value between uroseptic group I before URS and controls. The mean values of ANP in controls and uroseptic group I before and after URS were 23.63 ± 8.98, 22.56 ± 8.70, and 82.91 ± 30.43 ng/L, respectively, while the mean values of BNP were 12.72 ± 5.52, 13.24 ± 4.11, and 137.97 ± 57.79 ng/L, respectively. Similar changes were observed in mean values of ANP and BNP in uroseptic group I. Similar changes were found in mean values of the three peptides in uroseptic groups II and III.The plasma concentrations of ADM, ANP, and BNP in controls and uroseptic patients before and after URS are depicted in Figures p < 0.05). However, plasma concentrations of ET, CRP, LAC, and PCT were significantly higher in septic shock than in sepsis (p < 0.05).As shown in p < 0.05). There was also a significant difference in mean ADM value between severe sepsis and sepsis (p < 0.05). Similar changes were found in mean values of ANP and BNP.Scatterplots of The ROC curves of WBC, ET, CRP, LAC, PCT, ADM, ANP, and BNP for urosepsis are shown in p < 0.05).Kaplan-Meier curves for ADM, ANP, and BNP are depicted in Ureteral calculi represent a common condition that urologists encounter in everyday practice. Ureteroscopy is one of the most important treatment options for ureteral calculi that do not pass spontaneously or are unlikely to do so . This prIn the current study, the uroseptic rates were significantly higher and higher in proportion to the irrigation pressure. This result was further confirmed by logistic regression analysis of risk factors for urosepsis which showed irrigation pressure was an independent risk factor. Therefore, this result may provide a guide that it is necessary to perform URS under lower irrigation pressure in the clinical practice. Moreover, stone size was another independent risk factor for urosepsis. It can be easily explained that the operation time is longer with bigger stone size.In our study, plasma levels of ADM, ANP, and BNP were higher in uroseptic patients after URS than before URS and in controls, as well as WBC and plasma concentrations of ET, CRP, LAC, and PCT, but Scr and Ccr remained unchanged. No significant differences were found between uroseptic patients before URS and controls. Moreover, the plasma concentrations of ADM, ANP, and BNP were related to the severity of disease, as well as plasma concentrations of ET, CRP, LAC, and PCT , 33, 34.Biomarkers play important roles in diagnosis, differential diagnosis, risk stratification, therapeutic monitoring, and prognosis in sepsis. Many features of pathophysiologic progression correlate with the severity and outcome of the disease and become candidate prognostic biomarkers . Our stuSeveral clinical studies have demonstrated that ADM, ANP, and BNP are predictors of adverse outcome in patients with sepsis, but most of these studies were conducted in the ICU and contained relatively small sample sizes. The prognostic value of ADM, ANP, and BNP in uroseptic patients induced by URS in the urological department is still undefined.Our results suggest that the prognostic value of ADM is superior to ANP and BNP, and ADM, ANP, and BNP are robust independent predictors of in-hospital death in uroseptic patients. In uroseptic patients with ADM, ANP, and BNP levels above the cutoff values of our study, the in-hospital mortality was 35.1%, 33.3%, and 36.1%, respectively, with all patients dying within the first 10 days. In uroseptic patients with ADM, ANP, and BNP levels below the cutoff values, survival rates were 90.9%, 94.1%, and 91.7%, respectively, at the 30-day follow-up. These results demonstrate that ADM, ANP, and BNP are strong predictors of adverse outcome in patients with urosepsis.In summary, with the physiological roles of ADM taken together, our study shows that ADM, along with ANP and BNP, may participate in initiating the hyperdynamic response during the early stages of sepsis in uroseptic patients. In addition, ADM, ANP, and BNP are strong predictors of adverse outcome in patients with urosepsis.


New information from various clinical settings suggests that tight blood pressure control may not reduce mortality and may be associated with more side effects.We performed cross-sectional multivariable ordered logistic regression to examine the association between predialysis blood pressure and the short physical performance battery (SPPB) in a cohort of 749 prevalent hemodialysis patients in the San Francisco and Atlanta areas recruited from July 2009 to August 2011 to study the relationship between systolic blood pressure and objective measures of physical function. Mean blood pressure for three hemodialysis sessions was analyzed in the following categories: <110 mmHg, 110-129 mmHg (reference), 130-159 mmHg, and ≥160 mmHg. SPPB includes three components: timed repeated chair stands, timed 15-ft walk, and balance tests. SPPB was categorized into ordinal groups  based on prior literature.Patients with blood pressure 130-159 mmHg had lower odds  of scoring in a lower SPPB category than those whose blood pressure was between 110 and 129 mmHg, while those with blood pressure ≥160 mmHg had 0.56 times odds (95% CI 0.33-0.94) of scoring in a lower category when compared with blood pressure 110-129 mmHg. When individual components were examined, blood pressure was significantly associated with chair stand  and gait speed . Blood pressure ≥160 mmHg was not associated with substantially higher SPPB score compared with 130-159 mmHg.Patients with systolic blood pressure at or above 130 mmHg had better physical performance than patients with lower blood pressure in the normotensive range. The risk-benefit tradeoff of aggressive blood pressure control, particularly in low-functioning patients, should be reexamined. Recent studies have suggested the need for further examination of the relationship between blood pressure control and physical function. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial showed more adverse events among patients with diabetes randomly assigned to a systolic blood pressure target of <120 mmHg compared with a target of <140 mmHg without reduction in cardiovascular outcomes . A recenPatients with poor physical function could be at higher risk for these complications and simultaneously be less likely to benefit. These issues are particularly relevant among patients on hemodialysis because approximately seventy-six percent of dialysis patients are prescribed antihypertensive medications, and they experience significant impairments in physical function that have been associated with higher mortality in chronic kidney disease and community-dwelling elderly populations –9. AlthoWe used data from the United States Renal Data System (USRDS) ACTIVE/ADIPOSE  cohort, which includes measurements that make up the short physical performance battery (SPPB), to study the relationship between levels of blood pressure and objective measures of physical function in hemodialysis patients. We hypothesized that lower blood pressure would be associated with worse performance on the SPPB. In addition to examining blood pressure that was frankly low, we were also interested in examining whether blood pressure in ranges considered to indicate good blood pressure control would be associated with worse performance.The ACTIVE/ADIPOSE is a cohort study of the United States Renal Data System (USRDS) Nutrition and Rehabilitation/Quality of Life Special Studies Centers that enrolled 778 prevalent hemodialysis patients from the San Francisco Bay Area and the Atlanta metropolitan area between 2009 and 2011. The description of the ACTIVE/ADIPOSE study and methods have been published elsewhere . EnglishWe performed a cross-sectional analysis to examine the association between predialysis systolic blood pressure and components of the short physical performance battery among 749 patients who had blood pressure and physical function data available.et al. prior to a mid-week or end-of-week dialysis session [Our primary outcome, the SPPB was designed to assess lower extremity function in community-dwelling elderly individuals and includes three components: (1) timed repeated chair stands, (2) a timed 15-foot walk, and (3) balance testing over ten seconds. We performed SPPB assessments as described by Guralnik  session .Participants were asked to stand up from a chair and sit down again five times repeatedly as quickly as possible. A score of zero was given if a participant was unable to perform five chair stands. A score of one, two, three, or four was assigned to a participant who completed five chair stands in ≥16.7, 13.7-16.6, 11.2-13.6, and ≤11.1 seconds, respectively.Participants were asked to walk a marked 15-foot course at a normal pace. Two trials were conducted, and the faster of the two walks was used for analysis. Gait speed was calculated for each patient using distance in meters and time in seconds. Patients were scored from 0 to 4, where 0 points indicated inability to perform the walk and 4 indicated a gait speed of >0.83 m/s.Balance testing was comprised of three components: (1) semitandem stand (2) side-by-side stand and (3) tandem stand. Participants began with a semi-tandem stand where the heel of one foot was placed to the side of the first toe of the other foot. Those who were able to stand for 10 seconds in the semi-tandem stand position were tested in the full tandem stand with the heel of one foot directly in front of the toes of the other. Balance testing was scored on a 0-4 scale with a score of 4 indicating a full tandem stand for 10 seconds. Total SPPB score was calculated by the sum of the components.Although postdialysis blood pressure and 24-hour ambulatory blood pressure monitoring may be important predictors of outcomes in the hemodialysis population , 15, we Data on comorbidities were obtained from the information recorded on the Medical Evidence Form 2728 and included in the USRDS. Comorbidities from the Medical Evidence Form 2728 have been previously validated with sensitivity being high for hypertension and diabetes and intermediate for peripheral vascular disease, cerebrovascular disease and heart failure . Serum aWe compared patient characteristics using chi squared tests, t-tests, Mann-Whitney U tests, and linear regression as appropriate. Restricted cubic splines were generated to examine the association between total SPPB score and mean predialysis blood pressure.We used univariate and multivariate ordinal logistic regression with predialysis blood pressure categories as the primary predictor and predialysis SBP of 110-129 mmHg as the reference category. Models were constructed with the SPPB and each of the component measures as outcomes. Total SPPB score was categorized into three ordinal groups  as performed in prior studies . We examThe mean age of the cohort was 57.3 years SD 14.2). Patients in the highest blood pressure category were more likely to be African American and have higher interdialytic weight gains, while those in the lowest category had lower serum albumin (3.8 ± 0.7 mg/dl) than those in other groups (p = 0.02). Fifty-six percent of patients in the lowest blood pressure category and 75% of patients in the 110-129 mmHg group were prescribed at least one antihypertensive medication. There were no statistically significant differences in prevalence of comorbidities based on blood pressure , and there was no statistically significant interaction between systolic blood pressure and number of antihypertensive medications prescribed.When we examined the individual components of the SPPB in multivariable analysis, chair stand performance and gait speed were significantly associated with blood pressure while balance was not Figure . The oddBecause antihypertensive medications used in the treatment of heart failure or coronary artery disease could influence predialysis blood pressure, we conducted sensitivity analyses excluding participants with these diagnoses. When patients with heart failure (n = 142) were excluded from the primary analysis, the odds of scoring in a lower SPPB category remained similar . When patients with coronary heart disease were excluded from the analysis (n = 66), the point estimates were also similar .We have demonstrated that a predialysis systolic blood pressure of 130 mmHg or more is associated with better physical performance on the SPPB when compared with a predialysis systolic blood pressure of 110-129 mmHg among patients on hemodialysis. The relationship between low blood pressure and physical performance persisted even after adjustment for age and important comorbidities and even when we adjusted for number of prescribed antihypertensive medications. When the components of the SPPB were considered separately systolic blood pressure 110-129 mmHg was associated with worse chair stand when compared with 130-159 mmHg. Although both of the higher blood pressure categories were associated with higher SPPB score, a systolic blood pressure of ≥160 mmHg was not associated with a substantial improvement in SPPB score when compared to 130-159 mmHg. This finding suggests that raising the systolic blood pressure target as recently recommended by the JNC 8 for older individuals could optimize physical performance without the adverse events that are associated with systolic blood pressures greater than 160 mmHg among patients on dialysis [Prior studies in non-dialysis populations have shown that strict blood pressure control may not improve survival beyond conventional control. The ACCORD trial revealed that strict blood pressure control in patients with diabetes was not associated with a statistically significant improvement in survival and led to more adverse events . Among dEnd-stage kidney disease may be a model of accelerated aging, with cardiovascular and muscle mass changes typically observed in the elderly occurring even among younger patients . Recent Neither history of heart failure nor lower hemoglobin was significantly associated with a higher odds of being in the lowest SPPB in multivariable analysis. The lack of association with heart failure could be because the SPPB is a brief test that emphasizes mobility and strength and is not a test of endurance. Alternatively, the lack of association could reflect the common tendency for dialysis patients with fluid overload to be given a diagnosis of heart failure even in the absence of a structural cardiac abnormality. The association between albumin and physical performance was expected as higher albumin is reflective of better nutritional status or less inflammation. The association between physical performance and diabetes mellitus has also been described previously . When weTo put the SPPB scores in context, the SPPB score has been predictive of mortality and nursing home admissions in elderly populations. ACTIVE/ADIPOSE participants had a lower percentage of participants scoring in the highest category (10-12) and a higher percentage scoring in the lowest category when compared with the 70-year old Established Populations for Epidemiologic Studies of the Elderly (EPESE) cohort.  SPPB scoStrengths of our study include careful direct measurement of physical performance and use of the SPPB, which allows comparison with other dialysis and non-dialysis populations. Information about prescription medication was carefully collected and available for analysis. Nevertheless, several limitations of our study should be addressed. First, we relied on blood pressure data that were obtained in clinical practice rather than under carefully controlled conditions. Although this could introduce some additional variation, such variation would tend to bias our results to the null. In addition, our data mirror the information that physicians have available for clinical decision-making. Second, the cross-sectional analyses precluded us from determining whether low blood pressure itself led to poor physical performance as we hypothesized or if patients with poor physical performance had low blood pressures due to unmeasured comorbidities. Third, we did not have information on whether patients were taking antihypertensive medications as prescribed or the indication for the prescribed medication. Fourth, we relied on diagnostic codes for heart failure, without capturing detailed echocardiographic data on cardiac function, so we could not determine whether differences in cardiac function might have contributed to the observed results.Our findings demonstrate an association between lower blood pressure and poorer physical performance among a cohort of patients on hemodialysis. The association was present regardless of age or antihypertensive therapy. Although management decisions cannot be based upon these data alone, these findings raise the possibility that aggressive blood pressure control in patients on hemodialysis could lead to adverse consequences, and the risk-benefit tradeoff of aggressive blood pressure control, particularly in low-functioning hemodialysis patients, should be reexamined. In addition, future randomized trials of blood pressure control among hemodialysis patients should include physical performance measures.


Focal segmental glomerulosclerosis-like lesions have been proposed to be predictive factors for IgA nephropathy. This single center, retrospective cohort study was designed to clarify which clinical and pathological factors are predictive of decreased estimated glomerular filtration rate (eGFR) at 5 and 10 years in IgA nephropathy patients.Of the 229 patients with IgA nephropathy who were admitted to Aichi Medical University Hospital between 1986 and 2010, 57 were included in this study during the 5 to 10 years after renal biopsy. Clinical, laboratory, and pathological parameters were analyzed by multiple linear regression analysis with backward elimination to determine independent risk factors. After identifying such factors, we compared patients with and without each factor using the Student’s t test, Wilcoxon test, or Mann–Whitney U test.Four variables were identified as predictive factors for progression of IgA nephropathy: initial eGFR (p = 0.0002), glomerular tip adhesion (p = 0.004), global sclerosis (p = 0.019), and diastolic blood pressure (p = 0.024). The annual decrease in eGFR of patients with (n = 9) or without glomerular tip adhesions (n = 48) was 4.13 ± 3.58 and 1.49 ± 2.89 ml/min/1.73 m2, respectively (p = 0.015). Serum total cholesterol levels were 231 ± 45 mg/dl and 196 ± 42 mg/dl, respectively .The presence of glomerular tip adhesions predicts the progression of IgA nephropathy. High levels of serum total cholesterol may affect glomerular tip adhesions. IgA nephropathy is the most common glomerulonephritis, defined as predominantly IgA deposition in the mesangial area with mesangial proliferation. It varies from mild focal segmental proliferation to severe diffuse global proliferation with crescent formation. Many studies examining the relationship between the histopathological features of IgA nephropathy and clinical outcome suggest that glomerulosclerosis and interstitial fibrosis are predictive of poor prognosis . MesangiWe designed a retrospective, single center cohort study to clarify which clinical and pathological factors are predictive of decreased eGFR in patients with IgA nephropathy at 5 and 10 years after renal biopsy, which includes an analysis of many pathological findings related to FSGS-like lesions.The present retrospective cohort study was approved by the Ethics Committee of Aichi Medical University.Of the 821 patients who underwent renal biopsy between 1986 and 2010 at Aichi Medical University Hospital, 229 patients (27.9%) were diagnosed with IgA nephropathy based on the light microscopic and immunofluorescent study findings. In this group, 57 had sufficient clinical, laboratory, and pathological data and 5 to 10 years of follow-up , and final eGFR, which were calculated using the 4-variable Modification of Diet in Renal Disease (MDRD) Study equation . ΔeGFR wFour observers  independently evaluated the biopsy specimens under light microscopy with hematoxylin and eosin (HE), periodic acid-Schiff (PAS), periodic acid-silver methenamine (PAMS), and Masson’s trichrome (MT) staining. All samples contained more than 8 glomeruli, and 8 to 10 sliced sections per patient were observed. The pathological data included the total number of glomeruli, number of global sclerotic glomeruli, number of intact glomeruli remaining, number of glomeruli with crescent formation, total number of glomeruli with adhesions , degree of mesangial proliferation, and degree of interstitial damage. In order to focus on FSGS-like lesions, the glomerular tip domain is defined as the outer 25% of the tuft next to the origin of the proximal tubule, based on the Columbia Classification . In thisTubular atrophy and interstitial fibrosis were assessed according to the criteria of El Karoui et al . By lighA stepwise logistic regression model was used with each variable and ΔeGFR/days as the outcome variable. All analyses were performed with SAS software version 9.1 . Receiver operating characteristic (ROC) curve analysis was used to determine the cut-off point for variables that showed significant difference.Subsequently, we compared two groups with or without one factor using the chi-square test. Quantitative values are expressed as means ± SD, unless otherwise noted. Comparisons were performed using the Student’s t test, Wilcoxon test, or Mann–Whitney U test as appropriate. P values less than 0.05 were considered statistically significant.The backward elimination method was used to determine factors that strongly influence the decrease in eGFR. Briefly, the F value was determined for age, blood pressure, total protein, albumin, serum creatinine, eGFR, total cholesterol, and daily amount of urinary protein at the time of renal biopsy, number of globally sclerotic glomeruli, number of glomeruli with crescent formation, glomerular adhesion, or glomerular tip adhesion, which were divided by the number of glomeruli observed, and the tubulointerstitial damage score as defined in the Methods. Factors with the smallest F value were eliminated one by one. As a result, 6 factors remained: serum albumin, diastolic blood pressure, eGFR, number of globally sclerotic glomeruli, glomerular adhesion, and glomerular tip adhesion / the number of glomeruli observed.Based on the multiple linear regression analysis, p values for these 6 factors were determined. The p value of eGFR at the time of kidney biopsy (p = 0.000202) was the lowest, and the p value of glomerular tip adhesions (p = 0.004) was lower than the remaining 4 factors: serum albumin p = 0.138), diastolic blood pressure (p = 0.024), global sclerosis (p = 0.019), and total glomerular adhesion (p = 0.14)  Figure . Since 8There were no significant differences between groups with (n = 9) and without glomerular tip adhesions (n = 48) in terms of age, sex, systolic blood pressure, diastolic blood pressure, total serum protein, serum albumin, blood urea nitrogen, serum creatinine, eGFR, and proteinuria. There was a tendency towards hypercholesterolemia in the group with glomerular tip adhesions    times ΔeGFR/observed days was 4.13 ± 3.58 in the 9 patients with glomerular tip adhesions and 1.49 ± 2.89 ml/min/1.73 m2 in the 48 patients without glomerular tip adhesions (p = 0.015)  but not in a two-sided test (p = 0.064)  of patients, and 1.3% (11 of 816) of observed glomeruli, suggests that the presence of glomerular tip adhesions has low sensitivity and high specificity for the progression of IgA nephropathy. Further analysis will reveal the importance of glomerular tip adhesions in the progression of IgA nephropathy.Figure Many reports have demonstrated that young age, proteinuria, systolic blood pressure, hypoalbuminemia, initial eGFR, and severe pathological grade are predictive factors in IgA nephropathy progression . The preHypercholesterolemia showed a weak relationship with the presence of glomerular tip adhesions , even though hypercholesterolemia was not a risk factor for the overall progression of IgA nephropathy. There are several possibilities: one is that hypercholesterolemia directly influences glomerular tip adhesions, another is that substances related to serum cholesterol induce formation of glomerular tip adhesions. Regarding the first hypothesis, lipoprotein abnormalities are a putative risk factor of the progression of chronic renal insufficiency in humans . RecentlThe present study is limited by its single center, retrospective nature and the relatively small sample size of 57 patients, because we selected patients who could be sufficiently followed for 5 to 10 years after renal biopsy. However, the present study suggests the importance of glomerular tip adhesions, which may be related to FSGS-like lesions, in the progression of IgA nephropathy. Future studies with more patients and participating centers are needed to determine whether glomerular tip adhesions are a prognostic factor in IgA nephropathy.Glomerular tip adhesions predict decreased eGFR in relatively early stages of IgA nephropathy. High levels of serum total cholesterol may affect glomerular tip adhesions, even though hypercholesterolemia was not identified as a predictive factor for progression of IgA nephropathy.The authors declare that they have no competing interests.KM corrected and analyzed data. SK performed statistical analysis. KS, WK, and SB supported correcting data. KM, NM, HM, and HI independently evaluated pathological findings. HI designed the study. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2369/14/272/prepub


We have almost no information concerning the value of inferior vena cava (IVC) respiratory variations in spontaneously breathing ICU patients (SBP) to predict fluid responsiveness.SBP with clinical fluid need were included prospectively in the study. Echocardiography and Doppler ultrasound were used to record the aortic velocity-time integral (VTI), stroke volume (SV), cardiac output (CO) and IVC collapsibility index (cIVC) ((maximum diameter (IVCmax)– minimum diameter (IVCmin))/ IVCmax) at baseline, after a passive leg-raising maneuver (PLR) and after 500 ml of saline infusion.Fifty-nine patients  were included in the study. Of these, 29 (49 %) were considered to be responders (≥10 % increase in CO after fluid infusion). There were no significant differences between responders and nonresponders at baseline, except for a higher aortic VTI in nonresponders . Responders had a lower baseline IVCmin than nonresponders  and more marked IVC variations . Prediction of fluid-responsiveness using cIVC and IVCmax was low . In contrast, IVC respiratory variations >42 % in SBP demonstrated a high specificity (97 %) and a positive predictive value (90 %) to predict an increase in CO after fluid infusion.In SBP with suspected hypovolemia, vena cava size and respiratory variability do not predict fluid responsiveness. In contrast, a cIVC >42 % may predict an increase in CO after fluid infusion. Hypovolemia is a very frequent clinical situation in the intensive care unit (ICU) and is primarily treated with volume expansion. Unfortunately, only 40–70 % of critically ill patients with acute circulatory failure display a significant increase in their cardiac output (CO) in response to volume expansion . In septThis prospective study was performed in two ICUs at Amiens University Medical Center . Nonintubated, nonventilated, spontaneously breathing patients in whom the attending physician decided to perform fluid expansion were consecutively included. The decision by the attending physician to perform fluid expansion in our unit is usually based on the following criteria: clinical signs of acute circulatory failure  and/or oligoanuria (diuresis below 20 ml/h or 0.5 ml/kg/h) and/or acute kidney failure; and/or clinical and laboratory signs of extracellular dehydration. The exclusion criteria were as follows: clinical signs of hemorrhage, inability to defer fluid challenge for several minutes, arrhythmia, use of compression stockings and a contraindication to passive leg raising (PLR). The study's objectives and procedures were approved by the local investigational review board . No consent was needed for this observational and non-interventional study.All patients were placed in a semirecumbent position for baseline measurements. The SBP, diastolic blood pressure (DBP), pulse pressure (PP) and MBP were measured with an invasive arterial pressure monitoring system  and the heart rate (HR) was recorded. Cardiac output and IVC diameters were measured using echocardiography. The bed was then automatically moved to induce PLR of 30° ; blood p2) / 4. In an apical five-chamber view, aortic blood flow was recorded using pulsed Doppler, with the sampling volume located at the aortic annulus. The velocity-time integral (VTI) for aortic blood flow was calculated. Stroke volume (SV) and CO were calculated as follows: SV = VTI x AA and CO = SV x HR. Aortic area was considered to be stable throughout the experiment and so was measured at baseline only. It was used to calculate CO during PLR and after fluid infusion. The reported aortic VTI was the average of three to five consecutive measurements over a single respiratory cycle.The following clinical characteristics were recorded: age, gender, Simplified Acute Physiology Score II (SAPS II), weight, McCabe score, clinical problems, primary diagnosis, medical history . Echocardiography was performed using the HP Sonos 2000 and Philips Envisor . In a parasternal two-dimensional (2D) view, the aortic diameter (AoD) was measured at the aortic valve insertion (aortic annulus). The aortic area (AA) was calculated as follows: AA =  was calculated as (maximum diameter on expiration (IVCmax) – minimum diameter on inspiration (IVCmin))/ IVCmax. The intra- and inter-observer variabilities in the measurement of IVC diameter were 8.4 ± 6.6 % and 5.7 ± 2.7 %, respectively. Intra-observer reproducibility was 4.9 ± 4.3 % and 4.9 ± 4.3 % for CO and VTI, respectively, and interobserver reproducibility was 4.2 ± 3.4 % and 4.2 ± 3.4 %, respectively. All measurements were performed by echocardiography-trained intensivists.All continuous variables are expressed as the mean ± standard deviation (SD). The Kolmogorov-Smirnov test was used to check the normality of data distribution. Relationships between variables were analyzed by linear regression. Intergroup comparisons of continuous and categorical variables were performed with Student's T test and the chi-squared test, respectively.The patients were classified as responders (in whom CO increased by ≥ 10 % after fluid expansion compared with baseline) and nonresponders (in whom CO increased by < 10 %). Absolute values at baseline and changes in HR, pressure values, VTI (ΔVTI), SV (ΔSV), CO (ΔCO) and IVC diameter during PLR were analyzed. The correlation between these variables and changes in CO after fluid expansion and their value for predicting an increase in CO after fluid expansion were calculated by plotting a receiver operating characteristic (ROC) curve. The area under the curve (AUC) was calculated for all parameters and compared in a Hanley-McNeil test. Sensitivity, specificity, negative and positive predictive values, negative and positive likelihood ratios and the percentage of correct classification were calculated after defining a cut-off value. The threshold for statistical significance was set to p < 0.05. Statistical analysis was performed with MedCalc software .The characteristics of the study population are summarized in Table Twenty-nine patients (49 %) were considered to be responders, with an increase in CO of 10 % or more after fluid challenge. There were no significant differences between responders and nonresponders in terms of demographic and baseline clinical characteristics . None of the other variables were correlated with CO changes after volume expansion Table . The higIn practical terms, a reduction in IVC diameter of 42 % or more in spontaneously breathing patients distinguished between responders and nonresponders with high specificity (97 %) and a positive predictive value (90 %) but low sensitivity Fig. . We founOur results demonstrated that neither the IVC diameter nor IVC variability accurately predict fluid responsiveness in spontaneously breathing patients hospitalized in the ICU. Only inspiratory variations of IVC of 42 % or more may accurately predict an increase in CO after fluid infusion.Echocardiography is a reliable guide to cardiac function in ICU patients - especially in cases of septic shock, in which there may be several overlapping causes of circulatory failure  –18. For In spontaneously breathing patients, decreased intrathoracic pressure and increased intra-abdominal pressure during inspiration increase the venous return . The diaIn all these studies, RAP was used to assess fluid needs in patients with shock. Although an international working group  recentlyThis study has a number of limitations. The study population was small and so a large-scale study must be conducted to confirm these findings. The CVP was not measured as a comparator for fluid responsiveness of patients, although this correlation has been widely confirmed elsewhere. Lastly, a sniff test was not performed.In conclusion, we analyzed the IVC diameter and its variability in spontaneously breathing patients with suspected hypovolemia. The IVCmax was not predictive of fluid responsiveness. In contrast, we found that cIVC > 42 % may predict an increase in CO after fluid infusion in spontaneously breathing patients in the ICU.In ICU spontaneously breathing patients with hypovolemia, respiratory variations of inferior vena cava > 42 % have a high specificity to predict an increase of cardiac output after fluid infusion


P < .05) and white meats  was associated with a reduced risk compared with one serving per day of processed meats. Similarly, compared with one serving per day of processed meat, a reduced risk of diastolic blood pressure higher than 90 mmHg was associated with one serving per day of red meat , white meat . Thus, in these hemodialysis patients, intake of processed meat is significantly positively associated with higher blood pressure risk, and both sodium contents in processed meat and BMI significantly contributes to this association.In this cross-sectional study, we hypothesized that hemodialysis patients consuming greater processed meat is associated with hypertension risk, which can be partly explained by the high sodium content in processed meat. From September 2013 to May 2014, one hundred and four patients requiring chronic hemodialysis treatment were recruited from hemodialysis centers. Data on systolic blood pressure and diastolic blood pressure before receiving dialysis, and 3-day dietary records of the recruited patients were collected. HD patients with systolic and diastolic blood pressures greater than140 mmHg and higher than 90 mmHg, respectively, were considered hypertension risk. Protein foods were divided into 4 categories: red meat, white meat, soybeans, and processed meat . In a model adjusted for energy intake and hypertension history, additional servings of processed meats was positively associated to systolic blood pressure >140 mmHg , and diastolic blood pressure > 90 mmHg (odds ratio: 2.5 [1.2–5.5]). After adjustment for dietary sodium contents or body mass index (BMI), most associations were substantially attenuated and were no longer significant. In systolic blood pressure greater than140 mmHg, one serving per day of red meats (β = -1.22,  The life expectancy of hemodialysis (HD) patients appears shorter than that of the general population with the same gender and age ,2. CardiInflammation is reported another major risk factor for CVD in HD patients . In a crTherefore, in this study, we investigated the association between processed meat intake and two CVD risk factors in HD patients: HTN and inflammation marker levels. We also examined if substituting processed meat with another protein food could attenuate the positive association between processed meat and these two CVD risk factors.Clinicaltrial.gov. This study was conducted after approval by the Taipei Medical University Joint Institutional Review Board (no. 201302024). All patients signed consent forms before participation  were recruited from September 2013 to June 2014. All participants regularly underwent HD treatment three times weekly with a dialysis time of 3.5–4 h per session for at least three consecutive months. Furthermore, all HD patients were aged >20 years and had no malignant tumors, cirrhosis, or acute infection, and were not hospitalized one month prior to recruitment. The excluding criteria were HD patients with an extremely high serum CRP concentration, Kt/V <1.2, or inadequate protein intake  was found in their medical chart. Manifestations of CVD included myocardial infarction (ICD 10 code I24.1), heart failure (ICD 10 code I50) and stroke (ICD 10 code I61-I64). In the anthropometric measurements, body mass index (BMI) was calculated from the dry body weight. The seated systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured using electronic BP monitors . HD patients with a weekly average SBP >140 mmHg and DBP >90 mmHg were considered hypertension ,22. BesiAll patients were requested to white down a 3-day dietary record, which comprised details on one dialysis day and 2 nondialysis days (one each on a weekday and weekend). The process of collecting 3-day dietary record has been published . In brieFor assessing the reliability and validity of 3-day dietary records in this study, the Goldberg index and another 3-day dietary record of 77 participants were used ,28. The The protein foods were grouped according to the Nurses’ Health Study ,17,31, HP = 0.04). Therefore, both phosphorus and fatty acids components would be considered in the Model 2.The continuous variables were expressed as the mean ± standard error and mean , and the categorical variables were expressed as the number of subjects (%). The normal distribution was assessed by the Kolmogorov–Smirnoff test. Gender-linked differences between groups was tested using Student's t-test for normally distributed data, and otherwise using the simple linear rank test. Categorical variable proportions were compared between groups by using the chi squared test. Furthermore, multiple robust regression models were used for analyzing the association between the different protein foods and blood pressure and serum CRP concentrations. Multiple logistic regression models were used to determine the odds ratio for hypertension and inflammation among different protein foods. Model 1 was adjusted for dietary energy, and Model 2 was additionally adjusted for gender, age, HTN medication (only for SBP and DBP), and HD duration (only for serum CRP). Because HTN history and HTN medication had collinearity in the regression model for hypertension, and HTN medication had higher predictive power. Therefore, this study did not adjust for HTN history. In addition, because the BMI  and sodiThe effects of substituting one serving of processed meat with one serving of another protein foods was estimated by including both sources as continuous variables in the same multiple regression model ,17. The The demographic data of 104 participants was shown in P > 0.05) was observed between processed meats intake and serum CRP concentration, SBP, and DBP.All patients consumed 1.3 ± 0.2 servings of processed meat, 1.0 ± 0.1 servings of red meat, 2.4 ± 0.2 servings of white meat, 0.5 ± 0.1 servings of soybeans . The topSBP >140 mmHg and DBP >90 mmHg were considered as HTN in this study. After adjustment for gender, age, HTN medication, and dietary energy intake, each additional serving of processed meat positively associated with the risk of HTN . The oddThe substitution effects were estimated according to exchanging one serving of processed meat intake with another protein food containing equal protein. Substituted one serving of processed meat with one serving of red meat or white meat was negatively associated with risk of SBP >140 mmHg and DBP >90 mmHg in HD patients . These eThe equation included processed meats and alternative protein foods at the same time, and Model 2 for blood pressure: adjusted for gender, age, HTN medication and dietary energy, Model 2 for inflammation status: adjusted for gender, age, hemodialysis duration and dietary energy. Model 2 + BMI included adjusting for the interaction between BMI and processed meat. Model 2 + sodium included adjusting for the interaction between sodium contents and protein foods.For HD patients, SBP >140 mmHg was associated with an elevated risk of CVD events and mortality . In thisThis study revealed that greater intake of processed meat, but not unprocessed red meat, was associated with higher HTN risk in HD patients. This result was consistent with a previous 15-year prospective study conducted among a population of 44,616 disease-free French women, in whom a higher processed meat intake was associated with elevated HTN risk . CompareIn 2000, the National Heart, Lung, and Blood Institute circulated a warning that higher sodium intake would increase HTN risk . In accoStudies have suggested that dialysis patients should avoid excess sodium and alcohol to control their blood pressure ,46. In tIn this study, BMI was another significant factor in the association between processed meat and HTN. This result was consistence with that of the Nurses’ Health Study . The posPrevious studies have reported that higher intake of processed meat elevated the concentration of serum CRP in the general population ,16. FurtAlthough the interaction between phosphorus and sodium in processed meats was found in this study, the association between processed meat and HTN was modified by neither dietary phosphorus nor the interaction between phosphorus and sodium contents in processed meat. These findings were inconsistent with those of a previous study , and somThe Kidney Disease Outcomes Quality Initiative recommended that HD patients consume adequate dietary protein for preventing malnutrition and increasing their survival rate . The resThis study had several limitations. First, the sample size was small. However, the demographic data of the HD patients in this study was consistent with those reported by previous large studies, including a study conducted at 25 HD centers in Taiwan , the TaiIn conclusion, greater intake of processed meat by HD patients is positively associated with HTN risk, and this observation may be explained by the high sodium content in processed meat and BMI. Moreover, substituting one serving of processed meat with that of unprocessed red and white meat is negatively associated with HTN risk.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.