Pulmonary artery hypertension (PAH) is a common complication of congenital heart disease (CHD) and is associated with worse outcomes and increased mortality. The Doppler echocardiography (DE) is a commonly used imaging tool for both diagnosis and follow-up examination of PAH. Here is to evaluate the diagnostic performance of DE combined with NTproBNP/BNP as screening strategy in PAH patients with CHD.  A retrospective study in 64 patients with CHD has been carried out to compare estimate pulmonary artery systolic pressure (PASP) measured with DE to that measured with right heart catheterization (RHC). The Pearson correlation analyses were used to calculate the correlation coefficients between RHC and DE. The Bland-Altman analyses were carried out to assess the agreement between the two methods. ROC analyses were used to evaluate the diagnostic performance of DE, NTproBNP/BNP, and DE combined with NTproBNP/BNP. r = 0.4401, P < 0.01) was observed between PASP (78.1 ± 29.0 mmHg) measured during RHC and PASP (74.9 ± 19.7 mmHg) as estimated using DE. The Bland-Altman analysis demonstrated that the bias for DE PASP estimates was 3.2 mmHg with 95% limits of agreement ranging from -49.53 to 55.90 mmHg. The results of DE showed an AUC of 0.848 , the sensitivity of which was 98.3% and the specificity was 77.8%. The AUC of NTproBNP/BNP for the identification of PAH was 0.804 , the sensitivity of which was 81.4% and the specificity was 87.5%. The AUC of DE combined with NTproBNP/BNP was 0.857 , of which sensitivity was 100% and specificity was 77.8%. The positive predictive value (PPV) and negative predictive value (NPV) were 96.6% and 100%, respectively.  Our data have demonstrated that a mild correlation ( Our study shows that the Doppler echocardiography combined with NTproBNP/BNP has better diagnostic performance in pulmonary artery hypertension associated with congenital heart disease, especially when DE negative screening in PAH patients. Congenital heart disease, referred to as CHD, is an abnormality of cardiovascular morphology, structure, and function caused by developmental disorders of the heart and blood vessels, with an incidence of about 7‰ to 10‰ in live births, and is the primary birth defect disease in humans. In adults, approximately 6.5%-10% of CHD patients will develop into pulmonary artery hypertension (PAH) .NTproBNP or BNP are secreted by cardiomyocytes due to excessive stretching of the ventricles, which remain the most promising blood biomarkers for risk prediction of patients with PAH .Here, we investigate the accuracy of DE and, further, DE combined with NTproBNP/BNP in estimating the pulmonary arterial pressure of patients with CHD by comparing with RHC.A total of 64 patients diagnosed as CHD or PAH associated with congenital heart disease (PAH-CHD) by the Doppler echocardiography (DE) and RHC who were hospitalized in the Department of Cardiovascular Surgery, Tianjin Chest Hospital, between March 2017 and March 2022 were collected. All patients had no right ventricular outflow tract obstruction and tricuspid valve prolapse and no family history of pulmonary hypertension. The RHC examination was performed within 72 h after the DE examination, and the relevant parameters were recorded. This study was approved by the Ethics Committee of Tianjin Chest Hospital, and all patients and their families signed informed consent.The 2015 European Society of Cardiology/European Respiratory Society (ESC/ERS) guidelines for the diagnosis and treatment of pulmonary hypertension was used: mean pulmonary arterial pressure ≥ 25 mmHg by right heart catheterization at sea level and at rest . FurtherVmax2 + right atrial pressure (RAP), where V is the maximum velocity of tricuspid valve) was estimated with the tricuspid valve method (hereinafter referred to as the three-back method), and for PDA and VSD cases, PASP  was also estimated with the left-to-right shunt differential pressure method .Philips IE 33 Doppler ultrasonic diagnostic apparatus was applied with a probe frequency of 1 ~ 5 MHz. Supine position was placed before testing; the tricuspid valve area, tricuspid pressure gradient, left-to-right shunt pressure gradient, right atrial and right ventricular diameters, main pulmonary artery, tricuspid annular systolic excursion, and ejection fraction were measured under two-dimensional ultrasound at the end of expiration. Under the condition of excluding right ventricular outflow tract obstruction, according to the simplified Bernoulli equation, pulmonary artery systolic pressure , pulmonary arterial pressure (PAP), pulmonary arteriolar wedge pressure (PCWP), and aortic pressure; the saturation of each cardiac chamber and great vessels was measured. Hemodynamic parameters such as pulmonary blood flow (Qp), systemic blood flow (Qs), pulmonary circulation resistance (RP), systemic vascular resistance (Rs), and pulmonary vascular resistance (PVR) were calculated by the Fick method.Blood was collected after admission and transferred immediately to the Department of Laboratory. The samples were processed and analyzed using CLIA assay for plasma BNP  and ECLIA assay for serum NTproBNP concentrations . The normal reference range of NTproBNP was 0-300 pg/ml and also 0-100 pg/ml for BNP in our laboratory.P < 0.05 was defined as statistically significant difference. Mean ± SD was calculated to present continuous data, while the percent and frequency were used to present categorical data. Chi-square test and Student's t-test were used to analyze data when appropriate. Statistical significance was defined as a two-side value of P < 0.05. The Pearson correlation analyses were used to calculate the correlation coefficients between RHC and DE.SPSS 22.0 was used for statistical analysis, and A total of 64 CHD patients were prospectively enrolled in this study. All of the patients estimated PASP using both DE and RHC. Patients' baseline characteristics are presented in r = 0.4401, P < 0.01) (A wide range of PASP (33-160 mmHg by RHC and 25-110 mmHg by DE) was measured. A mild correlation was observed between PASP (78.1 ± 29.0 mmHg) by RHC and PASP (74.9 ± 19.7 mmHg) by DE ( < 0.01) . Using t < 0.01) .2 by RHC. And also, PAH was identified when PASP > 40 mmHg or mean PAP ≥ 25 mmHg at rest either by DE. ROC curve analyses were constructed to evaluate the predictive values of DE with/or NTproBNP/BNP levels for the identification of PAH (P < 0.001), the sensitivity of which was 98.3% and the specificity was 77.8%. The AUC of NTproBNP/BNP for the identification of PAH was 0.804 , the sensitivity of which was 81.4% and the specificity was 87.5%. The AUC of DE combined with NTproBNP/BNP was 0.857 , of which sensitivity was 100% and specificity was 77.8%. The positive predictive value (PPV) and negative predictive value (NPV) are listed in Here, PAH was defined as a PASP ≥ 30 mmHg, pulmonary artery wedge pressure ≤ 15 mmHg, and PVR index > 3 wood units·mn of PAH . The resr = 0.31 to r = 0.99 [The blood flow of left-to-right shunt in CHD continuously impacts the pulmonary artery, causing vascular remodeling, which in turn leads to the progressive increase of pulmonary arterial pressure and resistance, and finally reverses the blood flow direction to right-to-left and develops into Eisenmenger's syndrome (ES). Therefore, accurate diagnosis, follow-up, and timely intervention of PAH are of great clinical significance. Although the Doppler echocardiography is an excellent noninvasive screening tool for PAH, it has limited accuracy in estimating the right ventricular systolic pressure in PAH and is typically used for assessing the risk of PAH rather than for diagnosis . Many huAccording to Tsujimoto et al.'s review , a fixedOur study is a retrospective study assessing the value of DE in estimating pulmonary arterial pressure and diagnosing pulmonary hypertension and has a sample size of 64 subjects. We controlled for the time interval between the two examination methods within 72 hours, as well as the parameters measured and the examination conditions. These control measures will greatly reduce the limitations of the study and improve the credibility of the research. In our study, PASP estimated by DE showed a relatively mild correlation in linear regression analysis with PASP by RHC measurements in patients with CHD, and these results were consistent with previous studies –13.β1 and VEGF165b [Since pathological changes in the pulmonary arteries occur prior to cardiac affection in PAH, pulmonary derived biomarkers would be optimal to detect early PAH. However, although such biomarkers are promising results that have recently been reported as TGF-VEGF165b , 15, theVEGF165b . AnalysiThe NPV is higher than the single detection, suggesting that, when the Doppler echocardiography fails to detect while PAH is suspected by clinicians, BNP or NT-proBNP are useful as subsequent screening tests.In summary, our study also showed that the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of NTproBNP/BNP combined with the Doppler echocardiography for the prognosis prediction of pulmonary hypertension in CHD-PAH patients were higher than those of single detection. The results are consistent with the research of Yin et al. , and theNevertheless, there are several limitations regarding this study. First of all, there is noticeable heterogeneity across studies both in terms of the spectrum of the underlying congenital heart disease and the age of the patients. Secondly, two essays used for NTproBNP/BNP measurement and we used cut-off values for PAH diagnosis respectively here. Finally, both invasive and noninvasive measurements were carried out within 72 h in our study; however, PASP can fluctuate widely within a single day due to the variability of pulmonary vascular resistance.Our study shows that the Doppler echocardiography combined with NTproBNP/BNP has better diagnostic performance in pulmonary artery hypertension associated with congenital heart disease, especially when DE negative screening in PAH patients.


Background and Objectives: In chronic kidney obstruction, the severity of tubulointerstitial damage correlates best with the loss of kidney function and the risk for progression to end-stage kidney disease. The present study aimed to investigate the potential clinical significance of serum uromodulin (sUmod) as a marker of early kidney disfunction in patient with obstructive nephropathy (ON). Materials and Methods: Serum Umod level was measured by sensitive ELISA method in 57 adult patients with obstructive nephropathy and 25 healthy subjects in control group. Kidney function was precisely evaluated via measured glomerular filtration rate (mGFR) , effective renal plasma flow (ERPF) and Cystatin C level. Recruited patients were divided into subgroups based on the mGFR: group I—GFR ≤ 60 mL/min/1.73 m2 (N = 31), group II—GFR > 60 mL/min/1.73 m2 (N = 26). Results: A significantly lower level of serum uromodulin was measured in patients with ON (50.2 ± 26.3 ng/mL) compared to the control group (78.3 ± 24.5 ng/mL) (p < 0.001). The mean level of serum Umod was significantly different between group I (30.5 ng/mL ± 11.1) and group II (73.6 ng/mL ± 18.6) (p < 0.001), but not between group II (73.6 ng/mL ± 18.6) and control group (78.3 ± 24.5 ng/mL). There was a positive correlation between sUmod and mGFR  and ERPF (R = 0.572 p < 0.001), with lower sUmod levels in patients with impaired renal function. An inverse relationship was detected between sUmod and filtration markers—cystatin C , creatinine, urea and uric acid. ROC analysis of sUmod to differentiate between ON patients with GFR below 60 mL/min/1.73 m2 and above 60 mL/min/1.73 m2 resulted in AUC of 0.98  at a cut-off value of 46 ng/mL . Conclusions: The significant correlation of sUmod with kidney function parameters may imply potential clinical significance as a noninvasive biomarker of early kidney disfunction in obstructive nephropathy. Urinary tract obstruction (UTO) is a common urological condition caused by a variety of diseases that may occur in patients of all ages. Obstructive uropathy that leads to obstructive nephropathy (ON) is, although not the most frequent, an important cause of chronic kidney disease (CKD) . It is kProlonged obstruction of the urinary tract may cause atrophy of the renal parenchyma. Due to the lack of symptoms in the early stages of the chronic obstruction, renal function is already partially reduced when symptoms appear .Biomarkers of kidney function might help in detection of early stages of kidney failure. The most commonly used biomarker to evaluate global kidney function is the serum creatinine level. However, it is known that the serum creatinine level is insensitive to early changes in the GFR and unilateral kidney damage . NGAL, KOne of the possible biomarker candidates might be uromodulin (Umod), a protein mainly produced by the thick ascending limb of the loop of Henle and, to a lesser extent, in the initial segment of the distal convoluted tubule ,7.Despite its discovery more than 60 years ago, the primary physiological function of Umod is still not completely understood. Available data suggest that this protein might be of importance in the regulation of salt transport, protection against urinary tract infection and kidney stone formation, and might also participate in kidney injury and innate immunity . The impThe present study aimed to investigate the potential clinical significance of serum uromodulin (sUmod) as a marker of early kidney disfunction in patient with CKD caused by ON. Therefore, we correlated the sUmod level with kidney functional parameters, a representative and highly accurate measurement of the glomerular (measured GFR) and tubular function (measured ERPF), as well as with Cystatin C, the most sensitive marker of kidney damage.The cross-sectional study conducted at the Department of Nuclear Medicine, Center of Laboratory Medicine, Clinical Center of Vojvodina (CCV), from 2019 to 2022, was approved by the Ethics Committee of CCV in adherence with the Declaration of Helsinki. Written informed consent was obtained from all study participants.The study population included 57 patients diagnosed with CKD caused by ON. They were referred to the Department of Nuclear Medicine for renal scan and radioisotope clearance to evaluate total and split renal function. All the included patients were diagnosed to have CKD by means of clinical examination, biochemical analysis, and imaging abnormalities according to the K/DOQI criteria . Accordi2 (N = 31) or GFR > 60 mL/min/1.73 m2 (N = 26). Exclusion criteria for patients were: measured GFR (mGFR) < 15 mL/min/1.73 m2, patient with solitary kidney, diabetes mellitus, chronic liver diseases, acute inflammatory and infectious diseases and malignant diseases.Recruited patients were further divided into two groups based on the measured GFR values: GFR ≤ 60 mL/min/1.73 mThe control group consisted of 25 healthy individuals, potential kidney donors. Their renal function was evaluated by renal scan and clearance in accordance with the set algorithm for examination of renal function. They were referred to the Department of Nuclear Medicine by Department of Nephrology and Clinical Immunology of Clinical Center of Vojvodina.2). Blood and urine samples were taken on the same day. The GFR and ERPF were measured in all study subjects.All subjects were physically examined. Body height was measured by Harpenden anthropometer  to the nearest 0.1 cm, while body weight was measured in the standing upright position with a Seca scale . BMI was calculated as the ratio of body weight to the square of body height  according to the manufacturer’s instructions.In order to accurately determine renal function, the following parameters were measured:(a) GFR measurement2.GFR was determined (using the single-compartment model) via isotopic clearance of 99 mTc-labeled diethylenetriamine penta-acetic acid (99 mTc-DTPA) following a single injection of 37 MBq. Two venous blood samples were drawn 180- and 240-min post injection . The GFR(b) ERPF measurement2.ERPF was determined via isotopic clearance of 131I-labeled orthoiodohippuric acid (hippuran) by Blaufox method, in two blood samples collected 20 and 30 min after injection . The ERPQuality control of the radiochemical purity of isotopes (>95%) was performed with paper chromatography. A well gamma counter with NaI (Tl) crystal  was used to measure the radioactivity of samples.(c) Biomarkers of renal functionThe measurements of cystatin C concentration were performed by the immunoturbidimetric method on Mindray BS 2000 . Serum and urine levels of creatinine, as well as and serum urea and uric acid concentrations were determined by standard biochemical methods using commercial kits on analyzer Advia 1800 . Urinary albumin concentration was measured by nephelometric immunoassay.In order to exclude patients with diabetes, the fasting blood glucose level was measured using the glucose hexokinase method, as well as blood insulin level using an electrochemiluminescence immunoassay on ADVIA Centaur XP immunoassay system .p values less than 0.05 were considered significant. Uromodulin diagnostic performances in predicting GFR of less than 60 mL/min/1.73 m2 and GFR of less than 90 mL/min/1.73 m2 with optimal level of specificity and sensitivity were evaluated in receiver-operating curve (ROC)-analysis in order to determine the cut-off point. All statistical analyses were performed using the IBM SPSS Statistics 22  software package.Depending on the type of variables and the normality of the distribution, the data description was displayed as n (%), mean ± standard deviation or median (range). The correlation between variables was estimated using Pearson’s and Spearman’s correlation coefficient. A linear regression model was used for modelling the relationship of dependent variables with potential predictors. The predictors from univariate analyses that were statistically significant at a significance level of 0.05 were included in the multivariate regression models. All 2. There were no significant differences in age, gender and BMI between the groups. Measured GFR and ERBF in control group were significantly higher compared to participants with ON.General characteristics of patients with ON and control subjects are provided in 2 (N = 31); group II GFR > 60 mL/min/1.73 m2 (N = 26). Renal function parameters of patients with ON and participants of the control group are given in Recruited patients with ON were further divided into two groups based on the measured GFR values: group I GFR ≤ 60 mL/min/1.73 mp < 0.001). Significantly higher serum concentrations of creatinine , urea  and uric acid  were detected in group I compared to group II and control group (p < 0.001). Although lower serum concentrations in all three parameters were measured in control group compared to group II, difference was not statistically significant. A similar pattern was observed in serum cystatin C concentration with significant difference between group I (1.7 ± 0.5 mg/L) and group II (1.0 ± 0.2 mg/L) (p < 0.001), and an insignificant difference between group II and control group (0.8 ± 0.1 mg/L).There was significant difference detected in mGFR and ERPF values among ON patients with different degrees of renal hypofunction and healthy subjects (p < 0.001). The difference in mean level of sUmod was also significantly different between group I (30.5 ng/mL ± 11.1) and group II (73.6 ng/mL ±18.6) (p < 0.001), but not between group II (73.6 ng/mL ± 18.6), and control group (78.3 ± 24.5 ng/mL) (A significantly lower level of serum uromodulin was measured in patients with ON (50.2 ± 26.3 ng/mL) compared with the control group (78.3 ± 24.5 ng/mL) (5 ng/mL) .p < 0.001 and R = 0.572, p < 0.001), with lower sUmod levels in patients with impaired renal function (p < 0.001), creatinine, urea and uric acid. While sUmod concentration analogues to decrease in renal function, it behaves in an opposite manner in relation to the renal filtration markers.The correlation parameters of sUmod and renal function parameters are given in function . On the p < 0.001)  .p = 0.004), gender (p = 0.036), total cholesterol (p = 0.038) and fasting glucose level (p = 0.001)  . However2 and above 60 mL/min/1.73 m2 resulted in an AUC of 0.98  at a cut-off value of 46 ng/mL with a diagnostic specificity of 96.8% and sensitivity of 92.2% (2) and control group, it resulted in an AUC of 0.78  at a cut-off value of 50 ng/mL with a diagnostic specificity of 57.9% and sensitivity of 92.0% , as well as the sensitive routine clinical markers of renal damage such as cystatin C. Results of our study demonstrated that patients with CKD caused by ON are characterized by lower levels of sUmod compared to healthy subjects. In addition, significant differences in sUmod level were detected between the groups with different renal function status.To our knowledge, there are not many published studies examining the relation between Umod and renal function in patients with ON. Until now, most of the studies on tubular or early renal damage focused on urinary biomarkers ,22,23. MThe necessity for the combined assessment of several urinary biomarkers in the early detection of kidney damage in the upper UTO is explained by multifactorial etiology of obstruction making it impossible to diagnose all obstructions using just one biomarker . In a rep < 0.001) was inferior to plasma uromodulin . In addition, sUmod was found to be superior to discriminate between non-CKD patients and patients with first stage CKD compared to uUmod, which was not able to differentiate between non-CKD and first stage CKD subjects [The diagnostic accuracy of sUmod tends to be superior to uUmod. In a study by Steubl et al., uUmod level correlation with estimated GFR , while an sUmod level lower than 46 ng/mL suggests a GFR value below 60 mL/min . The pretty narrow range between cut-off values of sUmod might be explained by the fact that Umod production reaches plateau beyond GFR of 90 mL/min .The role of uromodulin as a biomarker of kidney injury was recently reviewed, concluding that serum uromodulin levels represent a valuable early predictor of renal, primarily tubular damage and that lower concentrations have a prognostic role in predicting the progression of kidney damage ,31. In aThe results we obtained demonstrated a significant correlation of serum uromodulin with kidney functional parameters and may imply potential clinical significance as a noninvasive biomarker of early kidney disfunction in CKD caused by obstructive nephropathy. Since the dynamic nature of Umod expression and secretion is well known, as well as it is known to change rapidly in response to different pathophysiological conditions, with serum Umod levels being less well established, further investigation is necessary. The primary focus of further research should be the evaluation of the value of sUmod in accurate selection of the patients who would benefit from timely intervention and, thus, prevent significant loss of renal function.


These findings indicate that neutrophils and their mediators could have an active role in asthma pathophysiology.Neutrophils (PMNs) contain and release a powerful arsenal of mediators, including several granular enzymes, reactive oxygen species (ROS) and neutrophil extracellular traps (NETs). Although airway neutrophilia is associated with severity, poor response to glucocorticoids and exacerbations, the pathophysiological role of neutrophils in asthma remains poorly understood. Twenty-four patients with asthma and 22 healthy controls (HCs) were prospectively recruited. Highly purified peripheral blood neutrophils (> 99%) were evaluated for ROS production and activation status upon stimulation with lipopolysaccharide (LPS), N-formylmethionyl-leucyl-phenylalanine (fMLP) and phorbol 12-myristate 13-acetate (PMA). Plasma levels of myeloperoxidase (MPO), CXCL8, matrix metalloproteinase-9 (MMP-9), granulocyte–monocyte colony-stimulating factor (GM-CSF) and vascular endothelial growth factor (VEGF-A) were measured by ELISA. Plasma concentrations of citrullinated histone H3 (CitH3) and circulating free DNA (dsDNA) were evaluated as NET biomarkers. Activated PMNs from asthmatics displayed reduced ROS production and activation status compared to HCs. Plasma levels of MPO, MMP-9 and CXCL8 were increased in asthmatics compared to HCs. CitH3 and dsDNA plasma levels were increased in asthmatics compared to controls and the CitH3 concentrations were inversely correlated to the % decrease in FEVThe online version contains supplementary material available at 10.1007/s10238-021-00750-8. H2 cells, also T follicular helper (TFH) cells, a specialized subset of CXCR5+ CD4+ T cells, are a major source of IL-4 and IL-21 [Bronchial asthma is a heterogeneous chronic inflammatory disease with a broad spectrum of severity . More thnd IL-21 , thus clnd IL-21 . T2-highnd IL-21 . In T2-lnd IL-21 , 14. T2-nd IL-21 , 15. Spend IL-21 . Both nend IL-21 , 18. CXCnd IL-21 .Neutrophils (or polymorphonuclear leukocytes: PMNs) are the most abundant circulating leukocytes in humans  and are high CD62Lhigh to CD16high CD62Llow [The pathophysiological role of neutrophils in asthma has recently begun to emerge . CirculaCD62Llow . NETs weCD62Llow . In addiCD62Llow . ActivatCD62Llow , 52.In this study, we evaluated the production of ROS from highly purified peripheral blood neutrophils from asthma patients of different severity compared to healthy controls. In addition, we compared the ex vivo activation status of neutrophils, the circulating levels of several neutrophil-derived mediators and of NET-derived biomarkers in healthy donors and asthma patients.2-agonist and/or leukotriene-receptor antagonist); 4/24 of patients were treated with daily medium-dose of ICS ; 3/24 of patients were on oral glucocorticoid therapy (mean prednisone intake 14.2 mg/die). Baseline characteristics of the patients and healthy volunteers included in the study are shown in Tables 1, in liters); the fraction of exhaled nitric oxide ; the score on the Asthma Control Test  [1, Forced Vital Capacity (FVC), FEV1/FVC were measured and the best of three forced maneuvers was recorded. Results were expressed both as absolute values and as a percentage of the predicted values referred to European Respiratory Society (ERS) reference values [We enrolled 24 asthma patients  from April 2020 to May 2021 at the Division of Clinical Immunology, Allergy and Immunodeficiency of the Department of Translational Medical Sciences, University of Naples Federico II. The study was conducted in accordance with Good Clinical Practice (GCP) guidelines and adhered to the Declaration of Helsinki II. Written informed consent was obtained from all participants. Patients were eligible for enrollment in the study if they were aged 18–70 years and had a history of allergist-diagnosed asthma. Key exclusion criteria were autoimmune diseases, infections, malignancies, a patient-reported smoking history or the onset of respiratory symptoms after the age of 40 years in current or previous smokers with a smoking history of at least 10 pack-years. None of the asthmatic patients has been or was treated with allergen-specific immunotherapy  or monoc4 weeks) . Spirome4 weeks) . FEV1, Fe values . FeNO wae values . Peripheg, 20 min, + 22 °C) as previously described [The study protocol, involving the use of human blood cells was approved by the Ethics Committee of the University of Naples Federico II (198/18), and written informed consent was obtained from blood donors according to the principles expressed in the Declaration of Helsinki. Leukocytes from peripheral blood of asthma patients and healthy controls were separated from erythrocytes by dextran sedimentation. Neutrophils were purified by Ficoll-Paque Histopaque®-1077  density gradient centrifugation , followed by Percoll  (65%) density gradient centrifugation (660 × escribed . These cescribed .6 cells/mL) were resuspended in the RPMI 1640 medium with 5% of fetal bovine serum (FBS)  and antibiotics at 37 °C and 5% CO2. The cells were incubated for 30 min after the addition of H2DCF-DA 10 µg/mL . H2DCF-DA is a fluorogenic dye that allows to determine hydroxyl peroxyl and other ROS activities within the cell [2DCF-DA is deacetylated by cellular esterases to a non-fluorescent molecule, which is oxidized by ROS into 2’,7’ dichlorofluorescein (DCF). DCF, a highly fluorescent molecule, is oxidized by fluorescent spectroscopy with maximum excitation and emission wavelengths of 492–495 and 517–527 nm, respectively. Neutrophils were washed in PBS and resuspended in RPMI 5% FBS in the presence or absence of different immunologic  or fMLP; 1 µM) or non-immunologic stimuli   and immediately analyzed in a 96-well plate and placed in a EnSpire Multimode Plate Reader . DCF mean fluorescence intensity was measured at an excitation wavelength of 492–495 nm and emission at 517–527 nm. The ability of LPS and fMLP to induce cytoplasmic ROS-catalyzed oxidation of DCFH in neutrophils was measured as compared to negative control.Neutrophils  and Zombie Violet dye  was added to evaluate cell viability . Then, the cells were stained  in PBS containing 1% FBS. The following antibodies were used: allophycocyanin (APC)-conjugated anti-CD66b , peridinin chlorophyll protein (PerCP)-conjugated anti-CD11b , fluorescein isothiocyanate (FITC)-conjugated anti-CD62L  and Phycoerythrin (PE)-conjugated anti-CD16 . Cells were acquired by MACS Quant Analyzer 10  and analyzed by FlowJo v.10 software. Doublets and debris (identified based on forward and side scatter properties), dead cells  and eosinophils (identified based on the CCR3+ exclusion gate) were excluded from the analysis. A representative example of the complete gating strategy is illustrated in Supplementary Fig. 1. Data are expressed as a percentage of positive cells or median fluorescence intensity [Highly purified (> 99%) neutrophils were kept in RPMI with 10% of FCS for 30 min at + 37 °C, then were washed with PBS solution and stimulated with LPS (100 ng/ml), fMLP (1 µM) or PMA (10 ng/ml). Cells maintained in RPMI 1640 medium containing 5% of FBS  were the negative control . 2 × 10Plasma levels of myeloperoxidase (MPO), matrix metalloproteinase 9 (MMP-9), CXCL8/IL-8, granulocyte–monocyte colony-stimulating factor (GM-CSF) and vascular endothelial growth factor (VEGF-A) of asthma patients and healthy controls were measured using ELISA kits according to the manufacturer’s instructions . A microplate reader  was used to determine sample absorbance at 450 nm. The ELISA detection range was 62.5–4000 pg/ml (MPO), 31.2–2000 pg/ml (MMP-9), 31.2–2000 pg/ml (CXCL8/IL-8), 7.80–500 pg/ml (GM-CSF) and 31–2000 pg/ml (VEGF-A).Plasma circulating free DNA (dsDNA), a marker for NET formation , 64, wasp < 0.05.Statistical analysis was performed by using Prism 7 (GraphPad software). Data are expressed as mean ± SEM of the indicated number of experiments. D'Agostino & Pearson normality test was used to test for normality of distribution, and statistical methods were chosen to fit non-normal distributions when appropriate. Values from groups were compared by Student’s t test or Mann–Whitney U test based on the parametric or nonparametric distribution of the continuous variables. Repeated measures one-way or two-way ANOVA was used were appropriated and described in the figure legends. Differences were assumed to be statistically significant when 1 was significantly lower in asthmatics compared to healthy donors . The median FENO was 48.4 ± 23 ppb. The absolute neutrophils count in asthma patients was increased than normal subjects . The absolute eosinophil count was significantly higher in asthmatics compared to healthy subjects . Serum IgE levels were 264.3 ± 70 IU/ml in asthmatic patients and 69.2 ± 107 IU/ml in control subjects (p < 0.0001). Demographics, clinical characteristics and laboratory data of individual asthma patients are presented in Table In this study, we enrolled 24 asthma patients and 22 healthy matched controls. Table 2DCF-DA) ROS detection assay. Figure ROS are key signaling molecules that play important roles in the progression of several inflammatory disorders , includi.To determine the activation status of human PMNs isolated from peripheral blood of asthma patients, we determined CD11b, CD16 and CD62L (L-selectin) expression on PMNs by flow cytometry , 68. PMNbright/CD62Ldim cells consist mainly of neutrophils containing hyper-segmented nuclei that show a more activated state [+CD62L− cell counts for healthy controls (D–G) and asthma patients (H–K), stimulated with LPS , fMLP  and PMA  or control medium . Collectively, these data indicate that when challenged with inflammatory stimuli, peripheral blood PMNs from asthmatics displayed a reduced activation status (CD11b up-regulation and CD62L shedding) compared to PMNs purified from controls.Under resting conditions, neutrophils expressed CD62L, which rapidly decreased  after stimulation with the three examined stimuli. Indeed, the CD16ed state . InteresHuman neutrophils contain and release of a variety of proinflammatory mediators , 71. Mye1/FVC of lung function in asthmatics  that activate specific receptors  expressed on the cytoplasmic membrane of these cells , 66. The2−), hydrogen peroxide (H2O2) and hypochlorous acid (HOCl) [2− production by circulating neutrophils was increased in asthma patients [2− by neutrophils was greater in asthma patients [2− inversely correlated with FEV1. More recently, it has been shown that peripheral blood neutrophils from asthmatics activated by fMLP and LPS induced an increase in ROS production [2− generation by human neutrophils [Human neutrophils are a prominent source of ROS, being capable of producing significant quantities of superoxide anion (Od (HOCl) , 94. Thed (HOCl) , 95. A lpatients . A similpatients . In asthoduction . Our resoduction , 97, thetrophils , 97, whetrophils  have meaTo support this hypothesis, we evaluated the changes of the neutrophil expression of CD11b and CD62L induced by LPS, fMLP and PMA in asthmatics and controls. Under basal conditions, there is a minimal surface expression of CD11b . All thrOur experiments were performed on normal density neutrophils (NDNs) isolated by Ficoll-Paque Histopaque® density gradient centrifugation. Several groups of investigators have identified and characterized a subset of human peripheral blood PMNs named low-density neutrophils (LDNs) , 98–101.Neutrophils are a rich source of preformed granular constituents which can be rapidly released . MPO is −/− mice showed reduced immune cell infiltration and bronchial hyperresponsiveness compared to wild type mice in a murine model of asthma [MMP-9, present in tertiary granules of neutrophils, was found in BAL of asthmatics  and it wf asthma . MMP-9 wf asthma , 78. Morf asthma . In thisHuman neutrophils contain and release CXCL8 . AsthmatGM-CSF is a pleiotropic cytokine that plays a role in the differentiation, activation and survival of several immune cells, including neutrophils . GM-CSF Angiogenesis, the formation of new blood vessels, is a complex process modulated by a plethora of stimulatory and inhibitory factors , 86. TheNETs were originally described as a protective mechanism by which neutrophils exerted an antibacterial role , 74. DurDifferent analytical methods  for the measurement of NET markers in asthma were used by several groups , 128–130Putative markers of NETs have been detected in different sites/biological fluids of asthmatics. DNA presence was initially described in bronchial biopsies of adult asthmatics . dsDNA h1/FVC in asthmatics. Second, several inhibitors of NET formation and molecules that degrade NETs are under active investigation for the treatment of inflammatory disorders and cancer [Our findings might have additional translational relevance for a number of possible reasons. First, there is the possibility that measurement of circulation NET-derived products  could represent an easily measurable plasma biomarker of asthma severity. In this context, we have found an inverse correlation between circulating levels of CitH3 and FEVd cancer . If furtd cancer  could beAt this point, the question obviously arises: what could be the stimuli that induce the in vivo formation of NETs in asthmatics? A plethora of immunologic and non-immunologic stimuli can induce NET formation in vivo. Among these, LPS , 132, ILT2-high asthma is characterized by type 2 inflammation involving Th2 lymphocytes, ILC2s, mast cells, basophils, eosinophils, type 2 cytokines and IgE –10. On tThis study has several limitations that should be pointed out. The sample size of the asthma patient and healthy control cohorts investigated in the present study is limited. Further studies on larger cohorts of healthy donors and patients could highlight the significance of NET formation in these patients. Although our results indicate that increased CitH3 plasma levels were inversely correlated to reduced lung function, at this stage, it would have been inappropriate to define CitH3 as a biomarker of asthma severity. We anticipate that it would be necessary to examine at least one order of magnitude larger cohorts. Asthma is a heterogeneous group of inflammatory disorders characterized by complex pathology, distinct subtypes and highly variable clinical courses –147. The1/FVC decrease. Together, these findings indicate that neutrophils and their products might have an active role in the pathophysiology of asthma.In conclusion, our study indicates that circulating neutrophils from asthmatics released ROS when activated by immunologic and non-immunologic stimuli. Plasma levels of several biomarkers of neutrophils activation such as MPO, MMP-9 and CXCL8 were increased in asthma patients compared to healthy subjects. Circulating levels of two NET-derived products such as dsDNA and CitH3 were increased in asthmatics compared to controls and were inversely correlated to FEVSupplementary file1 (DOCX 1700 kb)Below is the link to the electronic supplementary material.


Acute kidney injury (AKI) requiring renal replacement therapy (RRT) is a serious complication in the ICU that results in increased mortality and risk of chronic kidney disease (CKD). Some studies suggest RRT modality may have an impact on long-term renal recovery after AKI. However, other predictive factors of severe long-term CKD in ICU patients with AKI requiring RRT are unknown.We performed an ancillary study of the multicenter ELVIS trial in the population with AKI requiring RRT. Patients alive 3 months after RRT initiation were eligible. Serum creatinine levels available at 3, 6 and 12 months and 3 and 5 years were recorded. CKD stage was determined according to the glomerular filtration rate as estimated by the CKD-EPI formula. At each timepoint, two groups of patients were compared, a no/mild CKD group with normal or mildly to moderately decreased renal function  and a severe CKD group (stages 4 and 5). Our objective was to identify predictive factors of severe long-term CKD.M12 = 1.03 95% CI [1.02–1.05] per day) and that a high SOFA score at the initiation of RRT was not associated with severe CKD up to 5 years (ORM60 = 0.85 95% CI [0.77–0.93] per point).Of the 287 eligible patients, 183 had follow-up at 3 months, 136 (74.3%) from the no/mild CKD group and 47 (25.7%) from the severe CKD group, and 122 patients at 5 years comprising 96 (78.7%) from the no/mild CKD group and 26 (21.3%) from the severe CKD group. Multivariate analysis showed that a long RRT period was associated with severe CKD up to 12 months , and this ancillary study was registered with ClinicalTrials.gov, number: NCT03302624 .The online version contains supplementary material available at 10.1186/s13054-022-04233-4. Acute kidney injury (AKI) is a frequent complication in the intensive care unit (ICU) that affects the vital and renal prognosis of patients in the short and long term . ICU patThe aim of our study was to identify predictive factors for severe long-term CKD in ICU patients with AKI requiring RRT.We conducted an observational, retrospective multicenter ancillary study of the randomized ELVIS trial, which assessed the prevention of RRT catheter infections with ethanol lock . The stuEligible patients were aged 18 years or over, enrolled in the ELVIS trial, hospitalized in an ICU, had AKI requiring RRT with the placement of a double-lumen dialysis catheter, discharged from the hospital after 28 days and were alive 3 months after RRT initiation. The study population consisted of patients with at least one serum creatinine value available between 3 months and 5 years after RRT initiation. The exclusion criteria were CKD requiring chronic RRT at inclusion in the ELVIS trial and refusal to participate in the study.Additional data  to those collected prospectively in the ELVIS trial were retrieved from computerized medical records when possible. Otherwise, patients were contacted by telephone. Five contact tests were performed. If the patient could not be contacted, five attempts to contact the family or the attending physician were made. The patient was considered lost to follow-up if none of the information could be collected after five attempted contact. Patients were informed at the beginning of the interview of the aim and nature of the study and were told they could opt not to take part. If they agreed to participate, their responses were collected for analysis and anonymization. When possible, a picture of the blood test with creatinine level was sent by the patient. The data collected were the serum creatinine level available at 3, 6 and 12 months and at 3 and 5 years, the date of the start of dialysis, and the date of kidney transplantation. If there were several serum creatinine levels available at the same timepoint, the lowest level was recorded. The family or the attending physician was contacted for missing data and, when appropriate, the date of death. The clinical variables were those collected during the ELVIS trial. The RRT period was calculated to run from initiation in the ICU to the last day of treatment, which could be in the ICU or after discharge.The estimated glomerular filtration rate (eGFR) was measured at each timepoint  from the serum creatinine level, age, sex and ethnicity (13 patients were of African race/ethnicity) according to the CPK-EPI formula . For eacn = 52 at M3, n = 76 at M6, n = 76 at M12, n = 62 at M36 and n = 40 at M60).The values of the continuous variables are expressed as median . The values of the categorical variables are expressed as absolute values and percentages. The total population was separated into the no/mild CKD group and the severe CKD group, as previously defined at 3, 6 and 12 months and 3 and 5 years after RRT initiation. Missing CKD data were imputed by taking the most severe CKD stage before or after the timepoint for which data were missing (p ≤ 0.2) and their clinical relevance: age, only intermittent modality for RRT, insulin-dependent diabetes, chronic kidney disease, chronic respiratory failure with oxygen therapy, SOFA score at RRT initiation, RRT period, septic shock, and immunosuppression. Stepwise regression was then used to select the most informative predictor variables to include in the final multivariate model. The interactions between the explanatory variables were carefully checked before being included in the multivariate analysis. Special attention was also paid to multicollinearity. Linearity to the logit for continuous variables was checked with generalized additive models.The variables of the two groups were compared at each timepoint with Student’s test or Mann–Whitney test for the continuous variables and Chi2 or Fisher’s exact test for the categorical variables. The factors associated with severe CKD were then determined with a logistic regression model. The candidate variables for multivariate analysis were selected based on the results of the univariate analysis , moderate CKD group (stages 3A and 3B) and severe CKD group (stages 4 and 5). The results are expressed in terms of odds ratios (OR) without adjustment and 95% confidence intervals (95%CI). Analyses were performed with SAS 9.4 software . A Twelve of the 16 centers involved in the ELVIS trial agreed to participate in our study, providing a pool of 1390 patients out of 1496 that made up the initial inclusion population. Of these 1390 patients, 287 were alive 3 months after RRT initiation for AKI and therefore eligible for the study. At 3 months, 183 patients met the inclusion criteria and constituted the study population  from the no/mild CKD group and 47 (25.7%) from the severe CKD group, and at 5 years on 122 patients comprising 96 (78.7%) from the no/mild CKD group and 26 (21.3%) from the severe CKD group  were alive at 6 months, 158 (86.3%) at one year, 138 (75.4%) at 3 years, and 122 (66.6%) at 5 years  or recovery of renal function (10% vs 7% p = 0.5) between continuous and intermittent RRT [It is now well established that AKI is a risk factor for the development of, or progression to, CKD , 19, 20.tent RRT . Finallytent RRT . Howevertent RRT . To our tent RRT , 5. In atent RRT . Such istent RRT . It seemtent RRT . Some ofOur study showed an intuitively surprising association between a high SOFA score  and the 2 was collected, which may have been estimated with means other than CPK-EPI, and this could explain why some of these patients were in the no/mild group. We assessed the occurrence of CKD after AKI requiring RRT and not the renal recovery of patients. Third, generalizing our findings to all critically ill patients requiring RRT for AKI should be cautious because of the lack of information on a significant number of patients who were lost of follow-up or did not have bloodwork at the different timepoints assessed in the study.Our study has several limitations. First, the duration of the RRT period depends on when it was initiated and on the weaning criteria. There is currently no international consensus regarding the criteria for the initiation and weaning of RRT, and hence our findings were not affected by a modification of these criteria. The ELVIS trial  was carrSevere long-term CKD is found in one-fifth of ICU survivors treated with RRT for AKI. The duration of the RRT period has been identified as a risk factor for developing severe CKD in the long term. Our findings should be considered in future studies on the prognosis of ICU patients treated with RRT.Additional file 1: Table S1. Characteristics of patients lost to follow-up or with no data up to 5 years. Table S2. Comparison between no/mild chronic kidney disease group and severe chronic kidney disease group at 6 months. Table S3. Comparison between no/mild chronic kidney disease group and severe chronic kidney disease group at 12 months. Table S4. Comparison between no/mild chronic kidney disease group and severe chronic kidney disease group at 3 years. Table S5. Factors associated with severe chronic kidney disease group  when the classification is based on three groups .Additional file 2: Appendix 1. STROBE checklist.


In this study we investigated the association between information entropy in short length blood pressure signals and physical frailty status, in a group of patients aged 50+ recruited from the Falls and Syncope Unit at the Mercer’s Institute for Successful Ageing in St James’s Hospital, Dublin, Ireland. This work is an external clinical validation of findings previously derived in a population-based cohort from The Irish Longitudinal Study on Ageing (TILDA). The hypothesis under investigation was that dysregulation (as quantified by entropy) in continuous non-invasive blood pressure signals could provide a clinically useful marker of physical frailty status. We found that in the 100 patients investigated, higher entropy in continuously measured resting state diastolic blood pressure was associated with worse physical frailty score, as measured by the Frailty Instrument for primary care of the Survey of Health, Ageing and Retirement in Europe (SHARE-FI). Since physical frailty is defined as a pre-disability state and hence it can be difficult for clinicians to identify at an early stage, the quantification of entropy in short length cardiovascular signals could provide a clinically useful marker of the physiological dysregulations that underlie physical frailty, potentially aiding in identifying individuals at higher risk of adverse health outcomes. Frailty is a biologically driven decrease in reserve and resistance to stressors, resulting from collective declines across multiple physiological systems . Frailtyunintentional weight loss, exhaustion symptoms, grip strength, walking speed and self-reported physical activity. In this method, frailty is conceptualized as a pre-disability state  walking 100 metres?” or “…do you have difficulty climbing one flight of stairs without resting?”. One or more positive responses was coded as 1, and two negative responses as 0.Low activity was assessed by the question: “How often do you engage in activities that require a low or moderate level of energy such as gardening, cleaning the car, or doing a walk?”. This resulted in an ordinal variable, where: 1 = “More than once a week”; 2 = “Once a week”; 3 = One to three times a month”; and 4 = “Hardly ever or never”.SHARE-FI  is an adi, was calculated aszfatigue(i) represents the standardized score on the fatigue measure for the individual i and wfatigue is the sex-specific weighting associated with that measure . Weighting values were taken from a previous study where these values were derived from a cohort of 31,115 individuals from 12 different European countries, using data from the Survey of Health, Ageing and Retirement in Europe (SHARE)  and r  ranges. Solid lines show the resulting beta (β) coefficients and dashed lines show the associated p-values. Associations between the SHARE-FI score and sBP SampEn were not significant for any of the combinations of m and r investigated  provided significant results. Since for dBP SampEn, m = 5 and r = 0.4 provided the largest β coefficient value and lowest p-value, these values were utilized for all subsequent models.Results from the hyperparameter tuning are shown graphically as an Appendix to this work in ated see a. Figureβ = 0.38 to 0.43 (per 1 SD), p ≤ 0.008). All models also revealed a higher disease burden/severity (as quantified by CIRS-G score) with increased SHARE-FI score . In model 3(a), being a current smoker was associated with higher SHARE-FI score; however, smoking was not significant in model 3(b). The linear relationships between the SHARE-FI score and BP SampEn are also illustrated graphically in Results from robust linear regression models investigating the relationship between the SHARE-FI continuous score and BP SampEn are reported in In previous TILDA population-based studies, we found that continuous blood pressure signal entropy could provide a clinically useful marker of the physiological dysregulations that may underlie physical frailty ,22,23,24Signal entropy calculated in short length BP data during rest, as used in this study, may quantify the systemic dysregulation of the cardiovascular system that underlies physical frailty. There are several potential physiological causes for this dysregulation. An increase of sympathetic activity and/or modulation directed to the heart and/or blood vessels, as previously described in abnormal ageing states , could pThe reasons as to why dBP SampEn, and not sBP SampEn, were associated with physical frailty in the present study could be both physiological and statistical. Physiologically, sBP is more related with peripheral end-organ perfusion , whilst yes’ or ’no’), and that the continuous entropy measure was also dichotomized into ‘low’ and ‘high’ entropy, with ‘low entropy’ defined as bottom three quartiles of data. Additionally, 2 to 3 h of heart rate data was used in that study, versus the comparatively very short length (1 min) blood pressure data used in the present work, and as such these different approaches may be quantifying different physiological processes . Using similar methodologies , but with shorter data length (10 min) and entropy analyzed as a continuous variable, in 2014 Takahashi et al. reported higher entropy in pre-frail and frail groups, versus non-frail [age > 70 years, preoperative BMI < 18.5, hematocrit < 35%, albumin < 3.4 g/dL, or creatinine > 2.0 mg/dL.Other previous studies investigating the associations between cardiovascular signal entropy and frailty status have reported contradictory results, with some reporting higher levels of entropy in cardiovascular data to be associated with worse frailty status ,36, otheon-frail . Contradon-frail ; howeverThe approach to BP entropy calculation presented herein has been specifically designed for easy use in a clinical setting. All BP measures were non-invasive, non-ionizing, and were performed using a type of non-invasive continuous hemodynamic monitoring device that is generally available in specialized clinics. The short data length (1 min), and the fact that BP can be measured during supine rest, make the approach feasible and practical for use in a busy clinic. Entropy provides a single-value measure allowing for easy use by clinicians, which could theoretically be calculated and displayed at the bedside on the measurement device itself, though this will require further work with regards algorithm optimization and methodological developments for real-time data processing. Future work investigating how these measures vary over time would also be of interest, as perhaps BP entropy may provide an ‘early warning’ measure for monitoring transitions to more adverse frailty states, and it can be difficult for clinicians to identify with the naked eye the often slow but insidious process of frailty progression in individual patients. Additional future work will also be needed to come to a consensus as the most appropriate pre-processing and entropy calculation methodology to employ, and this would potentially allow for the establishment of age- and sex-specific normative values to use as reference guidelines in a clinical setting.There are additional limitations which should be considered when interpreting the results of the present work. While the BP SampEn variables are objectively measured, a number of the covariates, as well as certain components of the SHARE-FI score were self-reported. Additionally, the SHARE-FI operationalization used herein does not include objective measures of mobility; however, in our same FASU context it was previously shown that SHARE-FI significantly captured gait speed in this same clinical setting, adding to its validity . FurtherResults from this clinical replication study demonstrated a significant and independent association between diastolic blood pressure signal entropy and physical frailty status in a pilot sample of patients aged 50 years or older attending a falls and syncope clinic. These results mirror those we previously obtained from a large population-based cohort and demonstrate the potential that a simple automated measure of blood pressure signal entropy at rest could provide a clinically useful indicator of the early physiological dysregulations that underlie physical frailty in older adults.


Background and aims: Intravenous hydralazine and labetalol are recommended as first-line anti-hypertensives for controlling severe hypertension in pregnancy. Our study aimed at identifying the most effective drug with minimum side effects for preoperative management of severe hypertension in parturients scheduled for Caesarean delivery (CD). We also studied the effect of these drugs on patients already on oral labetalol in the antenatal period.Methods: A prospective observational study was done on 162 hypertensive parturients scheduled to undergo emergency CD who received hydralazine or labetalol in the preoperative period. Demographic data, booking status, hemodynamic data, time taken to reach adequate control of blood pressure (BP), drug efficacy, the incidence of persistent hypertension, adverse effects associated with the drugs, and maternal and fetal outcomes were noted.Results: The time taken for the control of BP was similar with both drugs . The mean number of doses required to achieve target BP was significantly less with hydralazine compared to labetalol . Patients on tablet labetalol in the antenatal period were poorly controlled when put on the same drug intravenously but had better control with hydralazine . The incidence of persistent hypertension was lower in patients treated with hydralazine compared with labetalol .Conclusion: Both drugs took a similar time for BP control. However, hydralazine was more efficacious, produced adequate control of BP in a higher number of patients, and had a lower incidence of persistent hypertension. Hypertensive disorders of pregnancy are one of the most common medical complications of pregnancy, being a major cause of maternal, fetal, and neonatal morbidity and mortality . The ultAlthough intravenous (IV) labetalol and hydralazine have been recommended as first-line medications, the treatment of hypertensive crises associated with pre-eclampsia and eclampsia remains under investigation. Despite the many studies and meta-analyses on the subject, there is no definitive consensus or recommendation regarding the best anti-hypertensive for controlling a hypertensive crisis preoperatively . A CochrThis was a prospective observational study conducted in the Department of Anaesthesiology of a tertiary care hospital from November 2016 to March 2018, after approval by the Institutional Ethical Committee. The study was registered at the Clinical Trials Registry India (CTRI/2018/05/013709). We studied 167 pregnant patients with hypertensive crises scheduled for emergency CD under spinal or general anesthesia. After a detailed pre-anesthetic check-up and a written informed consent, all hypertensive pregnant patients aged 21-45 years with single or multiple pregnancies who had a BP ≥ 160/110 with a gestational age >24 weeks and were given anti-hypertensive agents intravenously prior to the administration of anesthesia were included in the study.Demographic data, including age, weight, parity, and gestational age, were noted. The patient's attendance at the antenatal clinic (booked/unbooked) and any anti-hypertensives that were started in the antenatal period were noted. The blood pressure at which the patient presented for labor and delivery and the blood pressure at which the patient was taken for CD were noted. Anti-hypertensive drugs administered included hydralazine and labetalol as per the availability and choice of the attending anesthesiologist in the pre-operative room. Reconstitution of IV hydralazine was done by dissolving hydralazine 20 mg powder in 2 ml of sodium chloride 0.9% in the vial, then it was further diluted with 18 ml of sodium chloride 0.9% to give a final concentration of 1 mg/ml. Labetalol did not require reconstitution as it is available in ampoules of 4 ml, each milliliter containing 5 mg. Hydralazine (5 mg) was given IV over two minutes. After 20 minutes, BP was measured, and if SBP persisted ≥160 mmHg or/and if DBP ≥110 mmHg, 10 mg IV was repeated. The BP was measured again after 20 minutes. If BP was still above the desired limit, another 10 mg was administered, and if after 20 minutes BP was still uncontrolled, then the drug was changed to labetalol. Labetalol 20 mg was given IV initially over two minutes. After 10 minutes, the BP was measured, and if SBP persisted ≥160 mmHg or/and if DBP ≥110 mmHg, the dose was doubled (40 mg). If the BP was not controlled with this second IV dose, the next dose of 80 mg was given over two minutes. This 80-mg dose was repeated if adequate control of BP was not achieved . If the BP was still not controlled, then the drug was changed to hydralazine. Magnesium sulfate was given to parturients in both groups for seizure prophylaxis.The primary objective was the time taken to reach adequate control of BP (SBP 140-150 mmHg and/or DBP 90-100 mmHg) with intravenously used anti-hypertensive drugs  in patients with hypertensive disorders of pregnancy undergoing CD. The secondary objectives were to study the efficacy (number of doses required for adequate control), the number of patients who achieved adequate control of BP with each drug, the rate of persistent hypertension (requirement of changing anti-hypertensive medications), adverse effects, and the maternal and fetal outcomes with both drugs.These patients were monitored for the control of BP (every 10 minutes) till they were taken up for CD. The choice of anesthesia and intraoperative BP were noted. Postoperatively, the patient was followed six hours a day for 24 hours, and a note was made of persistent hypertension and the drugs administered for the same.The estimated sample size was based on the primary objective of the time taken to achieve the target BP. We defined a relevant difference of 10 minutes in the mean time between the two groups. Thus, with the sample size of at least 63 patients per group, there was 80% power with an effective size of 0.50 at an alpha of 0.05 to detect a difference of 0.05 between the two groups. Assuming a 20% loss in sample processing, at least 75 patients in each group were required.Statistical analysis was performed by the Statistical Package for Social Sciences program for Windows, version 17.0 . Normally distributed continuous variables were compared using the unpaired t-test, whereas the Mann-Whitney U test was used for those variables that were not normally distributed. Categorical variables were analyzed using either the chi-square test or Fisher’s exact test. A p-value < 0.05 was considered statistically significant.Out of the 167 patients enrolled, five patients underwent emergency CD in view of acute and severe fetal distress  without waiting for adequate control of BP and were excluded from the study. Therefore, a total of 162 patients were included, of whom 85 received labetalol (group L) and 77 received hydralazine (group H). The demographic data , and initial blood pressure) were comparable between the two groups . The DBP was 101.51 ± 9.84 mmHg and 100.92 ± 11.40 mmHg in the hydralazine and labetalol groups, respectively . Intraoperative mean SBP recordings in group L were significantly higher than those in group H at 10, 20, and 30 minutes  and were comparable at 40, 50, and 60 minutes. Intraoperative mean DBP recordings were comparable between the two groups at all time points. The requirement for intraoperative anti-hypertensive medications was also comparable in both groups. Nine patients in group H required additional anti-hypertensive  and 11 patients in group L required additional anti-hypertensive  for BP control intraoperatively prior to CD, even when they achieved adequate control of BP preoperatively . Postoperative mean SBP and DBP were comparable at 0, 6, 12, 18, and 24 hours. Patients who required postoperative control of BP were significantly more common in group L as compared to group H . Therefore, we can recommend that if a patient develops a hypertensive crisis and is already on oral labetalol, she should be administered hydralazine intravenously for the preoperative control of BP and not labetalol. Despite an extensive literature search, we were unable to find any published data citing the effect of oral labetalol on the control of preoperative BP with IV anti-hypertensives.Seven of the 20 patients who required intraoperative anti-hypertensive therapy had received GA, and 13 had received SA. Hence, the requirement for intraoperative anti-hypertensive therapy depends on the disease process itself and not on the technique of anesthesia. After the administration of SA, although there was a sympathetic blockade, an elevated BP was still seen, probably due to the chemical and humoral mediators that circulate in the blood of a hypertensive parturient. We were unable to compare these results with any other published literature.The incidence of fetal bradycardia was higher in the labetalol group. Fetal bradycardia can be a side effect of the drug itself or can result from other causes, such as fetal distress and meconium staining of liquor, the incidence of which was similar in both groups, hence the bradycardia can be attributed to labetalol. The meta-analysis by Magee et al.  reportedMaternal hypotension was significantly higher in the labetalol group, probably a side effect of the drug itself and not due to any other cause such as blood loss or hypovolemia. Also, all patients were preloaded equally with 1 liter of crystalloid, and still more patients in the labetalol group developed hypotension. Intraoperative hypotension was managed with an injection of mephentermine 6 mg given intravenously (maximum dose: 30 mg). Intraoperative fluid management was done according to the fluid deficit, maintenance fluid requirements, and surgical losses. Care was taken not to overload the patient, as hypertensive pregnant patients are known to have leaky capillaries. The incidence of nausea was significantly higher in the hydralazine group. The majority of other studies have quoted an equal incidence of nausea with both hydralazine and labetalol, probably because nausea is a multi-factorial symptom and its occurrence can hardly be attributed to a single cause alone ,13,16,17The outcomes (comparable in both groups) and complications cannot be attributed to one specific anti-hypertensive but are largely the result of the disease process itself. There is hardly any published data that compare the postoperative maternal outcome or rate of ICU admission after CDs in patients receiving hydralazine or labetalol as anti-hypertensives. Postoperative control of BP was better achieved in patients who received IV hydralazine in the preoperative period as compared to those who received IV labetalol.Our study has some limitations. It is an observational study, so there is a lack of precision as compared to a randomized control trial, and there is a probability of selection bias. The validity, both external and internal, may be compromised. Blood pressure recordings may be affected by pain due to uterine contractions prior to the administration of spinal anesthesia.IV hydralazine is the anti-hypertensive agent of choice for preoperative BP control in patients with hypertensive disorders of pregnancy undergoing CD as it is more efficacious, produces adequate control of BP in a higher number of patients, has a lower incidence of persistent hypertension, maternal hypotension, and fetal bradycardia as compared to IV labetalol, and with its use, the number of patients requiring anti-hypertensive agents in the postoperative period is reduced. Both fetal and maternal outcomes are comparable. Hypertensive pregnant patients who undergo emergency CD in view of fetal bradycardia should not be given intravenous labetalol for the control of BP preoperatively. Patients who were receiving tablet labetalol for the control of BP in the antenatal period should not be given IV labetalol for the control of BP preoperatively when scheduled for an emergency CD. However, more patients need to be studied to corroborate our findings.


Further studies are needed to expand the evidence for the association of rivaroxaban with a lower risk of adverse renal outcomes in patients with atrial fibrillation (AF) as compared with warfarin, especially in Asians.To determine whether there are differences in adverse renal outcomes between rivaroxaban and warfarin-treated AF patients.2 at follow-up measurement, starting dialysis, or having kidney transplantation, ≥ 30% decline in eGFR, doubling of serum creatinine level, and acute kidney injury (AKI) were evaluated. The two groups were compared using Cox proportional hazards regression in the weighted population.Using the Korean nationwide claims database partly linked to laboratory results, patients with AF who initiated warfarin or rivaroxaban from 1 January 2014 to 31 December 2017 were identified. Inverse probability of treatment weighting (IPTW) was used to balance the baseline characteristics of the two groups. The primary outcome (kidney failure) was defined as the need for maintenance dialysis or having kidney transplantation. For the exploratory analysis in a subset of patients with baseline and follow-up laboratory results, the composite of renal outcomes, including estimated glomerular filtration rate (eGFR) lower than 15 ml/min/1.73 m2DS2-VASc score was 3.9 in both groups. During a median follow-up of 0.93 (interquartile ranges 0.23–2.10) years, weighted incidence rates of kidney failure for warfarin and rivaroxaban were 0.83 and 0.32 per 100 person-years, respectively. Compared with the warfarin group, the rivaroxaban group was associated with a lower risk of kidney failure . In patients with preexisting chronic kidney disease or eGFR ≤ 60 ml/min/1.73 m2, rivaroxaban was more beneficial than warfarin in reducing the risk of kidney failure. For the composite of five renal outcomes in the exploratory analysis, the rivaroxaban group showed a lower risk than warfarin .We identified 30,933 warfarin users and 17,013 rivaroxaban users (51% of low dose rivaroxaban). After IPTW, the mean age was 70 years, and the mean CHARivaroxaban was associated with lower risks of renal adverse outcomes than warfarin in Korean patients with AF. Atrial fibrillation (AF) has been related to an increased risk of chronic kidney disease (CKD) later in life . For sevSince the introduction of non-vitamin K antagonist oral anticoagulants (NOACs), there has been some evidence that NOACs might be associated with improved renal function preservation compared with warfarin , 5. AccoRenal function deterioration is widespread in AF patients treated with OAC . As decrThis study aims to determine whether there are differences in adverse renal outcomes between rivaroxaban and warfarin-treated AF patients utilizing a nationwide population-based study in South Korea.http://nhiss.nhis.or.kr/bd/ab/bada000eng.do). After permission to use the data was obtained, the analysis was performed at the Korean NHIS Big Data Center, Seoul, Republic of Korea.This retrospective observational nationwide population-based cohort study was conducted using administrative claims data from the Korean National Health Insurance Service (NHIS) and the linked health check-up database of the National Health Insurance Corporation (NHIC) , 15. TheThe study period was from 1 January 2013 to 31 December 2018. The study’s enrollment period ran from 1 January 2014 to 31 December 2017, to allow for at least a 12-month follow-up period. Study enrollment flow is presented in The primary analysis included all eligible patients. Additionally, we designed the exploratory analysis to assess renal outcomes estimated by laboratory data, including a subset of patients who received at least two health examinations during the study period. These patients had baseline and follow-up eGFR measurements. As a baseline eGFR, we collected the results of the health examination performed within 2-year from the index date. Among patients with a baseline eGFR value, we included patients with at least one follow-up health examination data during follow-up.2DS2-VASc score, Charlson Comorbidity Index (CCI), and concomitant use of antiplatelet agents were evaluated as covariates. The operational definitions of co-morbidities were based on diagnostic codes, drug dispensing records, and inpatient/outpatient hospital visits within 3 years prior to the index date. Complete definitions of each covariate are presented in Age, sex, co-morbidities including hypertension, diabetes, dyslipidemia, heart failure, prior stroke, prior myocardial infarction, peripheral artery disease, chronic kidney disease, chronic obstructive pulmonary disease (COPD), and cancer, CHA2), serum creatinine (mg/dL) and eGFR (mL/min/1.73 m2) were collected. eGFR was calculated by a creatinine-based equation used from Modification of Diet in Renal Disease. In addition, smoking status , alcohol consumption , and physical activity were also evaluated from the self-reported questionnaires of health examination. Regular exercise was defined as performing moderate-intensity exercise ≥ 5 times per week or vigorous-intensity exercise ≥ 3 times per week ., 18.5, 12 at follow-up measurement, [2] starting dialysis or having kidney transplantation, [3] ≥ 30% decline in eGFR, [4] doubling of serum creatinine level, and [5] AKI . The [5] AKI . The comPatients were described at treatment initiation in terms of demographic and clinical variables. Continuous variables are presented as means and standard deviations or medians and interquartile ranges (IQR). The numbers and proportions of patients in each category are presented for categorical variables. Person-years of follow-up were calculated from the index date to the outcome event of interest, discontinuation of the index treatment, death, or the end of the study period, whichever comes first. Incidence rates were calculated as the number of events over the observed person-time and presented as per 100 person-years.2DS2-VASc score, Charlson Comorbidity Index, and concomitant medication. For the exploratory analysis, health examination variables such as body weight, body mass index (BMI), eGFR, smoking, alcohol consumption, and physical activity were additionally included for PS calculation. Detailed methods of IPTW are described in We used the propensity score (PS) methods to compare the rivaroxaban and warfarin groups . We utilAll statistical analyses were performed using SAS 9.3 .2DS2-VASc score  and Charlson Comorbidity Index . Among patients with baseline eGFR measurements, subgroup analyses were performed for eGFR ranges (> 60 and ≤ 60 ml/min/1.73 m2). Subgroup analyses were performed using a multivariable Cox proportional hazards regression model. The variables used in the multivariable Cox analysis were identical to those used in the PS calculation for the main analysis set. Tests for interaction were conducted to evaluate statistically significant (p < 0.1) subgroup differences in treatment.In the main analysis set, for the primary outcome, subgroup analyses were performed for age strata , sex, hypertension, diabetes, heart failure, CKD (defined by diagnostic codes), CHA2DS2-VASc score and CCI in the final multivariable Cox analysis, there is a possibility of model overfitting. Therefore, we conducted a sensitivity analysis excluding the CHA2DS2-VASc score, CCI, or both of these in the final model. Also, we performed a competing risk analysis with the Fine-Gray methods as a sensitivity analysis  approach, which was not censoring patients at discontinuation or switching the index treatment), [2] multivariable Cox proportional hazards regression models in the study population before IPTW following the on-treatment approach, [3] multivariable Cox analysis following the ITT approach, [4] 5% trimmed IPTW following the on-treatment approach, [5] 5% trimmed IPTW following the ITT approach, [6] a sensitivity analysis among patients with a 6-month or longer follow-up period to evaluate whether the main results are consistent in those who had neither drug discontinuation nor any renal outcome during the first 6 months, [7] a sensitivity analysis restricting the follow-up within 12 months, and [8] an analysis in the subset of patients with baseline eGFR measurements. The sensitivity analyses of  were performed using a multivariable Cox proportional hazards regression model, and the variables used in the multivariable Cox analysis were identical to those used in the PS calculation for the main analysis set. For [8], baseline eGFR values were additionally adjusted. In addition, although we included the CHAanalysis .2DS2-VASc score 3.9 ± 1.9), with 30,933 patients taking warfarin and 17,013 taking rivaroxaban. 2DS2-VASc score than the warfarin group. Co-morbidities such as hypertension, diabetes, dyslipidemia, heart failure, peripheral artery disease, and cancer were more common in the rivaroxaban group. In contrast, prior stroke, prior myocardial infarction, chronic kidney disease, and chronic obstructive pulmonary disease were more prevalent in the warfarin group. Antiplatelet co-use was more common in the warfarin group than in the rivaroxaban group. In the rivaroxaban group, standard dose rivaroxaban (20 mg once daily) was prescribed to 49% of patients, whereas low-dose rivaroxaban (15 mg once daily) was prescribed to 51%.This study comprised a total of 47,946 individuals . In the main analysis set, a median follow-up duration was 0.93 (IQR 0.23–2.10) years. Rivaroxaban group showed longer median follow-up duration than warfarin group .For the primary outcome we performed various sensitivity analyses that demonstrated results consistent with the main analysis. Rivaroxaban was associated with significant reductions in the risk for kidney failure in all analyses . The resp for interaction < 0.001). There was also a strong trend towards a reduction in the risk of kidney failure in patients with CKD defined as eGFR less than 60 ml/min/1.73 m2, compared with those with an eGFR greater than 60 ml/min/1.73 m2.The benefit of rivaroxaban compared with warfarin on the risk of kidney failure was consistently observed across almost all of the examined subgroups . However2 in the two groups (ASD < 0.001). The duration from baseline eGFR to index date and baseline eGFR to follow-up eGFR of the two groups did not show statistically significant differences.Among the total study population, 11,210 (23.4%) patients were included in the exploratory analysis. Baseline characteristics of the total population, warfarin, and rivaroxaban group are presented in 2 at follow-up measurement, 30% decline in eGFR, and incidence of AKI, respectively. Although there was no statistically significant difference in the risk of serum creatinine doubling, the rivaroxaban group had a lower chance than the warfarin group. During the follow-up period, none of the patients in this exploratory analysis started dialysis or had kidney transplantation. For the composite of five renal outcomes, the rivaroxaban group showed a lower risk than warfarin  years, five renal outcomes and the composite of renal outcomes were evaluated in the two groups. Weighted event numbers, incidence rates, and HRs are shown in In this large-scale observational cohort, we observed very consistent findings that rivaroxaban was associated with a lower risk of renal adverse outcomes than warfarin in Korean patients with AF. Also, consistently with the general consensus, we confirmed that rivaroxaban was associated with a lower risk of ischemic stroke, intracranial hemorrhage, and all-cause death than warfarin. The effect of rivaroxaban on renal preservation was more accentuated in patients with underlying renal function impairment. The strength of this study included a large number of patients with AF treated in diverse clinical practice settings who had linked insurance claims and laboratory results. Also, this analysis allowed us to examine multiple renal outcomes to evaluate the consistency of results across a variety of renal outcomes.Patients with AF should be aware of the potential deterioration in renal function. Renal impairment puts individuals with AF at greater risk of thromboembolism and bleeding . Also, tIn previous studies, including three NOACs , the results were slightly different among studies , 9, 10. 2 showed greater relative risk reduction with rivaroxaban than warfarin. Patients who are more vulnerable to the risk of kidney failure might get more benefit from rivaroxaban’s kidney protection effect. Kidney failure due to acute tubular injury with microhemorrhage might be more critical in patients with a smaller reservoir because of underlying renal impairment. This finding was consistently observed in previous studies , missing data, miscoding, or tactical coding issues. Second, the application of both on-treatment and ITT analysis in non-randomized studies has different limitations as follows: an on-treatment method leads to a loss of information on the reasons for treatment discontinuation, while an ITT approach would not reflect changes on treatments affecting the primary outcome. In our study, the primary purpose of this study was to compare warfarin and rivaroxaban for the risk of kidney failure in anticoagulated patients with AF. In real-world clinical practice, many patients changed their OAC agents from warfarin to NOAC . The cliIn Korean patients with AF, rivaroxaban was associated with a lower risk of renal adverse outcomes than warfarin. The renal preservation effect of rivaroxaban compared with warfarin was particularly pronounced in patients with preexisting renal impairment. Rivaroxaban should be explored for anticoagulation therapy in AF patients at high risk of renal function decline.http://nhiss.nhis.or.kr/bd/ab/bada000eng.do.Publicly available datasets were analyzed in this study. This data can be found at: Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.S-RL contributed to the design of the study, interpretation of the results and prepared the manuscript. E-KC, SO, KA, and GL contributed to the design of the study, interpretation of the results and critical revision of the manuscript. S-HP and K-DH contributed to the analysis of data and interpretation of results. All authors contributed to the article and approved the submitted version.E-KC: Research grants or speaking fees from Bayer, Biosense Webster, BMS/Pfizer, Chong Kun Dang, Daiichi Sankyo, Dreamtech Co., Ltd., Jeil Pharmaceutical Co. Ltd., Medtronic, Samjinpharm, Seers Technology, and Skylabs. GL: Consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, and Daiichi Sankyo. No fees are received personally. KA was employed by Bayer AG. This study was funded by Bayer AG. Bayer AG contributed to the design and conduct of the study; management and interpretation of the data; preparation, review, and approval of the manuscript; and the decision to submit the manuscript for publication.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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