Among the independent variables predictors of surgical success, the presence of Charge syndrome and rhinopharyngeal stenosis demonstrated higher risks for surgical revision . On the contrary, the hypoplastic inferior turbinate and bilateral C.C.A. showed a lower risk for severe restenosis by a higher endoscopic surgical space and creating a single larger opening . Conclusion: Several independent variables could influence the surgical success after C.C.A. endoscopic repair; however, more high-quality evidence is needed to generate an effective predictive model.Background: To assess the long-term outcomes and independent predictors of surgical success of a one-stage minimally invasive surgical procedure for congenital choanal atresia (C.C.A.). Methods: a retrospective multicentric study was conducted between 2010 and 2022. An endonasal endoscopic approach was performed in 38 unilateral or bilateral C.C.A. children. All the patients were clinically and radiologically assessed and followed for at least 2 years. Seven outcome measures were applied. Consequently, surgical success was correlated with all the independent variables reported. Results: 18/38 (47.36%) patients presented normal postoperative healing, 8/38 (21.05) had moderate restenosis (<50%), while 12/38 (31.57%) cases were severe (>50%), requiring a surgical revision. No statistical significance was found for average hospital stay between stenosis >50% and <50% patients ( Congenital choanal atresia (C.C.A.) is a rare craniofacial abnormality (1:5000/1:8000 new-borns), characterized in 71% of subjects by mixed bony and membranous obstructions while in 29% of cases, only bone is found . FrequenNevertheless, often the technique requires revision surgery, mainly due to restenosis from scar or granulation tissue formation. In this regard, nasal stenting or the topical application of mitomycin is still controversial in the literature ,13,14,15A retrospective multicentric study was performed at our ear, nose, and throat (E.N.T.) Units from 2010 to 2022. We followed the Strengthening the Reporting of Observational Studies in Epidemiology . We initAll the subjects were children reporting breathing or breast-suction disorders. Patients with unilateral choanal atresia were subjected to clinical assessment for chronic foul-smelling and unilateral rhinorrhea. On the contrary, subjects with bilateral C.C.A. presented respiratory distress at birth, intermittent cyanosis, and difficulties relieved once crying. These patients were preventively subjected to oral feeding through an orogastric tube.After failure to pass a catheter through the nasal cavity into the oropharynx, the diagnosis of choanal atresia was thus confirmed via clinical and endoscopic nasal assessment. Preoperative high-resolution spiral C.T. scans were performed through the bone algorithm, orienting perpendicularly to the hard palate plane. A C.T. section parallel to the posterior hard palate at the level of the pterygoid plates was obtained in all children. The sections were 0.5 to 1 mm thick. The width of the vomer at the posterior end and the width of the airspace of the choanae or membranous atresia were measured based on the measurement of the dimension from the lateral wall of the nasal cavity to the edge of the vomer of the posterior end.Exclusion criteria from the study were partial or incomplete data recorded for C.C.A. and subjects lost to follow-up assessment. Dependent variables such as age at diagnosis, gender, atretic plate type, side of atresia, unilateral vs. bilateral, locoregional associated disorders such as turbinate hypoplasia, rhynopharyngeal web and stenosis, surgical details, postoperative outcomes, surgical complications, recurrence rate as severe restenosis (>50%), and need for revision surgery were evaluated ,17.All the endoscopic surgical procedures were performed under general anesthesia, using 0° endoscopes  connected to a high-definition system . We performed a mucosal decongestion using cotton pledgets soaked through a saline solution with xylometazoline and lidocaine (5 mL and 2 mL/10 mL). Two different surgeons performed the procedures.Since bilateral forms lead to neonatal respiratory distress, management has included the use of an oropharingeal (Guedel type) or orotracheal intubation. In all cases of single- or bilateral C.C.A., we used the mucoperiosteal flaps technique, consisting of an incision and elevation of the flap at the nasal mucosa conjunction between the vomer and the atretic plate. The posterior nasopharynx was protected during the maneuver with cotton inserted through the contralateral choana or oropharynx of the patient to avoid possible subperiosteal detachment of the posterior cul-de-sac during perforation of the atresal wall. The atretic plate portion was perforated with a skeeter at the inferior-posterior portion. Thus, the enlargement of the inferomedial atretic portion was performed with the microdebrider for the fibrous component , while for the bone frame with a bite forceps and a drill . Enlargement of the bony structure was continued with the drill up to the roof of the nasopharynx and the sphenoidal rostrum at the top while laterally bringing the pterygopalatine block at the level of the lateral nasopharyngeal wall; however, careful attention was paid to the area of the sphenopalatine foramen to avoid injuring the sphenopalatine artery. If necessary, we introduced the drill into the contralateral nasal cavity to improve surgical visual control. Consequently, we carried out the procedure using retrograde forceps or eventually with the drill or the microdebrider. Subsequently, the mucoperiosteal flap was used to cover the lateral wall of the nasal cavity, the pterygoid plates, and the medial side of the neochoana and septum.In the presence of rhinopharyngeal stenosis or web under endoscopic visualization, a flap knife was used to cut the scarred mucosa on the posterior septum, on the posterior end of the inferior or middle turbinate, then excised with a shaver and Blakesley’s forceps.Stenting was routinely performed only after surgical correction of atresia for bilateral C.C.A. or revision surgery due to restenosis.In contrast, isolated unilateral C.A.A.s did not undergo routine stenting. In unilateral patients, we placed a silicone fashioned stent  (4 to 6 weeks) on the affected side and attached it to the columella with a suture. Bilateral C.C.A. patients, on the other hand, were treated with a modified endotracheal tube (4 to 6 weeks) with four holes in the back  of the neochoana, allowing both breathing and saline irrigation at follow-up.Nasal stenting was maintained until it failed to remain pervious under surrounding pressure, reducing the risk of restenosis or when an increased risk of infection, granulations formation, excessive nasal crusts, and persistent nasal discharge was detected. Moreover, the time was shorter in unilateral choanal atresia, fixed to the columella, and longer in bony plates, bilateral type, or revision surgeries.Postoperative pediatric management included continuous positive airway pressure (CPAP) up to 48 h. Oral feeding was administered in all patients after complete wakefulness, while an intraoral orogastric feeding tube was placed in case of overt dysphagia. Each patient was assessed according to age-related pain scales and subjected to subsequent pain therapy with acetaminophen according to guidelines . Proton-t-test was performed for the normally distributed values, while the Mann–Whitney U test was performed for the non-normally distributed values. The chi-square test was performed to test the observed and expected data difference. The outcome odds were calculated and modeled as a combination of the predictor variables. Results were reported as odds ratios (OR) with 95% confidence intervals (CI).Standard descriptive statistics were used, reporting mean and standard deviation for continuous variables and percentages for categorical ones. The independent Consequently, a Forest Plot diagram with all independent variables was generated. Due to the small sample size, the Jaccard coefficient between the dichotomous variables was calculated to observe the similarity between variables. The Jaccard coefficient J measures the similarity between sets of finite samples on binary (and non-binary) variables. It is defined as the size of the intersection divided by the size of the union of the sample sets:p < 0.05 was deemed to be statistically significant. All analyses were performed using the Social Sciences Statistical Program . The violin plots were performed using GraphPad Prism software . Violin plots represented median as black bars, quartiles with upper and lower borders in the white box, while the density estimation was expressed as more concentrated data with the fatter the image.It is observed that values of J < 0.5 between outcomes and variables correspond to the protective factors (OR < 1), and values greater than 0.5 (greater similarity) represent the risk factors (OR > 1). The Kruskal–Wallis H test was used to assess subgroup differences in non-parametric features. A value of p = 0.134).A total of 38 patients were included in the analysis, of which 24/38 (63.15%) isolated unilateral C.C.A. while 14/38 (36.84%) had bilateral C.C.A. . The meap = 0.804). A nonstatistical difference was also recorded for limited scar formation–partial restenosis (<50%), found in 8/38 (20%) subjects, including 4 (12%) bilateral and 4 (8%) unilateral (p = 0.385). In addition, severe restenosis (>50%) was reported in 12 (8%) cases, including 3 (4%) bilateral and 9 (4%) unilateral (p = 0.303), finally requiring surgical revision.Postoperative healing was overall normal at follow-up in 18/38 (68%) patients, including 7/38 (24%) bilateral and 11/37 (44%) unilateral C.C.A. cases . Pain killer usage was required for an average of 2.2 ± 1.05, with significantly higher needs for bilateral C.C.A. (2.9 ± 1.13 days) than unilateral (1.73 ± 0.67) (p = 0.003). A significantly higher hospital stay was found for subjects with unilateral than bilateral C.C.A. . In subgroups analysis between surgical revision patients, no statistical significance was reported for average hospital stay between stenosis >50% and <50% patients (p = 0.802) and postoperative pain (p = 0.075), while the surgical restenosis group demonstrated a higher delay in starting breast suction (p < 0.001). In the Kruskal–Wallis H test for healing subtypes, the patients reported no statistically significant differences in hospital stay length (p = 0.345) (p = 0.256) (p = 0.001)  a and pos= 0.256) b, while = 0.001) c.Among the independent variables’ predictors of surgical success, the presence of Charge syndrome and rhinopharyngeal stenosis demonstrated the higher risks for surgical revision  in the sample .Conversely, an associated hypoplastic inferior turbinate and bilateral C.C.A. showed a lower risk for severe restenosis and surgical revision need .A high correlation expressed with the Jaccard similarity coefficient was found between the surgical revision and the presence of variables such as the presence of Charge syndrome (J = 0.71), rhinopharyngeal stenosis (J = 0.68), osseous C.C.A. (J = 0.63), and Male gender (J = 0.63) .Congenital choanal atresia is a rare craniofacial anomaly developing from a unilateral or bilateral membranous or bony obstruction malformation of the choana ,5. The mp < 0.001 and p = 0.049, respectively) while bilateral AC (p = 0.085) showed slight but not statistically significant correlations [Different preoperative parameters have been analyzed in the literature in order to predict the outcome of surgical treatment in C.C.A. Velegrakis et al., in a 28-year retrospective study on outcomes of endonasal surgery for C.C.A., associated the presence of purely bony atretic plaque and CHARGE syndrome significantly associated with disease recurrence  with a high similarity index (J = 0.55).p < 0.001). Instead, the hospital stay difference was not significant in the subgroup comparison (p > 0.05) (p < 0.001). Instead, no significant correlation was demonstrated between healing grade and pain killer usage and hospital stay (p > 0.05 for both). The rarity of the disease has resulted in a small cohort of patients, although they have been enrolled for many years and in different hospital centers. The small sample reduced the statistical value of the risk factors analyzed. Furthermore, given that the technique used did not include two homogeneous groups treated with or without stents, the results should still be considered cautiously.On the other hand, bilateral C.C.A. was also a protective factor for restenosis , with a low similarity index (J = 0.47). However, it can be one of the signs of some malformation syndromes, the most common of which is CHARGE syndrome  . In 2008 > 0.05) b. Also, Current surgical approaches for C.C.A. should minimize the tendency for restenosis, shortening hospital stay, accelerating recovery and reducing postoperative pain. Several independent variables could influence surgical success after endoscopic repair of C.C.A., allowing the surgeon to choose the right surgical approach and appropriate postoperative follow-up. However, further high-quality evidence is needed to generate an effective predictive model.


Background: The study concerning the influence of Conbercept, which is an anti-Vascular endothelial growth factor (VEGF) agent, in intraocular pressure (IOP) spike is limited and warrants further investigation. The current study aimed to investigate the changes of intraocular pressure after intravitreal injection (IVI) of Conbercept and evaluate the risk factors associated with intraocular pressure spikes.Methods: Patients with diabetic macular edema receiving intravitreal injection of 0.05 ml (0.5 mg) Conbercept were involved in the study. All patients underwent slit lamp examination to determine the status of phakia/pseudophakia. The axial length was measured using IOL Master 500 before intravitreal injection. Patients underwent a Conbercept intravitreal injection with a 30-gauge needle in a standard fashion. The intraocular pressure was measured 2 min before injection, and 2, 10, 30 min, 1, 2, 5, 24 h after injection using a rebound tonometer. The changes of intraocular pressure and the relevant risk factors were evaluated. Patients were subdivided into phakic group and pseudophakic group to analyze the effect of lens status on intraocular pressure changes.Results: Forty patients with a mean age of 62.48 ± 12.22 years were included in the study. The mean intraocular pressure values at baseline and 2, 10, 30 min, 1, 2, 5, 24 h after injection were 14.81 ± 3.13 mmHg, 26.80 ± 9.43 mmHg, 18.76 ± 6.16 mmHg, 16.54 ± 5.94 mmHg, 15.64 ± 3.75 mmHg, 14.46 ± 3.03 mmHg, 14.10 ± 1.88 mmHg, 14.23 ± 2.71 mmHg respectively. The intraocular pressure after injection for 2, 10 min was significantly higher than baseline . The intraocular pressure between baseline and post-injection for 30 min or beyond were comparable . No significant difference was found between the phakic group and pseudophakic group (p = 0.422). The changes of intraocular pressure were positively correlated with age , but negatively with axial length .Conclusion: intravitreal injection of Conbercept may cause rapid spike of intraocular pressure, but is safe with respect to short-term changes. The intraocular pressure in patients with older age and shorter axial length is more likely to be higher after intravitreal injection. Diabetic macular edema (DME) is characterized by accumulation of exudative fluid at the macula and remains a major cause of visual impairment in patients with diabetic retinopathy . VasculaDespite the therapeutic advances of the anti-VEGF agents, repeated administrations are needed to achieve good anatomical and functional improvements. The accompanying short-term and long-term complications of repeated IVI like elevated IOP have been arousing our concern. IVI leads to sudden increase of volume in the vitreous cavity and subsequently increase the IOP. The course of IOP changes needs to be closely monitored and the safety outcome should be evaluated. Previous studies have found that the increased IOP immediately following IVI was volume-driven and generally transient and well tolerated . HoweverNon-contact tonometer (NCT) was used in the majority of previous study focusing on the current issue. However, NCT is not that reliable in patients with elevated IOP, because comparative studies have shown lower correlations with Goldmann applanation tonometer (GAT) in higher IOP ranges . Study aThis prospective observational study included consecutive patients receiving IVI of Conbercept at Guangdong Provincial People’s Hospital, Guangzhou, China, from October 2018 to June 2019. The study abided by the principles of the Declaration of Helsinki and was approved by the Research Ethics Committee of the Guangdong Provincial People’s Hospital . Informed consent was obtained from every subject before enrollment. We included DME patients who were older than 18-year old and able to understand and sign the consent form, and the initial IOP was less than 21 mmHg. Exclusion criteria were any kind of glaucoma or suspected glaucoma (IOP > 21 mmHg and/or cup to disc ratio >0.5), a history of intraocular surgery during the past 3 months, current use of steroid eye drops or IOP-lowering drops and any ocular surface disease precluding a reliable IOP measurement.All subjects underwent a complete ophthalmologic examination before IVI, including best-corrected VA (BCVA), slit-lamp examination, axial length measurement and IOP evaluation. The slit lamp exam was used to determine the status of phakia/pseudophakia and cornea. Axial length was measured with IOL Master 500 optical biometer . ICare Pro was used to measure the IOP. It is a portable device based on the induction of rebound principle and the detailed information was reported by previous studies . In a sip-value less than 0.05 was considered as statistically significant.Data analyses were performed using SPSS software Version 26.0 . Demographic and outcome data were summarized by frequency for categorical variables and mean ± standard deviation (SD) for continuous variables. Normality of continuous variables was assessed by the Kolmogorov-Smirnov test. The changes of IOP were defined as the IOP after IVI minus the baseline IOP. To estimate mean changes in IOP, a linear mixed model for repeated measures was used, taking into account the correlations between individuals’ repeated measures over time. Least-squares means with 95% confidence intervals (CI) were reported, adjusting for gender, age, axial length and lens status. Furthermore, we conducted subgroup analyses for the changes in IOP after stratification by lens status. Pearson correlation coefficient was used to evaluate the linear correlation between the IOP changes in the initial 2 min and clinical parameters. A Forty eyes of 40 patients with DME were included in the study. The mean age was 62.48 ± 12.22 years (range: 39–88). There were 26 male and 14 female with a mean axial length of 23.20 ± 1.06 mm (range: 21.33–25.21 mm). Among them, 57.5% (23/40) patients were phakic and 42.5% (17/40) were pseudophakic. The patients were subdivided into phakic group and pseudophakic group according to the status of lens. The basic clinical characteristics and demographics of the patients were shown in p < 0.01). Since 30 min after IVI, no significant difference was observed in IOPs between each subsequent follow-up and the baseline value. The results remained consistent even after adjusting for gender, age, axial length and lens status (Dynamic changes in IOP were demonstrated in s status . Only thp = 0.422). The trend of IOP changes was similar between the two groups  on IOP, patients were subdivided into phakic group and pseudophakic group. The changes of IOP from baseline to 24 h in phakic group and pseodophakic group were comparable , but negatively with axial length . Their correlations were shown in Pearson correlation coefficient showed that the changes of IOP were positively correlated with age (In the current study, we investigated the changes of IOP after the injection of Conbercept. Previous studies focused on ranibizumab, aflibercept and bevacizumab had reported similar findings . To the Previous studies examining the short-term changes of IOP after IVI showed that the elevated IOP returned to normal level in most patients in around 30–60 min . We alsoWhether the status of lens affects the changes of IOP after IVI remains controversial. The IOP spike after IVI is more likely to be higher in older patient. The study reporting the relationship between age and IOP changes after IVI for anti-VEGF agents is limited. The reason why IOP spikes higher in older patients may relate to the rigidity of the eyes. On one hand, previous studies have shown that the sclera may become calcified in aged subjects and the rigidity was positively correlated with age . On the Apart from age, the IOP changes were also related to the axial length. Similar to the previous studies, we also found that axial length was negatively correlated to IOP changes after IVI in adults . On the The current study has several limitations. The study might be more convincible if the sample size is larger. It should be noted that the injected volume was manually calibrated as all similar clinical studies. All the calibration was finished and injected by the same experienced ophthalmologist in order to ensure the precision and equal amount of anti-VEGF agent among all patients. Besides, our study did not attempt to evaluate other ocular metrics like anterior chamber depth.In conclusion, our study shows that Conbercept IVI may cause a considerable transient IOP increase, and it has already been described with the three other anti-VEGF agents. Most eyes in our series achieved normalization of IOP within 30 min without needs for any immediate intervention, such as paracentesis. The IOP rise after Conbercept IVI was greater in patient with shorter axial length and older age. On the basis of these preliminary results, patients undergoing IVI of Conbercept should be carefully monitored for at least 30 min after IVI to assess IOP elevation and thus ensure adequate optic nerve head perfusion. Although IOP increase tend to normalize in most patients after 30 min, preventive paracentesis can be considered when IOP spikes after IVI are very high, especially in eyes with shorter axial lengths and older age.


A large proportion of infertile men do not receive a clear diagnosis, being considered as idiopathic or unexplained cases due to infertility diagnosis based on standard semen parameters. Particularly in unexplained cases, the search for new indicators seems mandatory to provide specific information. In the etiopathogenesis of male infertility oxidative stress displays important roles by negatively affecting sperm quality and function. In this study, performed in a population of 34 idiopathic infertile men and in 52 age-matched controls, redox parameters were assessed in blood, leukocytes, spermatozoa, and seminal fluid and related to semen parameters. The main findings indicate that blood oxidative stress markers reflect seminal oxidative stress. Interestingly, blood leukocyte ROS production was significantly correlated to sperm ROS production and to semen parameters. Overall, these results suggest the potential employ of blood redox markers as a relevant and adjunctive tool for sperm quality evaluation aimed to preconception care. It has been recently estimated that, globally, 8–12% of couples suffer from infertility, with the male factor being a primary or contributing cause in approximately 50% of couples. Male infertility is a complex multifactorial pathological condition comprising congenital, acquired, or idiopathic factors .In particular, the involvement of oxidative stress, a condition characterized by an imbalance between reactive oxygen species (ROS) production and antioxidant defense systems, has been repeatedly invoked in the etiopathogenesis of male infertility ,5,6,7,8,Excessive ROS production has been also suggested to affect essential metabolic/functional sperm cell processes  and to dCurrently, oxidative stress evaluation is being increasingly practiced due to the huge body of evidence suggesting its clinical utility  particulUnfortunately, guidelines on standardized reference values for both pathological ROS levels and total antioxidant capacity (TAC) in seminal fluid are still lacking ,33. In oThe study was performed in accordance with the Declaration of Helsinki and approved by the Ethical Review Board of the Careggi University Hospital (reference n. 10709 approved on 27 April 2017). The study sample included a total of 34 idiopathic infertile men (aged 34–56 years) without abnormal andrological findings and with abnormal semen parameters belonging to couples with fertile women who attended the IVF Center of the Careggi University Hospital  for IVF procedures (IVF or ICSI) and 52 men matched by age, recruited as control group belonging to couples with tubal factor female infertility, defined as normozoospermic according to the World Health Organization 2021 criteria . All participants gave written informed consent to use the remainder of their semen sample prior to inclusion in the study.6/mL), azoospermia or severe criptozoospermia, history of smoking (>5 years), excessive alcohol consumption (≥15 drinks per week), endocrine disorders, drug intake, and those with varicocele. Additionally, men with significant comorbidities, including cancer, diabetes, obesity, autoimmune disease, gastrointestinal disease, kidney disease, and lung disease, and men seropositive for HIV, HCV, HBsAg, CMV IgM were excluded from the study. Medical anamnesis and physical examination were performed on all patients.At the baseline visit, men were routinely screened for serology, according to WHO 2021 guidelines including HIV 1/2, hepatitis C virus antibody (HCVab), hepatitis B surface antigen (HbsAg), hepatitis B surface antibody (HbsAb), hepatitis B c antibody (HBcAb), Treponema Pallidum Hemagglutination and Venereal Disease Research Laboratories (TPHA-VDRL), Ab anti-Clamidya Trachomatis, CMV IgM and IgG. The hormonal panel, including follicle-stimulating hormone (FSH), luteinizing hormone (LH), total testosterone (TT), thyroid-stimulating hormone (TSH), and prolactin (PRL), was required. All patients and controls included in the study displayed normal levels of FSH, LH, TT, PRL, and TSH  The genetic evaluation was performed, including the karyotype with the examination of microdeletions for chromosome Y and mutation of cystic fibrosis transmembrane conductance regulator (CFTR) genes. All men performed a urine analysis and urethral swab to detect urinary tract infections. The exclusion criteria were leukocytospermia (defined as leukocyte concentration greater than 1 × 106 per ml), total sperm number (106 per ejaculate), vitality , progressive motility , non-progressive motility , immotile spermatozoa , total motility  and morphology . For the determination of anti-sperm antibodies in semen, the mixed antiglobulin reaction (MAR) test was used as described elsewhere [At baseline, semen analysis was completed by following the World Health Organization (WHO) guidelines for semen examination 2021  . Semen plsewhere . A MAR tg for 1 h at 4 °C to remove cellular debris and then assayed for oxidative stress parameters.For each patient, semen and peripheral blood samples were obtained. Semen samples were collected on site by masturbation after 2–5 days of sexual abstinence. The ejaculate was allowed to liquefy before measurement . Ejaculates were then examined with standard procedures according to 2021 WHO guidelines . Seminalg for 15 min at 4 °C), aliquots of sodium citrate plasma were used for experiments or stored at −80 °C for further analyses [Blood samples were collected in Vacutainer tubes containing 0.109 mol/L buffered trisodium citrate (1:10) or EDTA (0.17 mol/L). After centrifugation , the supernatant was discarded, and cells were washed twice in PBS. The evaluation of leukocyte intracellular ROS levels was performed by incubating cells with H2DCF-DA (2.5 µM)  in RPMI medium without serum and phenol red for 30 min at 37 °C [An amount of 100 µL of EDTA-anticoagulated blood samples was suspended in 2 mL of BD FACS Lysing Solution , gently mixed, and incubated at room temperature in the dark for 15 min. Next, cells were centrifuged (700× at 37 °C . After lg for 8 min at 20 °C), the supernatant was stocked at −80 °C for further redox analyses, while sperm cells were incubated with H2DCF-DA (2.5 µM)  for 30 min at 37 °C as previously described and then analyzed by FACSCanto flow cytometer .Spermatozoa intracellular ROS production was assessed using the same discussed method. Samples were centrifuged  was used as standard. Absorbance was measured at 586 nm in a Microplate Fluorometer (Biotek Synergy H1). Results were expressed in terms of MDA equivalent (nmol/mL).Lipid peroxidation was assessed in both blood and seminal plasma using ALDetect Lipid Peroxidation Assay Kit , designed to measure malondialdehyde (MDA) in combination with 4-hydroxyalkenals in methanesulfonic acid. Briefly, 200 µL of undiluted plasma sample or standard curve point were added to 650 µL of N-methyl-2-phenylindole prepared in a solution of acetonitrile/methanol (3:1). Immediately, 150 µL of methanesulfonic acid containing 34 uM Fe (III) were also added to each sample starting the reaction. Samples were incubated at 45 °C for 4 h, then centrifuged twice at 15,000× TAC value in blood and seminal plasma was estimated using ORAC  method. This assay is based on the intensity fluorescence decay of a fluorescent probe, fluorescein, consequent to its oxidation by free radical species , generated after the thermal decomposition of 2,2′-azobis(2-amidinopropane) dihydrochloride (AAPH) azo-compound. A fluorescein solution (6 nM) prepared daily from a 4 µM stock in 75 mM sodium phosphate buffer (pH 7.4), was used. Trolox , a water-soluble analog of E vitamin, was used as standard. An amount of 70 µL of each plasma sample (diluted 1:200 in sodium phosphate buffer) or standard curve point was pre-incubated in each well with 100 µL of fluorescein for 30 min at 37 °C and then 50 µL of AAPH solution  was added starting the reaction . FluoresAll the experiments were performed 3 times on the same sample, each one in triplicate. For each subject, normality of data distribution of the replicated measures was confirmed by the Shapiro–Wilk test; after assessing the low intra-experiment and inter-experiment variability and the reproducibility of measures , each value per subject was calculated as the overall mean of the means of the 3 experiments.For intra-subjects continuous data, normal distribution was checked using the Shapiro–Wilk test. As the normality assumption was not confirmed, continuous data were reported as median values and interquartile range (IQR) and compared between infertile patients and controls using the Mann–Whitney test for unpaired data. Categorial variables were instead reported as absolute frequencies and percentages and compared between infertile patients and controls using the Fisher exact test.To investigate the possible association between sperm and systemic redox state and sperm quality, linear regression models were fitted, separately in infertile patients and controls. In addition, multivariable regression models were fitted in infertile patients, to take into account the impact of age and smoking habit on these associations.p-value of <0.05 was considered statistically significant.All statistical analyses were performed using the software Graph Pad Prism 8 and Stata version 14. A The demographic and clinical characteristics of the 34 idiopathic infertile men and 52 age-matched normozoospermic controls are reported in Semen parameters of the study cohorts are summarized in As reported in We performed linear regression analyses to assess the impact of sperm oxidative stress on sperm function in the 34 infertile patients. As indicated in When we explored the possible relationship between systemic oxidative stress parameters and sperm dysfunction B–F, we fConversely, when only control subjects were considered , no signFinally, to take into account the possible confounding role of age and smoking, multivariable regression models were fitted in infertile patients to assess the relationship between sperm and plasma redox state and sperm quality . NotablyA growing body of research indicates a link between oxidative stress and male infertility. Although findings about the estimation of redox parameters—more commonly in seminal plasma and less frequently in serum of infertile patients—have been reported ,44, onlyIn this study, performed in a selected population of idiopathic infertile males, we found that blood redox status is significantly altered both in terms of plasma oxidative stress markers and, prominently, in terms of blood leukocyte ROS production.One of our main findings is that global blood redox status reflects seminal fluid redox status. In our opinion, this finding can be used as a potentially relevant adjunctive indicator for male infertility diagnosis and management particularly in the case of idiopathic male infertility. Indeed, despite the already reported association between altered sperm quality and semen oxidative damage, men are not usually screened for systemic redox status nor treated to correct a possible redox imbalance. It is well known that sperm function can be highly influenced by alteration in seminal plasma and sperm microenvironment, inducing chemical and structural cellular modifications and modulating sperm fertilization potential .It is well established that ROS are required in the male reproductive system for their sperm fertilization properties, but it has also been clearly shown that ROS overproduction may display deleterious effects on sperm homeostasis leading and/or contributing to male infertility ,49,50,51Data from the current literature do not establish if redox status alterations in infertile men reflect active ROS generation by spermatozoa and/or indicate a passive consequence of systemic oxidative stress secondary to lifestyle factors or concomitant habits or diseases : this is a key question that needs to be addressed.The systemic redox status alterations that we revealed in infertile patients can be attributed to different conditions: higher blood leukocyte ROS production, increased plasma lipid peroxidation and reduced plasma total antioxidant levels respect to healthy subjects. Moreover, increased ROS levels in sperm and increased oxidative stress biomarkers in the seminal fluid were also unveiled, indicating a generalized redox imbalance in infertile men.In line with previous studies suggesting the role of oxidative stress in sperm cell alterations ,47,52, sAgarwal and collaborators underlined the detrimental effects of ROS on sperm motility and morphology: in vitro experiments demonstrated that lipid aldehydes addiction to spermatozoa promoted loss of motility in human sperm cells . AccordiThe assessment of ROS production in human spermatozoa is particularly difficult due to the low levels of sperm-derived ROS compared with those originating from contaminating cell types, particularly neutrophils. This is the reason why flow cytometry techniques were used in our study. This methodology allows the operator to analyze exclusively the sperm population while any contaminating cells, such as precursor germ cells or leukocytes, can be carefully gated out. Moreover, thanks to the fluorometric probes, redox alterations can be significantly correlated to altered sperm function conferring a significant clinical value to this assay .In infertile patients, we found that blood leukocyte ROS production significantly correlated with sperm ROS production, seminal plasma oxidative stress markers, and semen parameters. Additionally, blood oxidative stress markers significantly and positively correlated with semen redox parameters , indicating that blood redox alterations reflect sperm dysfunctions in infertile men. In this regard, in agreement with our data, Benedetti and collaborators showed a significant correlation between blood/serum oxidative stress and semen oxidative status in infertile men. In particular, they demonstrated a significant correlation between serum TAC, seminal plasma TAC, and semen parameters .Although a beneficial influence has been generally observed for antioxidants in reversing ROS-induced spermatozoa dysfunction, blood/seminal fluid redox status (in particular ROS production assays) and the use of antioxidants are not routinely used in clinical practice. Indeed, several studies have shown conflicting results about the effects of antioxidants on male fertility ,59,60. IThe reports about the existing association between blood and semen oxidative stress are still limited and controversial, potentially due to different strategies and applied methodologies. Guz and co-workers observed no correlation between blood and semen oxidative status, suggesting the independence of semen redox homeostasis from systemic microenvironment and external factors .Despite the relevant results, some limitations are present in the present study: the study was conducted on a small cohort of patients, and our findings  need larger studies for validation. Additionally, the causal relationship between oxidative stress and infertility cannot be rigorously explored with this type of study, and temporal variations in redox state or fertility parameters were not explored.Among the strengths of our study, we want to underline that peripheral blood collection is easier, more practical, less invasive, and less susceptible to sampling inadequacy than semen collection. In addition, recent studies have argued that the lack of standardization in the way routine semen analyses are performed across clinics, often absent of appropriate quality control measures, may limit the accuracy of test interpretations . This caIn conclusion, our results indicate and confirm the main involvement of oxidative stress in sperm dysfunction, witness that systemic blood oxidative stress reflects semen oxidative status, and suggest blood leukocyte ROS estimation as a new potential and less invasive indicator for male preconception care, especially for idiopathic infertile patients before IVF treatments. Moreover, oxidative stress evaluation may be useful for monitoring new therapeutic approaches based on antioxidant supplementation in order to improve male infertility diagnosis and management.


We aimed to clarify the efficacy of dapagliflozin versus liraglutide in patients with overweight or obesity and type 2 diabetes mellitus (T2DM) at the beginning of the coronavirus disease 2019 (COVID-19) pandemic.  T2DM patients with overweight or obesity who visited the Metabolic Disease Management Center at Tianjin Fourth Central Hospital from October 2019 to January 2020 were recruited and randomised to receive dapagliflozin or liraglutide for 24 weeks. Changes in blood glucose and lipid levels, blood pressure, and body weight, as well as the occurrence of hypoglycaemia and other adverse events, were compared. p = 0.001) and from 3.21 ± 0.94 to 2.98 ± 0.89 mmol/L (p = 0.014), respectively, in the dapagliflozin group. After COVID-19 outbreak, the number of patients taking sleep-promoting drugs increased from 4.9% to 9.4% (p = 0.029).  309 patients completed the study (143 in liraglutide group and 166 in dapagliflozin group). After 24 weeks, HbA1c, fasting blood glucose (FPG), and 2 h postprandial blood glucose (2hPG) levels significantly decreased from 8.80% ± 1.41% to 7.02% ± 1.05%, 10.41 ± 3.13 to 7.59 ± 2.16 mmol/L, and 17.90 ± 4.39 to 10.12 ± 2.47 mmol/L, respectively, in the dapagliflozin group, and from 8.92% ± 1.49% to 6.78% ± 1.00%, 10.04 ± 2.99 to 7.20 ± 1.63 mmol/L, and 17.30 ± 4.39 to 10.13 ± 4.15 mmol/L, respectively, in the liraglutide group. Changes in HbA1c, FPG, and 2hPG levels between groups were not significantly different. Systolic blood pressure (SBP) and low-density lipoprotein cholesterol (LDL-C) level significantly decreased from 144.1 ± 19.1 to 139.7 ± 16.2 mmHg ( Liraglutide and dapagliflozin had strong hypoglycaemic effects in patients with overweight or obesity and T2DM at the beginning of the COVID-19 pandemic. Dapagliflozin may be beneficial in improving SBP and LDL-C levels; however, further research is warranted. Type 2 diabetes mellitus (T2DM) is a common chronic metabolic disease with an increasing global prevalence. According to WHO criteria, the number of patients with diabetes mellitus (DM) in China has rapidly increased to 11.2%, and the number of patients with T2DM is the highest in the world , 4. ObesMetformin is a safe, low-cost, widely used, hypoglycaemic drug that has an outstanding ability to decrease plasma glucose levels and has been employed for over 60 years to treat early stages of T2DM . AdditioSodium-glucose transporter-2 inhibitors (SGLT2is)  and glucCoronavirus disease 2019 (COVID-19) threatened the world as a new public health crisis following its emergence in Wuhan, Hubei Province, China, in December 2019 . Cities 2 [Patients with T2DM who visited the Metabolic Disease Management Center (MMC) at Tianjin Fourth Central Hospital from October 2019 to January 2020 were recruited for the study. The study inclusion criteria were as follows: (a) age ≥ 18 years, (b) body mass index (BMI) ≥ 24 kg/m2 , (c) staThe exclusion criteria were as follows: (a) type 1 and other special types of diabetes such as gestational diabetes, (b) severe mental illness and unclear consciousness, (c) active tuberculosis and other infectious diseases, and (d) high risk for volume depletion, hypotension, and/or electrolyte imbalances (in the opinion of the investigator). Laboratory exclusion criteria included haemoglobin < 120 g/L , <110 g/L , or thyroid-stimulating hormone levels outside the central laboratory normal range.Enrolled patients voluntarily withdrew from the study during the observation period. Written informed consent was obtained from all participants.This was a single-centre, randomised, parallel, controlled clinical observational study that lasted for 24 weeks. According to the random number table and time sequence of patient enrolment, the researchers divided the patients meeting enrolment conditions into dapagliflozin and liraglutide treatment groups at a ratio of 1 : 1. Dapagliflozin was initiated at 5 mg and titrated up to 10 mg by the second week unless (in the opinion of the investigator) the patient was unable to tolerate titration to 10 mg, in which case the dose was maintained at 5 mg. The liraglutide group patients were subcutaneously injected 0.6 mg/d at the beginning, and this dose increased to 1.2 mg/d by the second week. If intolerance occurred during the process, the dose was adjusted to 0.6 mg/d.According to the MMC system, we collected the following information: name, sex, age, contact information, smoking/drinking history, family history of diabetes, history of hypertension, coronary heart disease (CHD), and diabetes course. Blood glucose, lipid, and HbA1c levels; body weight; and blood pressure were monitored and recorded during the observation period. The body weight of patients and systolic and diastolic blood pressure levels were recorded at baseline, week 12, and week 24. The blood index monitoring plan was as follows: (1) at baseline: fasting peripheral blood glucose (FPG), 2 h postprandial peripheral blood glucose (2hPG), HbA1c, alanine aminotransferase, aspartate aminotransferase, blood urea nitrogen, serum creatinine, haemoglobin, triglyceride (Tg), low-density lipoprotein cholesterol (LDL-C), fasting venous blood glucose, and serum insulin levels; (2) week 12: FPG, 2hPG, and HbA1c levels; and (3) week 24: FPG, 2hPG, HbA1c, Tg, and LDL-C levels. Nurses provided education regarding diet and exercise, blood glucose and blood pressure monitoring, and liraglutide injection techniques, as well as the identification and treatment of adverse events (AEs), including hypoglycaemia. AEs were recorded and treated throughout the study.The outbreak of COVID-19 in December 2019 caused enormous disruption to the daily routines of the global community . Variousth Central Hospital, and all steps were conducted in accordance with the principles of the World Medical Association Declaration of Helsinki . The IRB approved the collection and use of patient records according to the regulations for clinical trials in humans .The clinical study protocol was approved by the Institutional Review Board (IRB) of Tianjin 4The primary objectives of this study were as follows: (a) after 24 weeks, to assess the effect of the addition of dapagliflozin compared to the addition of liraglutide on HbA1c level, and (b) over 24 weeks, to assess the overall safety and tolerability of dapagliflozin compared to liraglutide.The secondary objectives were as follows: to assess 2 h incremental postprandial glucose excursion (PPGE), FPG, 2hPG, and the proportion of subjects with an HbA1c goal < 7.0% after 24 weeks of treatment. Changes in Tg and LDL-C levels, body weight, and blood pressure from baseline were compared between the two groups. Venous blood samples were collected in EDTA tubes from fasting patients in the morning. HbA1c levels were determined using affinity chromatography in a hospital standard laboratory .2). Patients with BMI (≥24 and <28 kg/m2) were considered overweight, and those with BMI ≥ 28 kg/m2 were considered obese [The following evaluation criteria were employed: (1) T2DM: the diagnosis of T2DM was based on the 2020 Chinese diabetes treatment guidelines: FPG level ≥ 7.0 mmol/L  or 2 h plasma glucose level ≥ 11.1 mmol/L [ed obese . (3) Homed obese : FPG leved obese  includedA sleep quality questionnaire was used in this study. Sleep quality was considered poor if it affected normal work during the day. Patients were also asked whether they took medication to promote sleep.The following safety indicators were evaluated: (1) hypoglycaemia: hypoglycaemia was diagnosed at a blood glucose level lower than 3.9 mmol/L . In thisGlycaemic efficacy endpoints were changes from baseline in HbA1c, 2 h incremental PPGE, 2hPG, and FPG levels and the proportion of patients who achieved an HbA1c goal of <7% at week 24. Safety endpoints included AEs, hypoglycaemia, or urinary tract infection.Other indicators included changes in body weight, blood lipid levels, and blood pressure from baseline to week 24.t-test was used to compare measurement data between the two groups, and a paired sample t-test was used to compare the groups before and after treatment. The chi-square test was used to compare the observed data. All statistical tests were performed using bilateral tests with an alpha of 0.05.In this study, the GPower software was used to estimate the required sample size and assist in evaluating the effect size and statistical efficacy. The Statistical Program for Social Sciences 26.0 software  was used for data collection and analysis. The Kolmogorov–Smirnov normal test was performed on the measurement data, the mean ± standard deviation was used to describe variables conforming to a normal distribution, and percentage (%) was used for counting data. An independent sample 2, mean HbA1c level of 8.85% ± 1.44%, and average T2DM duration of 6.3 ± 5.7 years. The baseline demographics and clinical parameters of the two groups are shown in A total of 360 patients were eligible for enrolment and volunteered to participate in the study from October 2019 to January 2020. There were 180 participants in each group, but only a total of 309 patients completed the study . There wt = 14.180, p ≤ 0.001; dapagliflozin group: −1.78%, t = 14.983, p ≤ 0.001), FPG , and 2hPG  levels occurred in both groups  and week 24 .Compared with baseline data , there wχ2 = 1.558, p = 0.212) and 24 . Additionally, there was no significant difference in the HQR between the liraglutide and dapagliflozin groups at week 24 .There was no significant difference in the compliance rate of HbA1c (<7.0%) between the liraglutide and dapagliflozin groups  at weekst = 3.306, p = 0.001) and LDL-C levels (−0.24 (−0.42–−0.05), t = 2.512, p = 0.014) in the liraglutide group. There were no significant changes in TG level, body weight, and DBP.The changes in body weight, SBP, DBP, and TG and LDL-C levels in the two groups after 24 weeks of treatment are shown in χ2 = 0.439, p = 0.508). A total of 20 patients had urinary tract infection, including 5 and 15 in the liraglutide and dapagliflozin groups, respectively, and 2 of them stopped treatment with dapagliflozin due to a severe urinary tract infection. There was no significant difference between the two groups .During the 24-week observation period, 50 patients experienced mild hypoglycaemia events (21 (14.7%) and 29 (17.5%) patients in the liraglutide and dapagliflozin groups, respectively). No significant differences between the two groups were noted . No serious AEs, such as severe hypoglycaemia, heart failure, or myocardial infarction, were noted in either group.χ2 = 13.839, p ≤ 0.001). The number of patients taking sleep-promoting drugs significantly increased from 15 (4.9%) to 29 (9.4%) .Following the start of the COVID-19 outbreak, the proportion of patients with poor sleep quality significantly increased from 27.5% to 41.7% , GLP-1RAs, including liraglutide and dulaglutide, provided better hypoglycaemic effects . A retroLiraglutide, a GLP-1RA, mediates several positive effects, including lowering glucose dependence and reducing appetite and body weight; furthermore, it provides antiatherosclerosis, neural protection, natriuresis, and bone osteogenesis benefits . DapagliObesity is one of the main risk factors for T2DM, and both constitute a major global health crisis . Weight However, in the present study, there were no significant changes in body weight between the two groups before and after the 24-week treatment period. Body weight is regulated by the interaction of a number of processes, including homoeostatic, environmental, and behavioural factors. Interventions based on lifestyle modifications are integral to the management of body weight . It is pThe SBP of patients in the dapagliflozin group decreased significantly before and after the 24-week treatment period compared to the liraglutide group. Dapagliflozin at a dose of 10 mg has been found to induce a modest reduction in blood pressure compared with placebo in patients with diabetes with a low risk of orthostatic reactions, regardless of baseline blood pressure, and without increasing the heart rate . The assBoth treatments were well-tolerated. In the dapagliflozin group, two patients left the study after contracting urinary tract infections. SGLT2is increased the overall risk of genital system infection but did not increase the risk of other safety events, such as amputation, fracture, acute renal injury, and hyperkalaemia. The safety outcomes of the study were consistent with those of previous studies .Even under the impact of COVID-19, liraglutide and dapagliflozin have strong hypoglycaemic effects in patients with overweight or obesity and T2DM. Compared to liraglutide, dapagliflozin may greatly improve blood pressure and blood lipid levels. Further research is needed to confirm this assumption. This study, however, has many limitations. The study is a single-centre study, and the enrolled patients were limited to the northern area of Tianjin. Since liraglutide is an injectable drug and dapagliflozin is an oral hypoglycaemic drug, the study was not double-blinded, and the conclusions need further verification.


Renal tubular impairment is prevalent in diabetic nephropathy (DN) and the histological severity predicted renal outcome. Biomarkers of tubular injury also increased in the urine of DN patients. The retrospective study aimed to assess the prognostic value of clinically widely applied urinary tubular injury markers, retinol-binding protein (RBP), β2-MG and NAG were retrieved from medical records. The primary outcome was end stage renal disease (ESRD). Cox proportional hazard analysis and restricted cubic splines were performed to evaluate the association of parameters with ESRD. Nomograms were constructed and concordance index (C-index) was used to measure the prediction ability.  A total of 305 patients with biopsy-proven DN were enrolled. The baseline urine total protein and components including albumin, IgG, RBP, β2-MG and NAG were positively correlated with the severity of interstitial fibrosis and tubular atrophy (IFTA). Positive correlations were also observed among β2-MG, NAG and mesangial expansion. Urinary RBP was not correlated with any glomerular lesions. Urinary RBP, β2-MG and NAG were risk factors for ESRD in hazard analysis with adjustment for age, gender and body mass index (BMI). The hazard ratios increased with the increment of baseline levels. In the multivariate Cox model including serum creatinine (SCr), total urinary protein, urinary albumin, urinary IgG and the tubular injury biomarkers, urinary RBP  remained as an independent risk factor for ESRD in DN patients. Patients were divided by the medium value of urinary RBP into the low RBP and high RBP groups. Survival analysis showed that significantly more patients in the high RBP progressed to ESRD compared to those in the low RBP group (p =0.02) when urinary total protein was less than 3.5 g/g. The C-index of the nomogram incorporating age, gender, BMI, SCr and total urine protein was 0.757. The value increased to 0.777 after adding urinary RBP to the model.  The levels of urinary RBP,  Urinary RBP excretion was only correlated with the severity of IFTA and independently predicted ESRD in DN patients. Diabetic nephropathy (DN) is a common but devastating complication of diabetes mellitus (DM). In the recent annual data report on kidney disease in China, diabetes was considered the cause of 26.70% of patients with chronic kidney disease (CKD) and presented in 33.14% of patients entering dialysis . The preβ2-microglobulin (β2-MG) did not predict ESRD independent of the known promoters [Urinary tubular injury markers increased early and vastly in diabetic patients with CKD. Their increments were observed in patients with normal albuminuria and could be used as complementary measurements to albuminuria and estimated glomerular filtration rate (eGFR) in early diagnosis of diabetic kidney disease, defined by the presence of microalbuminuria or impaired renal function , 7. In tromoters , 11. Theromoters . So therβ2-MG and N-acetyl-β-D-glucosaminidase (NAG), and their relationship with clinicopathological presentations.The present study recruited a relatively large number of DN patients confirmed by renal biopsy. It aimed to investigate the prognostic value of three widely available urinary tubular biomarkers, i.e., RBP, The study was in compliance with the Declaration of Helsinki and approved by the Committee on Research Ethics of the First Affiliated Hospital Zhejiang University School of Medicine. Subjects with renal biopsy-proven DN from March 2011 to August 2020 in our center were retrospectively recruited for the study. The exclusion criteria were CKD 3 stage, acute kidney injury, concurrent primary or secondary glomerulonephritis, or hypertensive nephropathy. Patients with follow-up for less than 6 months were also excluded except for those who reached the endpoint.β2-MG and NAG were to reflect tubular injury. The endpoint was defined as ESRD.Data were retrieved from the medical record. Laboratory examinations including glycated hemoglobinA1c (HbA1c), hemoglobin, serum albumin, serum lipids, SCr, eGFR and urinary proteins within 1 week of renal biopsy were collected. Urinary protein to creatinine ratio was used to represent 24-h urine protein. Urinary albumin and urinary immunoglobin G (IgG) were used to reflect kidney glomerular impairment, and urinary RBP, β2-MG  were measured by an immunoturbidimetric method using commercial kits. Urinary NAG was measured using the 6-methyl-2-thiopyridine-N-acetyl-indole-D-glucosaminidase substrate method . The values of urinary biomarkers were expressed as the ratio of the concentration to the concurrent urinary creatinine levels.First-morning urine samples were obtained for urinary tests. Total urinary protein was quantified by a pyrogallol red-molybdate method . The concentrations of urinary albumin , IgG , RBP , and Each biopsy specimen went through standard processing. Two pathologists reported the diagnosis and pathological features separately. The diagnosis and classification of DN were done according to the criteria of Tervaert et al. . Class IU test as appropriate. Categorical data were interpreted as counts and percentages, and the differences were analyzed using the Chi-square test. The pathological correlations to the biomarkers were calculated using the Spearman correlation coefficient. The association of a clinical indicator with renal survival time was analyzed using a univariate Cox proportional hazard regression model and restricted cubic spline while adjusting for age, sex and body mass index (BMI). Multivariable Cox proportional hazards regression models with forward LR were performed to find independent risk factors. Kaplan–Meier curves were used to analyze the outcomes. Nomogram prognostic model was constructed based on the results of multivariate Cox analysis. The predicted ability was measured by concordance index (c-index). P values <0.05 were considered significant.SPSS version 22.0 and R software version 4.1.0 were performed for statistical analyses. Quantitative variables were interpreted as the mean ± standard deviation or the median with an interquartile range. The differences were compared using Student's t-test or Mann–Whitney 2, and 120 (39.34%) patients were in CKD 3 Stage. Urinary RBP, β2-MG and NAG were increased in 95.74%, 89.51% and 89.05% patients, respectively. In renal pathology, tubulointerstitial impairment was prevalent. IFTA was observed in 99.34% of patients and graded as moderate or worse in 70.16% of the patients.A total of 305 DN patients were enrolled in the study , and 232ρ =0.191, p =0.001 between RBP and IFTA score; ρ =0.355, p <0.001 between β2-MG and IFTA score, ρ =0.139, p =0.044 between NAG and IFTA score). Urinary RBP did not correlate with glomerular impairment such as DN glomerular classes or mesangial expansion. While urinary β2-MG and NAG excretion were also significantly correlated with mesangial expansion. All the tubular injury markers were not associated with arteriolar hyalinosis.The pathological relations were shown in p<0.001), β2-MG  and NAG  were risk factors for ESRD  remained significant as an independent risk factor for ESRD (p =0.029), baseline urinary protein to creatinine ratio , SCr  were independent risk factors. BMI  and hemoglobulin  were independent protective factors.To further assess the independent effect, indicators were further adjusted for SCr. Urinary RBP and NAG remained significant. In the multivariate Cox model, we pooled all the clinical laboratory urinary kidney injury molecular markers, kidney function and influential clinical characteristics including blood pressure, hemoglobin and lipid indexes which were selected by the above variance analysis. In this model, urinary RBP . Patients in the high RBP group demonstrated higher blood pressure, severer lipid disorder with significantly higher serum concentrations of total cholesterol (p =0.011), low-density lipoprotein cholesterol  and high-density lipoprotein cholesterol  levels compared to those in the low RBP group, even with similar prescription of antihypertension and lipid-lowering drugs. There was no difference in the diabetic duration, diabetic retinopathy percentage and HbA1c level between the groups.As shown in p =0.015), serum albumin (p <0.001), higher urinary total proteins (p <0.001), urinary albumin (p <0.001) and urinary IgG (p <0.001) excretion compared to those in the low RBP group. There was no significant difference in baseline eGFR or SCr between the groups.Subjects in the high RBP group demonstrated significantly lower hemoglobulin .During the follow-up period of 22.73 months, significantly more patients in the half of participants with high RBP levels progressed to ESRD (Further, we constructed nomogram models to predict renal outcome, and the prediction ability was measured by C-index. In our patients, the conventional model involving age, gender, BMI, SCr and total urine protein level had a C index of 0.757. Adding urinary RBP excretion to the model increased the C index to 0.777 .RBP and β2-MG are biomarkers of tubular dysfunction with low molecular weights of 21 kDa and 11 kDa, respectively. They can be freely filtered by glomeruli and almost fully reabsorbed by proximal tubules [β2-MG was correlated with IFTA score, but did not add prognostic value to the known indicators of urinary protein excretion and eGFR [urinary β2-MG and NAG levels were also correlated with mesangial expansion. Their limited predictive value might be explained by the influence of glomerular damage or urine environment on measurement. β2-MG was unstable in acid urine, while RBP was reported to be a better alternative [β2-MG to detect the impairment of proximal renal tubules in Fanconi Syndrom [β2-MG found that urinary RBP yielded best diagnostic value for diabetic kidney disease [In the present cohort of 305 subjects with biopsy-proven DN, the vast majority demonstrated tubulointerstitial impairment and elevated urinary tubular injury markers. Among the three biomarkers we evaluated,  tubules . NAG is  tubules . A studyernative . It was  Syndrom . A study disease . In the We explored the clinical characteristics of DN patients with high urinary RBP excretion. Their demographic feature was a higher proportion of females affected, different from that of DN glomerulopathy. Patients with higher urinary RBP levels manifested lower hemoglobulin than their lower RBP counterparts. This could be explained by endogenous erythropoietin production in the tubulointerstitial compartment of kidney, since higher urinary RBP level was related to severer tubulointerstitial damage. Notably, although patients with higher urinary RBP levels exhibited more serious tubular injury, the baseline kidney function was comparable to those with lower urinary RBP levels. And there was no significant association between urinary RBP excretion and DN glomerulopathy. Some clinical features of patients with high urinary RBP could hardly be explained by glomerular damage, which supported the perspective of tubulopathy in DN progression.Patients with higher urinary RBP manifested dysregulation of cholesterol metabolism with higher levels of total cholesterol, LDL-C and HDL-C. Increased levels of cholesterol and LDL-C are linked to lipid accumulation and lipotoxicity in tissue. Heavy lipid droplet deposition is observed in renal tubules in DN and associated with tubular damage –20. Uptaprimary tubular injury. Two studies of diabetic patients with macroalbuminuria and all levels of albuminuria also identified urinary RBP as an independent relevant biomarker for kidney disease progression [To assess the prognostic value, urinary tubular markers, urinary total protein, urinary albumin, urinary IgG and kidney function were included in a multivariate Cox model. And urinary RBP remained significant as an independent risk factor for ESRD. In nomogram, a conventional model including SCr and total urinary protein was first constructed. Further adding urinary RBP to the model, the prediction ability measured by C-index improved. These results suggested that urinary RBP independently predicted renal prognosis in DN, and might be a useful noninvasive indicator for gression , 29. Tregression –32. UrinThe main strength of the study is its longitudinal design allowing assessment of the predictive value of the tubular markers. Besides, patients were biopsy-proven DN, help look into the pathological relationship of the biomarkers. The study also has limitations. It was a retrospective investigation from a single center. But our results showed agreements with those of previous studies, and complemented the prognostic role of urinary RBP in DN. Plus, the tubular injury markers we evaluated reflected a limited aspect of DN tubular injury.β2-MG and NAG correlated with the severity of tubulointerstitial damage in DN patients. Among them, urinary RBP was the independent risk factor for ESRD. The pathogenesis of tubular impairment is at least partially independent of glomerular lesions even in DN patients with obvious glomerulopathy. Urinary RBP might be a good monitor for therapeutic strategy targeting renal proximal tubules in DN patients.In conclusion, the tubular injury biomarkers, RBP,


To assess the effect of renal denervation (RDN) on renal vascular resistance and renal function in patients with drug-resistant hypertension (HTN) and type 2 diabetes mellitus (T2DM).Fifty-nine patients  with resistant HTN  and T2DM (mean HbA1c 7.5 ± 1.5%) were included in the single-arm prospective study and underwent RDN. Renal resistive index (RRI) derived from ultrasound Doppler; estimated glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration formula), office and 24-h ambulatory BP were measured at baseline, 6, and 12 months after RDN to evaluate the respective changes in renal vascular resistance, renal function, and BP during treatment.n = 23; −0.024 , p = 0.035} and did not change in those with baseline RRI < 0.7 . No significant change was observed in eGFR whereas BP was significantly reduced at 12 months after RDN by −10.9 /−5.5  mmHg, systolic/diastolic. No relationship was found between the changes in RRI and BP.Forty-three patients completed 12 months follow-up. The RRI changed depending on the baseline value. Specifically, the RRI decreased significantly in patients with elevated baseline RRI values ≥ 0.7 {Our study shows that RDN can decrease elevated renal vascular resistance (RRI > 0.7) and stabilize kidney function in patients with RHTN and T2DM independently of its BP-lowering effect. Type 2 diabetes mellitus (T2DM) and hypertension (HTN) are major contributors to the development and progression of chronic kidney disease (CKD) . Impairm2, pregnancy, renal artery anatomy ineligible for treatment, and severe comorbidity significantly increasing the risk of the intervention according to investigator’s assessment. Information about drug therapy was obtained through an interview. The study flow chart is present in Fifty-nine patients with RHTN and T2DM were included in a single-center prospective interventional study and underwent RDN at the Research Institute of Cardiology, Tomsk National Research Medical Center, between February 2011 and April 2021. The study was performed in accordance with applicable national and international standards . The study protocol was approved by the local ethics committee. All patients provided written informed consent prior to inclusion in the study. Eligible patients included men and women 18–80 years of age with office systolic blood pressure (SBP) ≥ 140 mmHg, while receiving three or more antihypertensive medications without changes for 3 months prior to enrollment. RHTN was verified according to European Society of Cardiology and European Society of Hypertension (ESC/ESH) Guidelines for the management of HTN /peak systolic velocity measured by renal triplex ultrasound at the level of the segmental arteries, according to the standard technique . The aveThe primary outcome was reduction in RRI for segmental renal arteries from baseline to 12 months post-procedure, and the secondary outcomes were changes in eGFR, and office and ambulatory BPs from baseline to 6 and 12 months after RDN. Improvement in renal vascular resistance was categorized as a decrease in RRI ≥ 0.05.n = 14), Symplicity Flex (n = 23), Vessix Reduce (n = 7), and Symplicity Spyral (n = 15) catheters in accordance with the manufacturer’s instructions, except that the treatments were performed mainly in the distal branches of the renal artery and, in some cases, extended proximally to the distal trunk if one or more branches were unsuitable for the treatment. The average number of ablations on each side ranged from 4 to 12. The mean number of point treatments delivered per patient was 13.1 ± 1.66. The number of ablations depended on the diameter of the artery (4–if the branch had a diameter of 4 mm or greater and 2–if the diameter was less than 4 mm). If less than 4 treatments were performed in the branch, 2 additional treatments were done in the distal trunk to achieve sufficient completeness of the intervention. Two subjects had accessory renal arteries (diameter was less than 4 mm) that were successfully treated.The RDN procedures were performed using MarinR 5F . The 95% confidence intervals (CI) were calculated to assess the size of the treatment effects according to the International Conference on Harmonization E9 Guideline: “Statistical Principles for Clinical Trials”. Analyses were performed based on the per-protocol principle. Statistical significance was set at p < 0.05.Statistica 10.0 ver. and SPSS 26 for Windows were used for the statistical analysis. The significance of differences in categorical variables was tested using Fisher’s exact test. The Shapiro–Wilk test was used to test the hypothesis of a normal distribution of continuous variables. Between-group differences were tested using unpaired The clinical characteristics of the patients are summarized in p = 0.011 at 6 months, and −0.024 , p = 0.035 at 12 months] but only slightly changed in those with baseline RRI < 0.7 . The frequency of improvement in renal vascular resistance (defined as a decrease in RRI by > 0.05) was almost two times higher in the first group at 6 and 12 months follow-up than in the second group , nd group .2), and a higher incidence of CKD (1.8 times). They also had higher pulse pressure levels and a higher frequency of ISHTN (3.6 times) and coronary artery disease (1.5 times). The number and spectrum of antihypertensive and antidiabetic therapies used in both groups were not significantly different . The BP changes were significant and comparable in both groups during the follow-up period .The decrease in RRI did not correlate with systolic BP reduction after RDN  blockade and sodium-glucose co-transporter 2 (SGLT2) inhibitors on renal hemodynamics in patients with HTN and T2DM has been previously described , 23. It Several studies have demonstrated sustained reduction in muscle sympathetic nerve activity , 28 and The main finding of our study is that the effect of RDN on renal vascular resistance in patients with RHTN and T2DM strongly depends on its baseline status, with a pronounced decrease in RRI in patients with elevated baseline values ≥ 0.7 and no effect otherwise. It is also noteworthy that some patients showed regression in RRI without significant BP reduction. The possible mechanisms of the positive effect of RDN on renal vascular resistance may include not only a decrease in sympathetic tone but also suppression of chronic low-intensity inflammation , 31, 32,This study has important clinical implications. Recently, Delsart et al. reported that an increase in RRI > 0.70 in hypertensive patients with T2DM and HTN over a 10-year follow-up remained a strong and independent predictor of cardiovascular and renal complications . Taking 2 annually (Another important finding of our study is that RDN was accompanied by stabilization of eGFR in patients with RHTN and T2DM, which normally show a steady decline in this index by 2–4 mL/min/1.73 mannually . Concernannually .In our study, we also described the clinical phenotypes of patients with high RRI. The high RRI phenotype was associated with older age and a high incidence of not only CKD and coronary artery disease but also ISHTN, which could reduce the BP response to RDN. However, according to our data, there was a significant decrease in BP after RDN in both groups, and the degree of BP response was comparable. Currently, information regarding the antihypertensive efficacy of RDN in patients with ISHTN is contradictory. In some studies, older age and ISHTN were predictors of BP nonresponse to RDN , 34. It There were several limitations in this study. First, this was a single-arm study with no sham-control group. However, several rigorously controlled studies of RDN have previously shown a quite insignificant effect of the sham procedure on BP at 3–6 months after the intervention –37. SecoIn summary, we showed that RDN can decrease elevated RRI 0.7 and stabilize kidney function in patients with RHTN and T2DM independently of its BP-lowering effect. Long-term follow-up is needed to assess cardiovascular and renal outcomes depending on changes in RRI after RDN in patients with RHTN and T2DM. Further research may be needed to study the relationship between changes in RRI and changes in markers of sympathetic activity and chronic low-degree inflammation. Considering that SGLT2 inhibitors reduce sympathetic nervous system activity , future The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Biomedical Ethics Committee of Cardiology Research Institute, Tomsk NRMC. The patients/participants provided their written informed consent to participate in this study.MM, AF, VM, and StP contributed to conceptualization, participated in the development of a general concept and research design, obtained, analyzed, and interpreted the data, and wrote the first version of the manuscript and prepared it for publication. AF, SeP, and VM contributed to methodology. MM and AF contributed to software. ES, TR, SK, and AV formed a sample of patients, organized data collection, and contributed to the revision of the original manuscript. All authors contributed to the article and approved the submitted version.


Our study aims to develop an effective integrated machine learning (ML) scheme to predict vascular events and bleeding in patients with nonvalvular atrial fibrillation taking dabigatran and identify important risk factors. This study is a post-hoc analysis from the Randomized Evaluation of Long-Term Anticoagulant Therapy trial database. One traditional prediction method, logistic regression (LGR), and four ML techniques—naive Bayes, random forest (RF), classification and regression tree, and extreme gradient boosting (XGBoost)—were combined to construct our scheme. Area under the receiver operating characteristic curve (AUC) of RF (0.780) and XGBoost (0.717) was higher than that of LGR (0.674) in predicting vascular events. In predicting bleeding, AUC of RF (0.684) and XGBoost (0.618) showed higher values than those generated by LGR (0.605). Our integrated ML feature selection scheme based on the two convincing prediction techniques identified age, history of congestive heart failure and myocardial infarction, smoking, kidney function, and body mass index as major variables of vascular events; age, kidney function, smoking, bleeding history, concomitant use of specific drugs, and dabigatran dosage as major variables of bleeding. ML is an effective data analysis algorithm for solving complex medical data. Our results may provide preliminary direction for precision medicine. Stroke is the leading cause of death and disability worldwide . Cardioe2DS2-VASc) [2DS2-VASc score has been widely used for years with convenience and reliability [Dabigatran etexilate, the only direct thrombin inhibitor, is an NOAC with two approved doses based on the Randomized Evaluation of Long-Term Anticoagulant Therapy (RE-LY) trial . In thisS2-VASc)  and hypeS2-VASc)  scores aiability ,15, insuiability . Machineiability ,20,21,22iability  and Chuniability  have conThis study is a post-hoc analysis based on RE-LY trial dataset. This study was reviewed and approved by the Research Ethics Review Committee of the Fu Jen Catholic University Hospital. The requirement for informed consent was waived, since the data contain only de-identified information.In the RE-LY trial, >18,000 patients with newly diagnosed arrhythmia and indications of secondary prevention with an anticoagulant were randomized to receive dabigatran 110 or 150 mg twice daily or an adjusted dose of warfarin with a median follow-up period of approximately 2 years. Exclusion criteria included a history of severe heart valve disorders, a recent stroke, and renal insufficiency. The primary outcome was stroke or systemic embolism and the primary safety outcome was major hemorrhage. The definitions and results of other secondary outcomes have been described in detail and published. We collected the data of patients taking dabigatran with complete follow-up in the RE-LY trial for the present analysis.We proposed an integrated ML feature selection scheme for predicting vascular events and bleeding in patients with NVAF taking dabigatran and for identifying important risk factors. 2DS2-VASc and HAS-BLED scores. BMI was classified according to the definition of the World Health Organization [First step: Identify risk factors as predictor variables and define target variables. For risk factors we referred to the recommendations in the guidelines of the American Heart Association and the European Society of Cardiology ,25, whicnization . Moderatnization .For analyzing the influence of these factors on efficacy and safety, we selected two target variables including vascular events  and major bleeding (P2: major bleeding defined as blood loss with a decrease in hemoglobin level of ≥2 g/dL (1.2 mmol/L), transfusion of ≥2 packed red blood cells, or symptomatic bleeding in a critical area or organ). Our presumed important variables and prognostic outcomes were individually categorized according to the definition shown in Subjects were identified according to participants’ characteristics and laboratory data collected during their enrolment in the RE-LY trial. Only patients with available complete information were included in our analysis. Two independent investigators confirmed prognostic outcomes according to the criteria mentioned in the trial.The study protocol included one traditional prediction method, logistic regression (LGR), and four ML techniques, viz., naive Bayes (NB), random forest (RF), classification and regression tree (CART), and extreme gradient boosting (XGBoost). NB is a popular ML model used for classification tasks. This algorithm can sort objects according to specific characteristics and variables based on the Bayes theorem. It calculates the probability of hypotheses on presumed groups . RF is aSecond step: Train NB, RF, CART, and XGBoost models and evaluate their predictive performance. The models are trained using two combinations of predictor and target variables. One combination involves using 18 variables (V1–V18) as predictors and vascular events (P1) as the target variable; the other combination involves using V1–V18 as predictors but bleeding (P2) as the target variable. In training these models, the data of recruited patients were randomly separated into 90% training and 10% testing datasets according to the 10-fold cross-validation (CV) method. Our scheme applied the 10-fold nested CV method for enhancing stability to estimate the best performance of each model . This prThese models’ efficacy were evaluated based on their mean and standard deviation of accuracy, sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve (AUC) . SensitiThird step: Importance ranking of risk factors. The “caret” R package version 6.0-90  was applAccording to the individual priority of the variables presented in the predictive models of vascular events and bleeding, we may establish an instruction concept for patients with NVAF taking dabigatran. In the final stage, we summarized our significant findings and discussed them in light of previous concepts.http://www.R-project.org; accessed on 2 March 2022; https://www.rstudio.com/products/rstudio/; accessed on 2 March 2022). The methods were applied using the R software with the required installed packages: “randomForest” package version 4.6-14 for RF [All analyses were conducted using R software version 4.1.2  and RStudio version 1.1.453  was an exclusion criterion for most NOACs [Kidney dysfunction was infrequently mentioned as a major risk factor for ischemic stroke. Severe kidney impairment , and patients with certain comorbidities were excluded. Second, the trial participants were regularly followed up for two years with good compliance that might be infrequent in our outpatients. Specific effects of other systemic diseases might be alleviated. Third, we intended to establish a prediction model for patients with NVAF taking dabigatran; vascular events including stroke, MI, systemic embolism, and vascular death were defined as the primary outcome. Given that we selected only one NOAC instead of an antiplatelet agent or combined therapy, and though an antiplatelet agent could prevent atherosclerosis, this issue might be affected by risk factors including dyslipidemia, lifestyle, and genetics, which were not included in our study. Nevertheless, our study design was suitable for clinical practice when considering the secondary prevention of cardioembolic stroke.Our study has several limitations. First, our findings must be applied with caution in clinical practice considering the inclusion and exclusion criteria of the RE-LY trial. The trial population comprised subjects with relatively low CHANOACs could replace warfarin owing to their similar protective effects and better safety quality in real-world studies. Appropriate dose selection and intensive risk factor control are necessary to achieve high-quality secondary prevention. In our research, RF and XGBoost generated higher accuracies and AUC values than LGR in simultaneously predicting vascular events and bleeding even with the disproportionate prevalence. Furthermore, these methods remained relatively stable between their sensitivities and specificities in the imbalanced data. This integrated ML feature selection scheme showed a great opportunity to solve complex medical data. Although further evaluation is indicated, our study might provide a preliminary direction of precision medicine for secondary prevention in patients with arrhythmia.


We compared hemodynamics and clinical events after heart transplantation (HTx) in patients stratified by the severity of residual pulmonary vascular resistance (PVR) after left ventricular assist device (LVAD) implantation for bridge to transplantation.We retrospectively analyzed patients who had undergone HTx at the University of Tokyo Hospital. We defined the high PVR group as patients with PVR of >3 Wood Units (WU) as measured by right heart catheterization performed 1 month after LVAD implantation.p = 0.0009). The differences in mean pulmonary artery pressure (mPAP), mean right arterial pressure (mRAP), and mean pulmonary capillary wedge pressure (mPCWP) tended to increase from the first year after HTx, and were all significantly higher in the high PVR group at 3 years after HTx . In addition, pulmonary artery pulsatility index was significantly lower in the high PVR group than in the low PVR group at 3 years after HTx . The composite event including hospitalization for heart failure, diuretic use, and elevated intracardiac pressure (mRAP ≥ 12 mm Hg or mPCWP ≥ 18 mm Hg) between the two groups was significantly more common in the high PVR group. Residual high PVR was still an important predictor  after multivariate Cox regression analysis.We included 85 consecutive HTx recipients, 20 of whom were classified in the high PVR group and 65 in the low PVR group. The difference in PVR between the two groups became apparent at 2 years after HTx (the high PVR group: 1.77 ± 0.41 WU, the low PVR group: 1.24 ± 0.59 WU, Our study demonstrates that patients with residual high PVR under LVAD implantation showed the increase of right and left atrial pressure in the chronic phase after HTx. Heart transplantation (HTx) is a treatment method for severe heart failure in which a patient’s heart, which cannot be saved by conventional treatment methods, is replaced with a healthy heart from a brain-dead person. However, shortage of donor heart is a common worldwide issue that limits the benefit of HTx , 2. To oN = 2). LVAD therapy included HeartMate II , EVAHEART , Jarvik 2000 , DuraHeart , HVAD , and Nipro-VAD . The study protocol conformed to the tenets of the Declaration of Helsinki, and was reviewed and approved by the University of Tokyo Institutional Review Board .All patients were implanted with LVAD at our institution between October 2004 and September 2018 or visited our institution’s outpatient clinic after undergoing LVAD implantation at another institution during the same period. Patients who underwent right heart catheterization for hemodynamic evaluation 1 month after LVAD implantation and were ultimately able to undergo cardiac transplantation were selected. Patients who died within 30 days of HTx were excluded  was present, only optimization of immunosuppression was performed, but when moderate ACR  wasOne month after LVAD implantation, right heart catheterization was performed for hemodynamic evaluation. Conversely, after HTx, right heart catheterization and endomyocardial biopsy from the right ventricular middle septum were regularly performed 1, 2, 3, 4, 6, 8, 12, 18, and 24 weeks according to the institutional protocol. It was performed yearly, 1 year after HTx. In this study, we used right heart catheterization data 1 month after LVAD implantation and 24 weeks, 1 year, 2 years, and 3 years after HTx. Right heart catheterization was performed by inserting a Swan Ganz catheter through the jugular or femoral vein. Right atrial pressure (RAP), right ventricular pressure, pulmonary artery pressure (PAP), pulmonary artery wedge pressure (PCWP), cardiac output (CO), and cardiac index (CI) were measured by Fick’s principle. In this study, we used mean right atrioventricular pressure (mRAP), mean pulmonary artery pressure (mPAP), mean pulmonary artery wedge pressure (mPCWP), and CI. The PVR, pulmonary artery pulsatility index (PAPi), diastolic pressure gradient (DPG), and transpulmonary gradient (TPG) were calculated as follows; PVR, (mPAP-mPCWP)/CO; PAPi, (sPAP-dPAP)/mRAP; DPG, dPAP-mPCWP; and TPG, mPAP-mPCWP. On the LVAD support, the setting of LVAD speed was generally set with reference of clinical findings and echocardiographic findings before right heart catheterization. In the right heart catheterization, hemodynamic data and echocardiographic measurements were recorded at the patient’s initial baseline LVAD speed. The LVAD speed was then lowered to several speeds with repeat collection of hemodynamic and echocardiographic data. The LVAD speed was then increased to several speeds with repeat data collection at each interval. We got the data of hemodynamics at the first LVAD speed in right heart catheterization. The right heart catheterization was identically performed for different LVADs.Blood tests were performed 1 month after LVAD implantation and sequentially after HTx. In this study, we collected data at 1 month after LVAD implantation and 4 weeks, 24 weeks, 1 year, and 3 years after HTx.e’ value is the average of the values measured at both the septum and the lateral wall. We collected the data 1 week, 24 weeks, 1 year, and 3 years after HTx.Echocardiography was performed sequentially after HTx. Normal echocardiographic parameters, including left ventricular diastolic dimension (LVDs), left ventricular dimension (LVDd), left ventricular ejection fraction (LVEF), and E/e’, were evaluated. The Using the diagnostic criteria for ACR by the International Society for Heart and Lung Transplantation (ISHLT), cellular rejection of grade 2R (ISHLT2004)/3A (ISHLT1990), or higher was classified as positive ACR.Right ventricular failure (RVF) was defined and classified according to the International Mechanically Assisted Circulatory Support (INTERMACS) Registry, in which late RVF was defined as meeting the moderate or severe INTERMACS RVF definition after discharge from the index LVAD implant, presence of inotrope, use of intravenous or inhaled pulmonary vasodilators for a duration of >1 week, or needing RV assist device implantation .Donor-recipient sex mismatch was defined as a female donor to a male recipient . Donor-rIn this study, using the general definition of pulmonary hypertension , cases wDuring follow-up after HTx, we defined worsening heart failure as the composite including heart failure hospitalization, diuretic use for the treatment of congestion, and elevated intracardiac pressure .t-test or Mann–Whitney U test was used for continuous variables, while Fisher’s exact test was used for categorical variables. Right heart catheter and blood data from a baseline of 1 month after LVAD implantation to each period after HTx and echocardiography data from the harvest to each period after HTx were analyzed using the paired t-test or Wilcoxon signed-rank test. The Bonferroni method was used to assess the significance of the multiple comparisons. To examine changes over time in PVR, PAPi, mRAP, mPAP, mPCWP, and CI, the mean value of each parameter was graphed in patients stratified by baseline PVR. Kaplan–Meier survival analysis was performed to assess (1) survival after HTx; (2) hospitalization for heart failure; and (3) composite events of hospitalization for heart failure, diuretic use for the treatment of congestion, and elevated intracardiac pressure (mRAP ≥ 12 mm Hg or mPCWP ≥ 18 mm Hg) between the two groups, which were compared using a log-rank test. Cox regression analysis was performed to explore significant predictors of the composite events of heart failure hospitalization, diuretic use for the treatment of congestion, and elevated intracardiac pressure. The cutoff value of each variable, except BMI and eGFR, for the hazard analysis was calculated using a receiver operating characteristic curve. We selected values that maximized the sum of sensitivity and specificity as the cutoff values to calculate the area under the curve. Multivariate analysis was performed using variables for which P < 0.1 was obtained by univariate analysis. Statistical significance was set at a P-value < 0.05.Data were expressed as mean ± standard deviation or median (interquartile range). Statistical analysis was performed using JMP software . Student’s p = 0.043). BMI was also significantly higher in the high PVR group . According to the types of LVAD, 29 patients were implanted with HeartMate II, 20 patients with EVAHERAT, 16 patients with Jarvik 2000, 13 patients with DuraHeart, 6 patients with Nipro-LVAD, and 1 patient with HVAD. No significant differences were found in the LVAD model between the two groups. There was no significant difference in the presence of significant tricuspid regurgitation. During LVAD support, RVF was observed in 12 patients (14.1%), which was not associated with the presence of high PVR. Flow of patients through the study is presented in p < 0.0001; low PVR group, 1.65 ± 0.59 WU (baseline) vs. 1.32 ± 0.61 WU (24 weeks after HTx), p = 0.0016]. The PVR levels in both groups became comparable 1 year after HTx; however, the difference between each group became evident 2 years after HTx  vs. 4.1 ± 2.1 mm Hg (low PVR group), p = 0.0042; and mPCWP, 13.4 ± 4.5 mm Hg (high PVR group) vs. 8.8 ± 3.3 mm Hg (low PVR group), p = 0.0040] (p = 0.0033] (fter HTx . In contfter HTx . The dif 0.0040] . In the  0.0033] . BNP lev 0.0033] . Moreove 0.0033] . By contp = 0.016). These results suggested that increased burden on both left and right ventricles in patients of the high PVR group. In contrast, there were no significant differences in immunosuppressants, beta-blockers, ACE inhibitors, or MRAs between the two groups.p = 0.30, p = 0.54 p = 0.0017, p = 0.0058; (2) donor age, HR 6.8, 95% CI 2.2–21.0, p = 0.0008]. By performing multivariate analysis using both these factors and pre-HTx eGFR, residual PVR proved to be a significant predictor for this combined event .In the Kaplan–Meier survival curve analysis, the presence of high PVR after LVAD implantation did not affect survival after HTx . These results demonstrated the remaining pulmonary hypertension after HTx had continuously negative impact on the long-term clinical course after HTx. In the discussion about pulmonary vascular tone, the difficulty in accurately measuring pulmonary vascular tone abnormalities is noted. Indeed, the abnormality could not be detected by the value of PVR temporally after HTx in this study. It might be due to low sensitivity of PVR for the detection of pathological pulmonary vascular tone in normal hemodynamics, which is also the case in DPG and TPG. The more useful marker for the detection of pulmonary vascular tone should be developed in further study, which might lead to more concise elucidation between pulmonary vasculature and cardiac function. Lundgren et al. demonstrated the deranged PVR response during exercise despite normal PVR at rest after HTx . Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.NK: conceptualization, methodology, data curation, validation, and writing – original draft, review, and editing. EA: conceptualization, methodology, validation, data curation, and writing – review and editing. MH, MA, SS, OK, MO, and IK: supervision. MT, CB, JI, HY, AS, KN, YI, and KF: data curation. All authors contributed to the article and approved the submitted version.EA belongs to the Department, endowed by NIPRO-Corp, Terumo-Corp., Senko-Medical-Instrument-Mfg., Century-Medical, Inc., ONO-pharmaceutical-Co., Ltd. Medtronic-JAPAN Co., Ltd, Nippon-Shinyaku Co., Ltd, Mochida Pharmaceutical Co.; Boehringer Ingelheim Pharmaceuticals Inc., Abiomed-Inc, AQuA-Inc, Fukuda-Denshi Co., Ltd, and Sun-Medical-Technology-Research Corp. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.