High dietary salt intake is known to aggravate arterial hypertension. This effect could be of particular relevance in the setting of primary aldosteronism (PA), which is associated with cardiovascular damage independent of blood pressure levels. The aim of this study was to determine the impact of therapy on salt intake in PA patients.A total of 148 consecutive PA patients  from the database of the German Conn’s Registry were included. Salt intake was quantified by 24-hour urinary sodium excretion before and after initiation of PA treatment.Observational longitudinal cohort study.Tertiary care hospital.P = 0.047). Higher urinary sodium excretion correlated with an increased cardiovascular risk profile including proteinuria, impaired lipid, and glucose metabolism and was associated with higher daily doses of antihypertensive drugs to achieve blood pressure control. In unilateral disease, urinary sodium excretion dropped spontaneously to 176 mmol/d (P = 0.012) 1 year after unilateral adrenalectomy and remained low at 3 years of follow-up (174 mmol/d). In contrast, treatment with mineralocorticoid receptor antagonists (MRA) in bilateral PA patients was not associated with a significant change in urinary sodium excretion at follow-up (179 mmol/d vs 183 mmol/d).At baseline, unilateral PA patients had a significantly higher urinary sodium excretion than patients with bilateral disease (205 vs 178 mmol/d, PA patients consuming a high-salt diet, estimated based on urinary sodium excretion, respond to adrenalectomy with a significant reduction of salt intake, in contrast to MRA treatment. Nowadays, salt remains an important spice and preservative and very popular especially as part of Western diet. However, high salt intake has undesirable health effects and is regarded as an independent cardiovascular risk factor. Beside its negative impact on left ventricular mass and arterial stiffness, high salt intake results in an elevated risk of stroke and cardiovascular disease as well as an increase of blood pressure  began in the age of ancient Babylonia and Egypt, where salt was already used in the preservation of food. As a symbol of the importance of salt, Roman soldiers received their salary, derived from the Latin word pressure . For thipressure .One of the main regulators of salt and water balance is the steroid hormone aldosterone, which is synthesized in the zona glomerulosa of the adrenal cortex and is stimulated by increased renin and angiotensin II plasma levels. Aldosterone acts predominantly via the epithelial sodium channel (ENaC) in the distal nephron leading to increased sodium reabsorption and loss of potassium. Primary aldosteronism (PA) is characterized by excessive secretion of aldosterone despite suppressed renin levels. It affects 5% to 10% of patients with high blood pressure and is the most frequent cause of endocrine hypertension , 10. AldA recent study showed that reducing dietary salt intake in PA patients results in a substantial reduction of left ventricular mass index and therefore is of clinical relevance . AlthougIt was the objective of this study to investigate long-term intake of salt in a large cohort of PA patients and to analyze its association with treatment—unilateral adrenalectomy or mineralocorticoid receptor blockade by spironolactone. It was our hypothesis that PA is associated with high sodium consumption and that remission from excessive aldosterone levels and action  might positively affect salt intake.From 2008 to 2015, we prospectively enrolled 323 patients with PA in the Munich center of the German Conn’s Registry. For the present study, we selected patients fulfilling the following criteria: confirmed PA treated by either adrenalectomy (ADX) in unilateral PA or MRA in bilateral PA and 24-hour urinary sodium excretion measurement at baseline, and 1 and 3 years after initiation of specific PA directed treatment, respectively. Patients with urine volume <500 mL/d were excluded to ensure completeness of 24-hour urine collection. We identified 148 patients fulfilling the inclusion criteria; they became our study cohort. All patients gave written informed consent, and the protocol of the German Conn’s Registry was approved by the ethics committee of the University of Munich.At time of diagnosis and at each visit, patients underwent standard procedures including collection of anthropometric data, clinical characteristics, current medication, and laboratory testing. Blood pressure was measured using an automated device over 24 hours. To estimate daily salt intake, the patients conducted a 24-hour urine collection at baseline after adjustment of medication for further testing of PA to determine urinary sodium excretion at each visit.For diagnosis of PA, patients underwent standardised testing, which was performed according to Endocrine Society Practice Guidelines . The diaGenotyping for KCNJ5, ATP1A1, ATP2B3, and CACNA1D was performed in surgically resected tumor tissue of unilateral PA as described elsewhere .U test or Kruskal-Wallis test, respectively. Within-group changes from baseline to follow-up were calculated by Wilcoxon signed-rank test. Spearman’s rank order was used to perform bivariate correlation analysis. Stepwise multiple regression analysis was performed for multivariate analysis. Two-tailed probability values <5% were considered to be statistically significant. Statistical analysis was done using standard statistical software .All values are expressed as median, 25th and 75th percentile, if not mentioned otherwise. Body mass index (BMI) was calculated as weight in kilograms divided by the square of the height in meters. Data between groups were compared using Mann-Whitney 2, and had low potassium and high aldosterone levels, as expected. Twenty-four-hour systolic blood pressure (SBP) and diastolic blood pressure (DBP) was elevated with 144/93 mm Hg despite receiving a median of 2.5 doses of antihypertensive drugs per day (DDD). Median urinary sodium excretion was 184 mmol/d, reflecting a daily salt consumption of more than 10 g, which is more than twice of the amount recommended by the World Health Organization  and higher plasma aldosterone values (P < 0.001) as well as higher 24-hour urinary potassium excretion , as expected. Patients with unilateral PA had higher pro b-type natriuretic peptide  and urinary sodium excretion .There was no significant difference according to age, sex, BMI, or blood pressure in bilateral versus unilateral PA . UnilateP < 0.001; P = 0.012) after ADX, which was not the case in patients with bilateral disease treated with MRA. This drop was maintained at 3 years in unilateral PA, whereas sodium excretion remained high in bilateral disease . After adjustment for sex, because KCNJ5 mutation is found more frequently in females , these differences disappeared, in line with a sex-related influence of salt intake rather than a specific genetic impact of the KCNJ5 mutation  as well as 3-year  follow-up  and 3-year reassessment .After initiation of treatment of PA urinary sodium excretion still correlated with parameters of metabolic syndrome including dyslipidemia, higher fasting plasma glucose, hemoglobin A1c, and BMI . SimilarP = NS). Taking into account the average sodium excretion from baseline to 3-year follow-up, 11 of 15 cardiovascular events occurred in the high-sodium group.Over time, we recorded 15 cardiovascular events in our patients. Dividing the total cohort symmetrically into low and high urinary sodium excretion according to baseline values, we observed 10 cardiovascular events in the high sodium group, but only 5 in the low sodium group . Following ADX, estimated daily salt intake was reduced from 11.9 g to 10.2 g without any further lifestyle intervention in the unilateral group but remained unchanged in the bilateral subgroup treated with MRA. In conjunction with the findings of He et al , who repIn addition to the sodium-retaining function of aldosterone, several physiological pathways have been proposed by which aldosterone affects sodium intake. These include sodium sensing via the ENaC in the tongue and salt appetite regulation in the brain. The ENaC is expressed in the gustatory system and more precisely in the taste buds of the tongue. Although not all mechanisms are completely understood, treatment with amiloride is known to reduce taste intensity for sodium . In rodeThe most popular hypothesis based on evidence from rodent studies is that aldosterone is involved in salt appetite via activation of mineralocorticoid receptor in the brain and up-regulation of serum- and glucocorticoid-induced kinase SGK1. Rats injected with aldosterone into the cerebral fourth ventricle or the amygdala increased daily salt intake, an effect that could be blocked by pretreatment with intracerebroventricular application of MRA including spironolactone , 42. TheIn contrast to our findings, Catena et al found a significant decrease of urinary sodium excretion not only in a cohort of 30 patients with unilateral PA undergoing ADX, but also in 35 bilateral PA patients after 1 year of MRA treatment . The maiOur study represents a retrospective analysis of prospectively collected data of patients included in our Munich center of the German Conn’s Registry. A limitation in this context is the lack of dietary assessments  to evaluate sodium intake. However, dietary assessments often deal with difficulties quantifying sodium concentration in different sources as well as underestimation in case of social acceptability . A minorThe strengths of our study include the prospective standardized collection of all data and biomaterial within the context of the German Conn’s Registry. This allowed us to include a large number of patients both with unilateral and bilateral disease who were adequately phenotyped in a standardized fashion and had a 3-year follow-up. Furthermore, we used 24-hour urinary sodium excretion to estimate dietary salt intake, which is considered the gold standard, despite its pitfalls concerning complete 24-hour collection and variability .


A total of 103 HMP and 103 SCS instances fitted the matching criteria. Prior to PS matching, the CIT was longer in the HMP group , while the delayed graft function (DGF) rates were 29.8% and 32.3% in HMP and SCS, respectively. In the PS matched groups, the DGF rate was 64.1% in SCS vs. 31.1% following HMP: equivalent to a 51.5% reduction of the DGF rate . DGF was associated with decreased 1- and 3-year graft survival  or a 4.1-fold increased risk of graft failure . HMP significantly reduces DGF in kidney transplantation. DGF remains a strong predictor of graft survival.Hypothermic machine perfusion (HMP) has been introduced as an alternative to static cold storage (SCS) in kidney transplantation, but its true benefit in the clinical routine remains incompletely understood. The aim of this study was to assess the effect of HMP vs. SCS in kidney transplantation. All kidney transplants performed between 08/2015 and 12/2019 ( Kidney transplantation (KTx) is the therapy of choice for patients with end-stage renal disease (ESRD). The shortage of donor organs results in an ever-increasing waiting list and accumulating patient deaths. The donor pool and organ utilization have been expanded in recent years through the use of an increased number of marginal organs . ExtendeEarly attempts of dynamic organ preservation in the 1960s  were not®  and UW Machine Perfusion Solution (Belzer MPS®) were used for HMP. Before undergoing HMP, every kidney experienced a period of SCS. Kidneys from DCD were excluded since they represent only 1% of kidneys in our cohort. En-bloc KTx from pediatric donors, simultaneous pancreas kidney transplants (SPK), combined liver and kidney transplants (LKTx) and combined heart and kidney transplants (HKTx) were also excluded. The study was carried out in accordance with the STROBE  checklist [Following institutional ethics board approval (study number 1246/2019), a retrospective analysis of all deceased donor KTx performed at the Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, between August 2015 and December 2019, was conducted. Patients had undergone either single or double KTx from deceased donors. The LifePort Kidney Transporterhecklist . The decKidney graft loss was defined as return to chronic dialysis. Graft survival was not censored for death. DGF was defined as the need for at least one dialysis within the first seven days after transplant with the exception of dialysis for hyperkalemia or hypervolemia within the first 12 hours post-transplant . CytomegStandard immunosuppression included induction therapy with 20 mg basiliximab for first-KTx recipients (day 0 and 3); tacrolimus was administered from the first postoperative day onwards, aiming for trough levels of 8–10 ng/mL during the first three months, according to our institutional standard; mycophenolate mofetil 1000 mg was given twice daily together with a steroid taper. Patients undergoing re-transplantation received a single dose of 8 mg/kg antithymocyte globulin (ATG) as induction therapy. For infection prophylaxis, ampicillin/sulbactam was administered for three days. In case of CMV mismatch (D+/R−) or induction therapy with ATG, an antiviral prophylaxis with valganciclovir was applied for 90 days. Patients with DGF received neither additional treatment  nor standardized protocol biopsies.Continuous variables are presented as mean ± standard deviation (SD) in case of a normal distribution and as median and range otherwise. Categorical data are presented as number of cases with percentage. 2χ-test or Fisher’s exact test for categorical variables, as appropriate. Standardized mean differences [Baseline characteristics between kidney preservation (HMP/SCS) were tested using the independent-sample Mann–Whitney U test for non-normally distributed continuous variables and ferences  for compA propensity score matching with caliper of 0.05 was performed based on following variables: donor type (SCD/ECD), CIT, gender and CMV mismatch, number of transplants (first or Re-Tx) and ET-senior program . The quaThe effect of HMP on the incidence of DGF was modelled with the conditional logistic regression analysis. Patient and graft survival were calculated with Kaplan–Meier survival analysis method. Kaplan–Meier curves were limited at a number at risk of 10% of patients. The effect of DGF on graft survival was assessed using Cox regression analysis.p-value of less than 0.05 was considered to indicate statistical significance. All analyses were performed with SPSS  version 25 . A p = 0.638). Mean CIT was 17.5 ± 5.1 h and 13.3 ± 4.6 h in the HMP and SCS group, respectively . In the remaining 223/347 patients (64.3%), kidneys were transplanted following SCS. DGF occurred in 37/124 patients (29.8%) and 72/223 patients (32.3%) following HMP and SCS . n = 101) compared to ECD (n = 105); 41/101 (40.6%) vs. 57/105 (54.3%), p = 0.049. DGF was significantly less frequent following HMP compared to SCS; (32/103 (31.1%) vs. 66/103 (64.1%), p < 0.001, p = 0.001 for SCD and ECD (p = 0.001). DGF occurred in 98/206 patients (47.6%) and was less frequent in recipients of SCD organs ( and ECD B. A condn = 81) of transplants were performed during nighttime. SCS kidneys were more likely to be transplanted during nighttime  compared to HMP kidneys. Nighttime vs. daytime kidney transplant procedures did not differ in regard to postoperative complication rate (27.2% vs. 27.2%), DGF (49.4% vs. 46.4%) and graft loss (9.5% vs. 8.8%). When stratifying transplant procedures by time of surgery, 39.3% (p = 0.963). The flow increased significantly over the course of HMP (70mL/min (range 6–239) vs. 107mL/min (range 48–240), p < 0.001) and the intra-renal-resistance (IRR) index declined over time (0.39 mmHg/mL/min (range 0.6–4.7) vs. 0.22 mmHg/mL/min (range 0.1–0.5), p < 0.001). Flow and IRR index at 15 minutes of HMP were 82 mL/min (range 6–239) and 0.30 mmHg/mL/min (range 0.1–4.66) in patients with an immediate graft function compared to 55 mL/min (range 18–191) and 0.46 mmHg/mL/min (range 0.1–1.22) in patients with DGF; p = 0.074 and p = 0.080, respectively. At the end of perfusion, flow and IRR did not differ among patients with, and without DGF; .Median HMP time was 6.2 hours (1.9–18.8). Preservation time did not differ between patients with immediate graft function and DGF , lymphoceles (n = 19/9.2%), urological complications (n = 15/7.3%), wound infections (n = 13/6.3%) and vascular complications (n = 4/1.9%). Wound infections occurred significantly more often following SCS than after HMP; 10/9.7% vs. 3/2.9%, p = 0.041. The incidence of all other postoperative complications was comparable between groups as listed in Within the median observational period of 24 months, postoperative complications occurred in 56/206 patients (27.2%) and were comparable in patients receiving kidneys after HMP 27/103 (26.2%) and SCS 29/103 (28.2%). Most common complications were hematoma (After a median follow-up of 24.2 (range 0.33–53.8) months, 1- and 3-year patient survival was 99.0% and 97.1%, respectively. The 1- and 3-year graft survival rate reached 95.6% and 91.8%, respectively. p = 0.185 and p = 0.272, respectively, In the HMP group, 1- and 3-year patient survival was 100% and 99.0% and graft survival reached 97.1% and 95.2%, respectively. Primary non function (PNF) occurred in one patient following HMP. Following SCS, 1- and 3-year patient survival was 99.0% and 95.2%, whereas graft survival reached 94.2% and 88.4%, respectively. Patient and graft survival rates at 3-years post-transplant did not differ significantly between HMP and SCS . One year patient survival was 100% in patients with immediate graft function and 99% in patients with DGF . Patient survival at 3 years after transplantation was superior in cases with immediate graft function vs. DGF, but the difference did not reach statistical significance . In a Cox regression analysis, recipients suffering from DGF had a 4.1-times increased risk of graft failure  compared to 39.0 mL/min/1.73m2 (range 16.7–98.8) in patients after transplanting an SCS organ; (p = 0.177). Serum creatinine at last follow-up was 1.54 mg/dL (range 0.5–4.14) after HMP and 1.61 mg/dL (range 0.8–3.80) in patients after SCS (p = 0.260).In patients receiving a kidney after HMP, the glomerular filtration rate (GFR) at last follow-up was 44.8 mL/min/1.73 m2 (range 11.3–82.0) vs. 45.9 mL/min/1.73 m2 (range 15.6–122.4); p < 0.001 for both, 2 (range 15.6–122.4) vs. 51.7 mL/min/1.73 m2 (range 11.3–99.4); p < 0.001 for both.Serum creatinine and GFR at last follow-up were inferior in patients with DGF: 1.92 mg/dL (range 0.9–4.14) vs. 1.44 mg/dL (range 0.5–3.9) and 33.9 mL/min/1.73 mThe present study assesses the outcome after deceased donor kidney transplantation in organs undergoing HMP compared to a propensity score matched SCS cohort. Our analysis reveals a relatively strong clinical benefit of HMP with significant lower DGF rates in both ECD and SCD kidneys. However, the novel and important finding of our study is the fact that we can operate in a back-to-base fashion, accepting SCS kidneys and connecting them to HMP as soon as the organs arrive at our center. To our knowledge, our study describes for the first time that now a similar beneficial result with HMP over SCS can be achieved with SCS and end-HMP for 6.2 hours. Boffa et al presented the POMP trial by the COPE consortium  fairly rp = 0.001) in our cohort. While the protective effect of HMP is presumably more pronounced in ECD kidneys [Delayed graft function is the most significant early complication after deceased donor kidney transplantation. Further to its immediate effect on patient wellbeing and hospital stay, DGF has a negative long term impact on graft and patient survival . The inc kidneys ,28, we f kidneys . Interes kidneys . Graft survival at three years reached 91.8% (95.2% following HMP and 88.4% following SCS). In our series, the difference in graft survival between HMP and SCS did not reach statistical significance. With the apparent trend, we believe that this is due to the small sample size and reference properly powered studies (e.g., the Eurotransplant trial [Moreover, HMP led to a shift towards more daytime kidney transplant procedures. The impact of the daytime of surgery on the outcomes after transplantation is contradictory. Fechner et al observed a higher incidence of complications as well as inferior graft survival following nighttime kidney transplant procedures . In our ®. Further to the established HMP techniques, oxygenation during HMP has shown beneficial effect in several preclinical studies [Most studies performed in the last decade used the LifePort Kidney Transporter studies ,33,34. F studies . These fPoor kidney function in the first week is detrimental for both the patients’ perception and the longevity of the deceased donor kidney. Hypothermic machine perfusion was found to be clearly beneficial in several randomized clinical trials. We herein provide evidence that the actual benefit of HMP in the real-world scenario might be more significant and impactful than expected. Hypothermic machine perfusion impressively halved the DGF rate compared to SCS kidneys after similar periods of CIT. For the purpose of achieving the most optimal kidney preservation, HMP should be the preferred technique. Moreover, SCS kidney transportation in the ice box is relatively cheap, but if the back-to-base approach is used and the recipient center based HMP allows to achieve a beneficial effect, this could be very attractive and still cost-effective, especially within an international long-distance exchange organization. Future studies should emphasize on the impact of different durations of CIT accompanied by short periods of HMP to detect possible “rescue” time frames to consider even short periods of end ischemic HMP, for example, 2–3 hours only, crucial for optimal outcome after deceased donor kidney transplantation.


Adyn derived from echocardiographic measurements of stroke volume variations can predict the success of a one-step decrease of norepinephrine dose. In this prospective single-center study, 39 patients with vasoplegic syndrome treated with norepinephrine and for whom the attending physician had decided to decrease norepinephrine dose and monitored by thermodilution were analyzed. EAdyn is the ratio of pulse pressure variation to stroke volume variation and was calculated from echocardiography stroke volume variations and from transpulmonary thermodilution. Pulse pressure variation was obtained from invasive arterial monitoring. Responders were defined by a decrease in mean arterial pressure (MAP) > 10% following norepinephrine decrease. The median decrease in norepinephrine was of 0.04 [0.03–0.05] µg kg−1 min−1. Twelve patients (31%) were classified as pressure responders with a median decrease in MAP of 13% [12–15%]. EAdyn was lower in pressure responders . EAdyn was able to discriminate between pressure responders and non-responders with an area under the curve of 0.86 . The optimal cut-off was 0.8. EAdyn calculated from the echocardiographic estimation of the stroke volume variation and the invasive arterial pulse pressure variation can be used to discriminate pressure response to norepinephrine weaning. Agreement between EAdyn calculated from echocardiography and thermodilution was poor. Echocardiographic EAdyn might be used at bedside to optimize hemodynamic treatment.The purpose of this study was to determine whether dynamic elastance E Once the patient is stable and the underlying disease is treated, vascular function is progressively restored, and vasopressor weaning can start. Because prolonged weaning is responsible for unnecessary exposure to vasopressors (and their side effects) and because inappropriate early weaning can lead to arterial hypotension with tissue hypoperfusion, optimal vasopressor weaning is a cornerstone of hemodynamic treatment5.Acute circulatory failure is the result of several pathological mechanisms: hypovolemia, cardiac failure and/or vasoplegia. In the critically ill, arterial hypotension resulting from vasoplegia is a common symptom of a more complex process. Vasopressors are used to treat arterial hypotension, and they are therefore one of the main treatments for acute circulatory failure. Norepinephrine is the first-line vasopressor in intensive care6. Dynamic elastance (EAdyn) might be estimated as the ratio of stroke volume variation (SVV) to pulse pressure variation (PPV). Authors have demonstrated that EAdyn measured by calibrated pulse contour analysis (PCA- EAdyn) and by uncalibrated pulse contour analysis can predict the pressure response to a decrease in norepinephrine9. Patients with acute circulatory failure and treated with vasopressors are not always monitored by calibrated pulse contour analysis. However, PPV is available for most ICU patients and SVV can be measured by echocardiography. Because the agreement between critical care echocardiography and transpulmonary dilution is moderate10, we aimed to determine whether EAdyn calculated from echocardiographic SVV (TTE- EAdyn) could discriminate pressure response to a decrease in the dose of norepinephrine. Our secondary objective was to determine the agreement between EAdyn measured by calibrated pulse contour analysis and EAdyn measured by echocardiography.Dynamic elastance is a real time indicator of the interaction between the heart and the vascular system−1 min−1, with no difference between responders and non-responders. The median decrease in norepinephrine was 0.04 [0.03–0.05] µg.kg−1 min−1, again with no significant difference between groups .Baseline characteristics are shown in Table Adyn was lower in pressure responders  , the TTE-EAdyn predicted the decrease in arterial pressure , a specificity of 74% (CI95% [54–89]), a positive likelihood ratio of 3.54, and a negative likelihood ratio of 0.11. The bounds for inconclusive TTE-EAdyn were 0.47 and 0.8, and 7 patients (18%) had inconclusive TTE-EAdyn values (Supplementary file Adyn predicted the decreased in MAP with an AUC of 0.86 (CI95% [0.67–0.96]). The optimal cut-off was of 0.90.At baseline, TTE-E  and thus to determine which treatments should be used or withdrawn. High EAdyn might indicate an inappropriately high arterial load compared with stroke volume. According to the concept of ventriculo-arterial coupling, stroke work is optimized when the ventricular and arterial systems are coupled14. Because of its action on both α and β adrenergic receptors15, norepinephrine has an effect on arterial load, cardiac preload and /or cardiac contractility16. Norepinephrine might therefore be associated with both preload and non-preload stroke volume changes17. In patients with high EAdyn, lowering arterial load by decreasing norepinephrine might improve ventriculo-arterial coupling. The optimization of stroke work could compensate for the drop in arterial vasoconstriction, explaining the good tolerance (MAP non-response) to norepinephrine weaning. The method developed by Chen to obtain EAdyn requires complex calculation18 and simplified methods are not reliable in the ICU19; these limits suggest that bedside measurement of EAdyn may be more clinically appropriate than the measurement of ventriculo-arterial coupling. Recently, Monge Garcia et al. have demonstrated that Eadyn was inversely related to ventriculo-arterial coupling6, and that Eadyn could be used to track changes of ventriculo-arterial coupling following hemodynamic treatment.In practice, E21. The sample size also limited the use of parametric approach and prevented the realisation of more specific analysis such as ROC curve comparison between TTE-EAdyn and PCA-EAdyn (or TTE-SVV and PCA-SVV). The monocentric nature of the study limits the external validity, but our results are in accordance with previously reported data9. Finally, we did not measure ventriculo-arterial coupling.We acknowledge that this study has some limitations. First, the small sample size limits the power of the analysis, however, the results are significant and the sample size is in accordance with previous studiesAdyn calculated from the echocardiographic estimation of the SVV and the invasive arterial PPV could discriminate pressure response to norepinephrine decrease. Despite the poor agreement between SVV measurements obtained by thermodilution and by echocardiography, EAdyn might be useful at the patient’s bedside to optimize vasopressive treatment.EComité de Protection des Personnes Nord-Ouest II CHU—Place V. Pauchet, 80054 AMIENS Cedex 1). All subjects or next of kin  if the patient was unable to be informed, received written information about the study and provided their informed consent to participate. The study was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki. This prospective, observational study was conducted in the intensive care unit (ICU) of the Amiens University Hospital between July 2016 and March 2017. We included patients with a diagnosis of vasoplegic syndrome, treated with norepinephrine, and for whom the attending physician decided to decrease the norepinephrine dosage. Patients treated with epinephrine and/or dobutamine, and patients with arrhythmia, intra-abdominal hypertension or younger than 18 years old were excluded.This is an ancillary study using data from a prospective observational cohort. The study objectives and procedures were approved by the local ethics committee . Transthoracic echocardiography  was performed by a physician with advanced echocardiography certificate. Left ventricular ejection fraction (LVEF) was calculated using Simpson’s method on a four-chamber view. The diameter of the left ventricular outflow tract (LVOT) was measured on a long-axis parasternal view at the time of patient inclusion. The LVOT velocity–time integral (VTILVOT) was measured with pulsed Doppler on a five-chamber apical view. Stroke volume  was calculated as VTIAo × aortic area. Cardiac output (CO) (l/min) was calculated as SV × heart rate (HR). Respiratory variation of SV (SVVTTE) was calculated as: SVVTTE = (SVmax–SVmin)/((SVmax + SVmin)/2))*100. The maximum and minimum SV values were identified during one respiratory cycle (expiratory/inspiratory times), and averaged over 5 cycles to obtain SVmax and SVmin23. We calculated the reproducibility of SVVTTE that was 8.1 (± 4.4) %. The physician who performed echocardiography was blinded to the results of the study.All patients were monitored with arterial catheterisation, central venous pressure (CVP) 13. We measured SVV with a calibrated pulse contour analysis , representing the average of three successive values. Echocardiographic dynamic arterial elastance (TTE-EAdyn) was calculated as the ratio of PPV/SVVTTE, and calibrated pulse contour analysis dynamic arterial elastance (PCA-EAdyn) was calculated as PPV/SVV.PPV was automatically calculated by the Philips monitoring system, representing the average of five successive values. SVV and PPV were sampled during the same time period on a radial arterial lineTTE, SVV, PPV, and cardiac output (CO) were recorded at baseline. The dose of norepinephrine was then decreased. After the hemodynamic variables had stabilised, defined as < 10% variation in MAP over a 30-min period, a second set of measurements  was recorded. Ventilator settings and sedation were kept constant throughout the study period. All patients had mechanical ventilation in volume-controlled mode. Ventilator settings  were not modified during the study period.The intervention assessed in this study was a one-step decrease in the dose of norepinephrine. The following clinical parameters were recorded for each patient: age, gender, surgical/medical history, and indications for norepinephrine treatment. Hemodynamic variables including HR, systolic arterial pressure (SAP), mean arterial pressure (MAP), diastolic arterial pressure (DAP), central venous pressure (CVP), SVV95%): 4–10). Based on LSC, we defined a positive response (pressure responders) as a decrease in MAP of over 10%8. Qualitative data were compared with a chi-squared test or Fisher’s test, and quantitative data were assessed with a Student’s t test or Kruskal–Wallis sum rank test, as appropriate. Paired data were compared with paired Student’s t test or Wilcoxon signed rank test. Changes in hemodynamic variables were expressed as percentages from baseline value. Receiving operator characteristic (ROC) curves were drawn and the areas under the curve (AUC) were calculated. The optimal cut-point was determined using the Youden Method. The concordance correlation coefficient between TTE-EAdyn and PCA-EAdyn was calculated, and the agreement was represented on a Bland–Altman plot. A grey-zone approach was used, and values for which both sensitivity and specificity were lower than 90% were considered inconclusive. The threshold for statistical significance was set at p < 0.05. RSTUDIO  was used for all statistical analyses.Retrospective power analysis shows that a sample of 39 patients enable to demonstrate an area under the receiver-operating-characteristic curve greater than 0.77, a power of 80%, and an α risk of 0.05. The distribution of variables was assessed using a Shapiro–Wilk test. Data are expressed as numbers, proportions (in percent), medians [interquartile range] or as means (standard deviation). The coefficient of variation (CV), precision and least significant change (LSC) for MAP were calculated on the overall population. The LSC was 7% . All subjects or next of kin  if the patient was unable to be informed, received written information about the study and provided their informed consent to participate.This is an ancillary study using data from a prospective observational cohort. The study objectives and procedures were approved by the local ethics committee (Supplementary Information


ObjectiveThe objective of the study is to identify the predominant determinants of arterial stiffness as assessed by pulse-wave-velocity (PVW) amongst various 24-hour ambulatory blood pressure monitoring (ABPM) parameters in Indian hypertensive subjects.MethodSubjects of both genders between 18-60 years with hypertension and who were either drug naïve or on stable anti-hypertensive treatment for at least three months were included in the study. All subjects underwent clinical evaluation with a medical history, biochemical investigations, and assessment of arterial stiffness by PWV along with 24-hour ABPM.ResultsWe found the males were younger than females amongst hypertensive cohort  and had shorter duration of hypertension  and had lower 24-hour average pulse pressure  at baseline. Younger people (<40-years) as compared to those >40-years of age had the lower carotid-femoral (cf) PWV  and average brachial-ankle (ba) PWV . Bivariate analysis revealed that amongst all the 24-hour ABPM parameters, 24-hour aPP had the strongest correlation  with arterial stiffness as assessed by PWV. Also, statistically significant correlation was found in age group <40 years between cf-PWV and both 24-hour aPP  as well as night-time aPP ConclusionWe conclude that 24-hour aPP showed the strongest correlation with arterial stiffness parameters and best correlated with arterial stiffness variables amongst 24-hour ABPM parameters, especially amongst subjects <40 years of age. The pulsatile blood pressure (BP) was a better predictor of aortic PWV than the continuous part of BP. Cardiovascular diseases are the leading cause of death worldwide, and now India is also synchronizing with global data. The major risk factor contributing to cardiovascular diseases is hypertension (HTN), which contributes to nearly 7.1 million premature deaths, two-thirds of all strokes, and half of all myocardial infarction every year [It affected an estimated 118 million inhabitants in India in 2000; this number is projected to double to 214 million by 2025 . PresentRecently ambulatory blood pressure monitoring (ABPM) is also gaining importance due to its benefits like measurement of the white coat effect, masked effect, and nocturnal dipping in hypertensives. Arterial stiffness is increasingly recognized as an important and independent contributor to cardiovascular (CV) morbidity and mortality in many patient subsets, particularly in the elderly, hypertensive, and those with end-stage renal disease -12. AortSeveral studies have measured arterial stiffness in Indian subjects, but none has adequately reported its relationship with HTN by employing ambulatory BP monitoring -15. ThisFifty-one subjects aged between 18 to 60 years presenting to the cardiology outpatient department from a period from January 2017 to December 2017 who were diagnosed to be a case of essential hypertension and who were either on no anti-hypertensive medication or on stable anti-hypertensives for the preceding three months or more were included in the study.Subjects not willing to participate, diagnosed as a case of secondary hypertension, impaired renal functions, pregnant, with previously established cardiovascular disease, essential hypertension on medication for less than three months, and with a present history of any acute systemic illness were excluded from our study. We also excluded patients with diabetes mellitus or who had a history of tobacco consumption due to potential confounding effects of these factors on arterial stiffness. The study protocol was approved by the institutional Ethics Committee (IEC). Informed consent was obtained from all the participants prior to their enrollment in the study. Once enrolled, all subjects underwent clinical evaluation and biochemical investigations and assessment of arterial stiffness and ambulatory BP monitoring.Statistical analyses were done using SPSS for Windows version 24.0 . Comparisons between the groups were carried out using the independent Student t-test. Correlations among different arterial stiffness measurements were assessed using Pearson’s correlation coefficients. A p-value < 0.05 was considered statistically significant.The baseline clinical characteristics of the study population are presented in Table 2) with an overall mean body mass index of 28.71 kg/m2.Out of all the subjects (n=51), 29 subjects (56.1%) were on regular treatment with either single or a combination of anti-hypertensive medications for more than three months. The remaining 22 subjects (43.9 %) were not on any regular anti-hypertensive medication. The distribution of subjects according to BMI is as follows: the majority (94.11 %) were overweight  cholesterol.The distribution of 24-hour ambulatory parameters is given in Table Arterial stiffness parametersWe analyzed various pulse wave velocity parameters  during the study. We divided the subjects into two groups according to gender and compared the various parameters between the two groups. The results of the independent sample t-test for both males and females are presented in Table We analyzed the subjects into two groups according to age  and compared the various parameters between the two groups. The results of the independent sample t-test for both the age groups are presented in Table Pearson’s correlation coefficients (r) between 24-hour ambulatory blood pressure parameters and pulse wave velocity parameters are presented in Table We found a statistically non-significant correlation  between systolic nocturnal dipping and cf-PWV. Pearson’s correlation coefficient between pulse wave velocity and other clinical parameters is presented in Table Pearson’s correlation coefficient between pulse wave velocity and 24-hour ambulatory blood pressure parameters in the age group <40 years and >40 years is presented in Table Our study is the first study amongst Asian Indians to report the relationship between various 24-hour ambulatory blood pressure parameters and arterial stiffness in middle-aged hypertensive subjects. The results of our studies show:1) arterial stiffness increases progressively as BP increases;2) 24-hour average pulse pressure, day-time average pulse pressure, night-time average pulse pressure, 24-hour average SBP, day-time average SBP, and age were statistically significantly correlated with cf-PWV, the strongest correlation being with 24-hour average pulse pressure;3) there was no significant correlation between ‘nocturnal dipping’ and arterial stiffness;4) in the age group <40 years, we found a statistically significant correlation between cf-PWV and both 24-hour average pulse pressure and night-time pulse pressure;5) the pulsatile BP had more impact on aortic PWV than the continuous part of BP.Arterial stiffness is related to BP and is an independent predictor of CV events in hypertensives, so it is recommended in evaluation . Ngim etSa Cunha et al. recommended gender difference - in both sexes, SBP showed a correlation with PWV, while only in women, DBP was correlated with PWV . In contInterestingly, Nurnberger et al. reported a contrary result . They shIn a similar study by Kim et al., authors measured BP by invasive measures and also found that among a number of BP parameters, PP demonstrated the greatest association with aortic PWV in normotensive and untreated middle-aged and elderly hypertensive subjects . As the Our study is the first Indian study to report the relationship between various 24-hour ambulatory blood pressure parameters and arterial stiffness in middle-aged hypertensive subjects.One of the limitations of our study was that although the non-invasive technique showed acceptable reproducibility, the length of the arterial segment was usually estimated by direct superficial measurement of the distance between two transducers. As arteries get longer and more tortuous with age, aortic PWV will therefore be overlooked by a non-invasive procedure. The restricted sample size was also another drawback of the analysis.This study concluded that in hypertensive middle-aged subjects, 24-hour average pulse pressure showed the strongest correlation with arterial stiffness and was the predominant determinant of arterial stiffness among different 24-hour ambulatory blood pressure parameters. Pulsatile BP had more impact on aortic PWV than the continuous part of BP. In combination with the previous studies, the present study also suggests that the role of ambulatory BP parameters as a predictor of PWV could be different according to the age range of the population studied.


Increased cerebral arterial pulsatility is associated with cerebral small vessel disease, recurrent stroke, and dementia despite the best medical treatment. However, no study has identified the rates and determinants of progression of arterial stiffness and pulsatility.In consecutive patients within 6 weeks of transient ischemic attack or nondisabling stroke (OXVASC [Oxford Vascular Study]), arterial stiffness (pulse wave velocity [PWV]) and aortic systolic, aortic diastolic, and aortic pulse pressures (aoPP) were measured by applanation tonometry (Sphygmocor), while middle cerebral artery (MCA) peak (MCA-PSV) and trough (MCA-EDV) flow velocity and Gosling pulsatility index  were measured by transcranial ultrasound . Repeat assessments were performed at the 5-year follow-up visit after intensive medical treatment and agreement determined by intraclass correlation coefficients. Rates of progression and their determinants, stratified by age and sex, were determined by mixed-effects linear models, adjusted for age, sex, and cardiovascular risk factors.P<0.0001) and aoPP  but not significantly for MCA-PI overall . However, PWV increased at a faster rate with increasing age , while aoPP and MCA-PI increased significantly above the age of 55 years . Higher aortic systolic blood pressure and diastolic blood pressure predicted a greater rate of progression of PWV and aoPP, but not MCA-PI, although current MCA-PI was particularly strongly associated with concurrent aoPP (P<0.001).In 188 surviving, eligible patients with repeat assessments after a median of 5.8 years. PWV, aoPP, and MCA-PI were highly reproducible , with progression of PWV (2.4%; Arterial pulsatility and aortic stiffness progressed significantly after 55 years of age despite the best medical treatment. Progression of stiffness and aoPP was determined by high blood pressure, but MCA-PI predominantly reflected current aoPP. Treatments targetting cerebral pulsatility may need to principally target aortic stiffness and pulse pressure to have the potential to prevent cerebral small vessel disease. White matter hyperintensities are particularly associated with a history of hypertension and markers of vascular aging,1 such as aortic stiffness and pulsatility of blood flow in the aorta and the cerebral circulation.7 However, despite suggestive post hoc analyses of clinical trials,9 no dedicated prospective study has identified treatments to reduce progression of cerebral SVD.11Small vessel disease (SVD) is associated with acute lacunar stroke,12 However, there is no evidence for a temporal relationship between arterial stiffness, aoPP, and cerebral pulsatility and their progression over time. Furthermore, an accurate estimate of the rate of progression and its determinants is critical for the planning and interpretation of clinical trials that aim to prevent progression of arterial stiffness and pulsatility,13 particularly after control of classical cardiovascular risk factors such as hypertension.Reducing cerebral arterial pulsatility and aortic stiffness, and resulting clinical harms, depends upon understanding the rate of progression and identification of the physiological processes responsible for elevated pulsatility. In cross-sectional analyses, cerebral arterial pulsatility is strongly associated with aortic pulse pressure (aoPP), a relationship that is partially mediated by arterial stiffness, implying increased transmission of aoPP to the brain through stiff vessels.We, therefore, determined the rates of progression of residual arterial stiffness, aoPP, and cerebral arterial pulsatility and their determinants over 5 years in a population of patients with recent transient ischemic attack or minor stroke, after optimal control of blood pressure and cardiovascular risk factors according to current guidelines.peter.rothwell@ndcn.ox.ac.uk) upon reasonable request.The data that support the findings of this study are available from P.M.R. , an echocardiogram, and 5 day ambulatory cardiac monitor. All patients were assessed by a study physician, reviewed by the senior study neurologist (P.M.R.), and were followed up face to face at 1, 3, 6, and 12 months and 2, 5, and 10 years. Medication is prescribed according to guidelines, most commonly with dual antiplatelets (aspirin and clopidogrel) for 1 month and monotherapy thereafter, high-dose statins , and a combination of perindopril and indapamide, with the addition of amlodipine and other agents as required to reach a target of <130/80, guided by home telemetric blood pressure monitoring for the first month in the majority of participants.Consecutive, consenting patients with transient ischemic attack or minor stroke were recruited between September 2010 and September 2019, as part of the Phenotyped Cohort of OXVASC (Oxford Vascular Study).As part of the OXVASC phenotyped cohort, a routine prospective cardiovascular physiological assessment is performed at the 1-month follow-up visit. Since August 2017, all surviving participants still registered with OXVASC primary care physicians are eligible to undergo a repeat physiological assessment when attending for their 5-year follow-up visit. Participants undergoing a repeat study as part of an assessment for a recurrent cerebrovascular event >2.5 years after their initial physiological assessment could also be included. Participants were excluded if they were under 18 years of age, cognitively impaired , pregnant, and had autonomic failure, a recent myocardial infarction, unstable angina, heart failure (New York Heart Association class 3–4 or ejection fraction <40%), or untreated bilateral carotid stenosis (>70%). OXVASC is approved by the Oxfordshire Research Ethics Committee.14 with consistent sites of measurement at baseline and follow-up, as possible. Transcranial Doppler  was performed with a 2-MHz probe at the temporal bone window on the same side as carotid applanation, where possible. The waveform envelope was acquired at 100 Hz simultaneously with ECG and blood pressure at 200 Hz , via a Powerlab 8/30 with LabChart Pro software (ADInstruments).17 The middle cerebral artery (MCA) was insonated at the site of peak velocity closest to 50 mm, or if this was not adequate, at the depth giving the optimal waveform, excluding patients with velocity transitions indicative of a focal MCA stenosis. All waveforms were visually inspected, and beats corrupted by artifact were excluded. Absolute peak, trough, and mean cerebral blood flow velocity (CBFV) was calculated as the average of the remaining beats during a 15-second window, from the envelope of the spectrum. Where reported, mean BP was calculated as diastolic blood pressure (DBP)+1/3×pulse pressure. MCA pulsatility was calculated as Gosling pulsatility index . Rate of change in PWV and aortic and cerebral hemodynamic indices were determined as the absolute difference or the percentage change from baseline, divided by the number of years between assessments.Physiological tests were performed at rest in a quiet, dimly lit, temperature-controlled room (21–23 °C). Applanation tonometry  was used to measure carotid-femoral pulse wave velocity , aortic augmentation index, and aortic systolic blood pressure (aoSBP) and aortic diastolic blood pressure (aoDBP) and aoPP,t test. Rates of progression of measures of arterial stiffness, aortic blood pressure, and CBFV were determined by linear mixed-effects modeling, with autoregressive covariance structure to account for repeated measures. Analyses were stratified by age and sex, with rates of progression determined by the interaction with the time interval between visits, as continuous indices and stratified by age group . Potential determinants of absolute values and rates of progression were assessed, unadjusted, and adjusted for age, sex, and cardiovascular risk factors . Results are reported according to the STROBE reporting guideline.18Consistency in measures between baseline and follow-up was determined by intraclass correlation coefficients and linear regression and visually by the Bland-Altman plots. Significant changes in indices between baseline and follow-up were assessed by paired Analyses were performed in R and Matlab r2018.Figure S1). Of the included patients, 150 had arterial stiffness assessments at baseline and follow-up, while 139 had TCD performed on both occasions. Demographic characteristics were similar between patients undergoing arterial stiffness and TCD measures , with PWV as the most reproducible index. Absolute indices of aortic blood pressure or CBFV were also significantly reproducible, but less so than pulsatility or arterial stiffness measures, with weaker correlations between baseline and follow-up values , aoPP, and cerebral arterial pulsatility were all highly reproducible within individuals over the 5 years of follow-up (Table es Table .P=0.04). The increase in aoPP reflected a significant fall in aoDBP , with a rise in aoSBP (P=0.01), but both cerebral peak and trough flow velocities fell with time . Cerebral arterial pulsatility increased nonsignificantly across all patients , although the rate of change of aoPP or MCA-pulse pressure above 55 years was not consistent across age groups .aoPP was significantly greater in women than in men and increased at a faster rate Table , while MP=0.048). Similarly, higher aoSBP and aoDBP, elevated heart rate, and a greater cerebral pulsatility were associated with a greater rate of increase in aoPP, with persistent associations with progression of aoPP and aoSBP and aoDBP, even after adjustment for arterial stiffness and aortic blood pressure (P=0.0001 for both).Elevated aoSBP, aoDBP, and aoPP were all associated with a greater rate of progression of PWV Table , but croIn contrast to aortic measures, a greater rate of progression of MCA-PI was only associated with increased age and female sex Table  and a loThis is the first study of progression of aortic stiffness, aoPP, and cerebral arterial pulsatility in a single patient cohort, following good blood pressure control. Over 5 years, aortic stiffness and aortic systolic pressure rose while aortic diastolic pressure fell, with a resulting increase in aoPP. Cerebral pulsatility rose above the age of 55 years, reflecting a fall in end-diastolic velocity with no rise in peak systolic velocity. The rate of rise in PWV and aoPP was associated with age and elevated aortic blood pressure, but only age, female sex, and a low end-diastolic flow velocity predicted an increased rate of rise in MCA-PI, although the current MCA-PI level was strongly associated with concurrent aoPP.17 cerebral SVD was associated with cerebral arterial pulsatility, which was principally associated with aortic stiffness and transmission of increased aoPP to the brain. Furthermore, there were similar distributions of aortic stiffness, aoPP, and cerebral arterial pulsatility by age and sex, and the cross-sectional relationship between aoPP and cerebral arterial pulsatility was partially mediated by arterial stiffness.19 This longitudinal follow-up study confirms the strong concurrent association between aoPP, aortic stiffness, and cerebral arterial pulsatility and further demonstrates that aortic blood pressure level predicts a greater increase in the rate of progression of aortic stiffness and pulsatility. As such, although an acute reduction in aoPP may reduce cerebral arterial pulsatility directly, control of midlife elevated aortic blood pressure, and DBP in particular, may reduce progression of arterial stiffness and aoPP and, therefore, future cerebral SVD and its sequelae. Furthermore, this population had undergone intensive blood pressure monitoring and treatment, with a minimal difference between treatment at the time of initial assessment and at follow-up 5 years later,20 although there was an increase in clinic systolic blood pressure between baseline and follow-up, potentially influencing measurement of PWV, although this could reflect a white-coat response especially as home readings were not available. Nonetheless, this study demonstrates that residual aortic blood pressure and pulsatility were still associated with increased cerebral pulsatility despite excellent control of blood pressure and other risk factors, presenting a potentially modifiable risk factor in addition to current standard treatment.In previous cross-sectional analyses in this population,21 and the stronger relationship between midlife elevated DBP with cerebral white matter hyperintensities,22 compared with greater systolic blood pressure and pulsatility above the age of 55 years. Furthermore, although DBP fell as arterial stiffness increased, a higher aoDBP was still the strongest driver of progression of PWV and, therefore, a subsequent fall in DBP. This indicates the likely critical role for control of midlife DBP to prevent later progression of aortic stiffness and pulsatility and resulting cerebral pulsatility.The majority of the progression in arterial stiffness and pulsatility occurred after the age of 55 years, with steadily increasing rates of progression of arterial stiffness consistent with previous studies in hypertensive populations. Both aortic and cerebral pulsatility were greater above 55 years but with a limited ongoing increase in the rate of progression thereafter. This apparent transition at ≈55 years of age is consistent with the average age of transition to late-life hypertensive phenotypes23 amlodipine reduced aortic systolic pressure to a greater extent than a β-blocker, while cilostazol reduced cerebral pulsatility in the ECLIPse study .24 Currently, isosorbide mononitrate and cilostazol are being assessed in the LACI (Lacunar Intervention)-1/LACI-2 studies ,25 antihypertensives in the TREAT-SVDs trial , and sildenafil in the OxHARP trial .Although no systemic hemodynamic measures were specifically associated with progression of cerebral pulsatility, current cerebral pulsatility was most strongly associated with concurrent aoPP. As such, targetting both excess aortic systolic pressure and diastolic pressure in midlife while not excessively reducing diastolic pressure in late life may reduce progression of aoPP and, therefore, later-life cerebral arterial pulsatility. This may be possible with peripheral vasodilators that reduce wave reflection from the peripheral circulation. For example, in the CAFE study ,27 Furthermore, despite the moderate size, associations were strong and consistent with previous evidence while building upon it. Second, not all participants underwent both TCD and arterial stiffness measures. This is inevitable in a pragmatic study including all patients with transient ischemic attack or minor stroke, due to the relatively high incidence of participants with poor bone windows for TCD or, for PWV, significant large artery disease or increased body mass index. Third, due to the age and frailty of the population, only 50% of the baseline population could be reassessed at 5 years, as many were deceased or had moved out of the area. This may result in underestimation of the degree of progression of age-related variables due to attrition of higher risk patients with greater progression, but any resulting bias is likely to be conservative. Furthermore, the median age of the population was relatively old for a follow-up study , supporting the relevance of these results to the population most at risk. Fourth, patients with atrial fibrillation were included in the analyses as PWV and PI are still relevant in this group, but atrial fibrillation may reduce reliability of assessment of PWV in particular. Finally, without repeat brain imaging, we were unable to assess whether progression of cerebral arterial pulsatility mediates the relationship between arterial stiffness, aoPP, and progression of cerebral SVD.This study does have some limitations. First, it is relatively small. However, it is still significantly larger than any other available study recording both aortic and cerebral indices, and other studies have not assessed progression of these measures in this patient population.Overall, the strong relationship between residual aortic blood pressure after intensive blood pressure treatment and longitudinal progression of arterial stiffness and pulsatility supports the need for further research to determine the temporal relationship with other key physiological mechanisms affected in SVD, such as blood pressure variability, cerebral autoregulation, and cerebrovascular reactivity, which represent alternative potential treatment targets. Further trials will then be necessary to determine whether modifying cerebral pulsatility or other mechanisms translates to a reduction in progression of cerebral SVD, proceeding to large clinical trials to determine whether such interventions translate to meaningful clinical effects.Arterial pulsatility and aortic stiffness progressed significantly over the age of 55 years in a population of patients with transient ischemic attack or minor stroke. Progression of aortic measures was most strongly associated with age and elevated aortic blood pressure, while only age, sex, and low diastolic CBFV predicted progression of cerebral arterial pulsatility. However, aoPP was the strongest association of concurrent cerebral pulsatility, identifying a potentially treatable mechanism to limit progression of cerebral SVD.We are grateful to all the staff in the general practices that collaborated in the OXVASC study (Oxford Vascular Study): Abingdon Surgery, Stert St, Abingdon; Malthouse Surgery, Abingdon; Marcham Road Family Health Centre, Abingdon; The Health Centre, Berinsfield; Key Medical Practice; Kidlington; 19 Beaumont St, Oxford; East Oxford Health Centre, Oxford; Church Street Practice, Wantage. This work uses data provided by patients and collected by the National Health Service as part of their care and support and would not have been possible without access to these data. The National Institute for Health Research recognizes and values the role of patient data, securely accessed and stored, both in underpinning and leading to improvements in research and care. This research was funded, in whole or in part, by the Wellcome Trust, grant number 206589/Z/17/Z. A CC BY licence is applied to author accepted manuscript arising from this submission, in accordance with the grant’s open access conditions. A.J.S. Webb devised, acquired, supervised, and analyzed the physiological assessments; devised, analyzed, and supervised the statistical analysis; and drafted, analyzed, edited, and submitted the manuscript. A. Lawson, Dr Mazzucco, and K. Wartolowska acquired data. A. Lawson analyzed and cleaned data. P.M. Rothwell established and supervised the OXVASC study; devised, initiated, and supervised the physiological studies and statistical analyses; and edited and supervised the manuscript.The OXVASC (Oxford Vascular Study) is funded by the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC), Wellcome Trust, Wolfson Foundation, British Heart Foundation, and the European Union Horizon 2020 programme . P.M. Rothwell is in receipt of an NIHR Senior Investigator award. A.J.S. Webb and this work is funded by a Wellcome Trust Clinical Research Development Fellowship (206589/Z/17/Z) and British Heart Foundation Project grant (PG/16/38/32080). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health.None.Figures S1–S3Tables S1–S4


Advanced age , serum alkaline phosphate level , and log-transformed osteocalcin levels  were identified to be negatively correlated with VRI in KT recipients. Multivariable forward stepwise linear regression analysis revealed that the serum level of osteocalcin  and advanced age  were significantly and independently associated with VRI in KT recipients. Conclusions: Higher serum osteocalcin level was associated with lower VRI and poorer endothelial dysfunction among KT recipients.Background and Objectives: Osteocalcin is the most abundant noncollagenous protein in bone matrix, which is considered a marker of bone formation. Previous studies indicate that circulating osteocalcin can be expressed by osteoblasts and even by osteoblast-like cells in vessel walls, and it is often associated with arterial stiffness. Our study aims to examine the potential association between osteocalcin levels and endothelial function among kidney transplant (KT) recipients. Materials and Methods: Fasting blood samples were obtained from 68 KT recipients. To measure the endothelial function and vascular reactivity index (VRI), a digital thermal monitoring test (VENDYS) was used. A commercial enzyme-linked immunosorbent assay kit was also utilized to measure serum total osteocalcin levels. In this study, a VRI of less than 1.0 indicated poor vascular reactivity; a VRI of 1.0–2.0 indicated intermediate vascular reactivity; and a VRI of 2.0 or higher indicated good vascular reactivity. Results: Our findings show that 8 KT recipients (11.8%) had poor vascular reactivity (VRI < 1.0), 26 (38.2%) had intermediate vascular reactivity (1.0 ≤ VRI < 2.0), and 34 (50%) had good vascular reactivity. Increased serum osteocalcin levels ( Cardiovascular disease is one of the major causes of morbidity and mortality in kidney transplant (KT) recipients. The annual rate of cardiovascular events is approximately 3.5% to 5%, and these events are responsible for approximately 30% of all-cause deaths . This coEndothelial dysfunction is a key initial event in the pathogenesis of atherosclerosis, and it contributes to the formation and progression of plaque . It has Osteocalcin, a γ-carboxyglutamic acid containing noncollagenous protein, has been identified to be secreted by osteoblasts, and they are usually stored in bones, bound to hydroxyapatite and calcium; in its undercarboxylated form, it is released into circulation. It is now generally accepted that impaired bone metabolism may lead to the development of vascular calcification; this concept is consistent with the observation that bone loss is associated with increased vascular calcification and increased incidence of cardiovascular events . VasculaA total of 68 patients, who received non-preemptive KTs at a medical center in Hualien, Taiwan, between September 2015 and February 2016, were included in this study. The study protocol was approved by the Research Ethics Committee of Hualien Tzu Chi Hospital of the Buddhist Tzu Chi Medical Foundation (IRB104-84-B) and was conducted in accordance with the tenets of the Helsinki Declaration. All patients provided their written informed consent before participating in this study. Hypertension has been defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher; patients who had received any antihypertensive medication in the previous 2 weeks were considered to have hypertension. Patients were excluded from the study if they had a dialysis access fistula or grafts in the upper extremities, acute infection, heart failure, acute transplant rejection status, and malignancy at the time of blood sampling; some opted not to join the study.Participants were weighed, wearing lightweight clothing without shoes, to the nearest 0.5 kg, and body height was measured to the nearest 0.5 cm. Body mass index was calculated as the weight in kilograms divided by the height in meters squared .Fasting blood samples (approximately 5 mL) of all participants were immediately centrifuged at 3000 g for 10 min. An auto-analyzer  was used to measure serum levels of blood urea nitrogen (BUN), creatinine, fasting glucose, total cholesterol, triglycerides, calcium, and phosphorus . CommercAfter patients fasted overnight and abstained from using tobacco, alcohol, caffeine, and vasoactive medications, we collected endothelial function parameters by using a digital thermal monitoring device approved by the US Food and Drug Administration . After letting the patients rest in a supine position for 30 min in a room with a temperature of 22 °C to 24 °C, blood pressure cuffs were put on their right upper arm, and skin temperature sensors were placed on bilateral index fingers . Digital thermal monitoring of both hands was performed during 5-min stabilization, 5-min cuff inflation, and 5-min deflation. The right upper arm cuff was rapidly inflated to 50 mm Hg greater than systolic blood pressure for 5 min and then rapidly deflated to invoke a reactive hyperemic response in the fingertip distally. The more the temperature rebounded, the better the vascular reactivity. VRI has been defined as the maximal temperature difference between the rebound curve and the zero reactivity curves during the period of reactive hyperemia period, calculated by the VENDYS software. VRIs were found to range from 0.0 to 3.5; a VRI of less than 1.0 indicated poor vascular reactivity; a VRI ranging from 1.0 to 1.9, intermediate vascular reactivity; and a VRI of 2.0 or greater, good vascular reactivity ,11.p-value of less than 0.05 was considered statistically significant. All statistical analyses were performed using the statistical package SPSS for Windows .Data were calculated as means ± standard deviation (SD) and were assessed for normal distribution using the Kolmogorov-Smirnov test. Measured values between groups  were assessed using a Kruskal-Wallis analysis for parameters with non-normal distribution  and one-way analysis of variance for normally distributed data; then measured values were analyzed using Fisher’s protected t-test. Fasting glucose, triglycerides, BUN, creatinine, and osteocalcin levels were log-transformed to fulfill normality. Variables that correlated with VRI were examined using simple linear regression analyses, and significant variables were included in a multivariable forward stepwise regression analysis. A p = 0.001). Among the comorbid conditions, 31 patients (45.6%) were identified to have diabetes, and 26 (38.2%) had hypertension. Prescribed immunosuppressant drugs included tacrolimus, taken by 45 patients (66.2%); mycophenolate mofetil, taken by 43 patients (63.2%); steroids, taken by 59 patients (86.8%); rapamycin, taken by 4 patients (5.9%); and cyclosporine, taken by 14 patients (20.6%). Among the different groups, no significant differences were noted in the following factors as follows: gender; transplantation model; the presence of diabetes or hypertension; use of tacrolimus, mycophenolate mofetil, or mycophenolic acid; or the use of steroids, rapamycin, or cyclosporine.The clinical characteristics and immunosuppressant drugs used by KT recipients are presented in r = −0.361, p = 0.002) and serum osteocalcin level  were found to be negatively correlated with VRI values in KT recipients. Forward stepwise linear regression analysis of the variables that were significantly associated with VRIs revealed that a low serum level of osteocalcin  and advanced age  were significantly and independently associated with VRIs in KT recipients.Clinical characteristics and serum VRIs for the 68 KT recipients are presented in Our findings showed that increased serum osteocalcin level was associated with poor VRI, which was suggestive of endothelial dysfunction, and that this association was not dependent on the age of KT recipients.Serum osteocalcin levels were observed to be elevated in patients with chronic kidney disease; this could be attributed to decreased renal clearance and increased bone metabolism. Increases in serum osteocalcin levels in parallel with kidney disease progression are closely related to iPTH levels ,14. AfteThe real effect of osteocalcin on atherosclerosis and cardiovascular diseases remains unknown; the use of serum levels to predict cardiovascular events and mortality has yielded conflicting results. In one study, lower osteocalcin levels were associated with carotid atherosclerosis in patients with chronic kidney disease who were not receiving dialysis . In anotThis study has some limitations. First, the study sample was relatively small, and the number of patients with poor vascular reactivity was the smallest of all the three groups. Second, this was a cross-sectional study, and thus we could not determine the causality. Third, we did not measure levels of uncarboxylated osteocalcin, which is shown by some studies to be the bioactive form of osteocalcin. Larger prospective studies are needed in the future to address these questions.This study showed that higher serum osteocalcin level was associated with lower VRI and poorer endothelial dysfunction among KT recipients.


The prevalence of diabetes mellitus (DM) among patients with chronic kidney disease (CKD) has been increasing in recent years in China. This study aimed to evaluate the association between DM and health-related quality of life (HRQOL) in patients with CKD.In our study, participants with CKD stage 1 to 4 from 39 centers in China were screened and enrolled. The Kidney Disease Quality of Life (KDQOL™-36) questionnaire was used to assess HRQOL. Participants were divided into a diabetic group and a non-diabetic group. Demographic data, clinical data, and HRQOL scores were compared between the two groups. Multivariable robust regression was used to analyze the factors related to HRQOL in CKD patients.P < 0.05). HRQOL scores in the “symptoms and problems”, “effects of kidney disease”, and “SF-12 physical function” dimensions were significantly lower in the diabetic group than the non-diabetic group . DM was negatively correlated with the symptoms and problems (regression coefficient for log transformed [175-score] = 0.010) and the SF-12 physical function dimension (regression coefficient = − 2.18) .A population of 2742 CKD patients was included in this study. CKD patients with DM were older and had lower education level, longer treatment periods and a higher prevalence of cardiovascular disease than CKD patients without DM (HRQOL of diabetic patients with CKD was worse than that of non-diabetic patients with CKD. DM was an independent and negative factor affecting HRQOL in patients with CKD. Chronic kidney disease (CKD) has become an important public health problem worldwide –4. The fHealth-related quality of life (HRQOL) is one of the major goals of modern medicine, which is appropriate for CKD and DM patients receiving long-term treatment and care for their progressive and complex conditions. Assessing HRQOL and related factors in patients with CKD and DM is important to guide the educational direction of health and appropriate individualized care. Although DM has become the main cause of CKD, the HRQOL of Chinese patients with both CKD and DM is still unknown. Our study was designed to describe HRQOL in patients with CKD and DM and to analyze the association between DM and HRQOL in patients with CKD in stages 1 to 4 from C-STRIDE. Early identification and intervention of glucose metabolism problems in patients with CKD by clinicians will contribute to their high quality of life.n = 514) or the Kidney Disease Quality of Life (KDQOLTM-36) questionnaire (n = 326) were excluded from the analysis. In our study, the participants were divided into a diabetic group and a non-diabetic group. Demographic data, specific clinical data, and associated HRQOL scores were compared between the two groups. In the stratified analysis, the participants were divided into two groups according to their eGFR: CKD stage 1 to 2, with eGFR≥60 ml/min/1.73 m2, and CKD stage 3 to 4, with an eGFR range of 15-59 ml/min/1.73m2.The C-STRIDE study enrolled participants with CKD in stages 1 to 4 between November 2011 and June 2017; this study was carried out in 39 clinical centers located in 28 provinces in China. The specific design has been published in a previous paper [Height, weight, waist circumference, and hip circumference were measured in all patients. Specific biochemical markers were evaluated, such as serum creatinine (SCr), blood urea nitrogen (BUN), ACR, and FPG, as baseline data. In addition to the KDQOL™-36 scale, the questionnaire also contained general information, annual income, health-care costs, lifestyle, chronic comorbidities, complications, and medications, etc. Data collection was performed by trained staffs.2 for at least 3 months. CKD was divided into 5 stages according to the KDIGO criteria [2) ≤ estimated glomerular filtration rate (eGFR) < 60 (ml/min/1.73 m2) or eGFR≥60 (ml/min/1.73 m2) with 24-h urinary protein≥3.5 g, urinary albumin/creatinine ratio (ACR) ≥ 2000 (mg/g), or corresponding values on the urine dipstick or urinary protein creatinine ratio (PCR) [2), and the inclusion criteria for patients with other causes of CKD were set as 15 (ml/min/1.73 m2) ≤ eGFR< 60 (ml/min/1.73 m2); patients with non-glomerulonephritis were identified according to the following criteria: 15 (ml/min/1.73 m2) ≤ eGFR< 60 (ml/min/1.73 m2) or eGFR≥60 (ml/min/1.73 m2) [2, normal weight 18.5–23.9 kg/m2, overweight 24.0–27.9 kg/m2, or obese ≥28 kg/m2. ACR was calculated by spot urine albumin and creatinine. FPG was defined as non-caloric food intake for at least 8 h. Cardiovascular disease (CVD) was defined as the history of myocardial infarction, congestive heart failure, or arrhythmia events .CKD was defined as either kidney damage or a decreased eGFR of less than 60 ml/min/1.73 mcriteria . The eGFcriteria  or by thcriteria . The diacriteria , alternaio (PCR) . Glomeru1.73 m2) . SmokingThe Chinese version of the KDQOL™-36 questionnaire was used to assess HRQOL in CKD patients; this was proven to be a simple, effective, and credible instrument –16. The t-test was used for the continuous variables conforming to the Gaussian distribution, while the Mann-Whitney U test was used for the continuous variables conforming to a skewed distribution. Normality for the distribution of each variable was tested by calculating skewness and kurtosis. The absolute value of either parameter greater than 3 was considered as the indication for a skewed distribution. The variables in skewed distribution, such as ACR, were under a logarithmic transformation before being used in the linear regression model. Categorical variables were presented as proportions and examined by the chi-square test. Univariate linear analysis was used to reveal the relationship between different variables and the dimensions of HRQOL. The homoscedasticity for each variable was tested by using the White test. If evidence of heteroscedasticity was detected, robust regression with the estimation method of M would be used. Multivariable regression analysis was performed to identify factors associated with HRQOL. Covariates in the multivariable regression were selected from those with statistical significance in the univariate analysis. However, FPG was not included in the multivariable regression, because the variable was a component to define DM and may introduce high collinearity in the model. Covariates included in the multivariable regression models were age, sex , education (≥high school vs. <high school), treatment period (≥1 year vs. < 1 year), economic burden (≥ 70% vs. < 70%), smoking (yes vs. no), BMI, ACR (log transformed), DM (yes vs. no), and CVD (yes vs. no). Collinearity was tested by calculating variance inflation factors. Similarly, given some independent variables violating homoscedasticity, robust regression was employed in the multivariable analysis. Finally, we examined the association between diabetes and HRQOL stratified by CKD stages. A P value < 0.05 (2-sided) was considered statistically significant. Missing values were filled with mean/median values for continuous variables and classified as a separate category for categorical variables before including the variables in the multivariable regression analysis. Sensitivity analysis was conducted by including the patients with complete data.Data analysis was performed by investigators who had not participated in the screening. All statistical analyses were performed using Statistical Analysis System . Continuous data are presented as the mean ± standard deviation (SD) or median . The 2; 59.59% were males, 40.41% were females, and 22.2% had DM. The mean scores or median scores of the 5 HRQOL dimensions were as follows: symptoms and problems = 89.76 ± 11.59, effects of kidney disease = 86.72 ± 13.07, burden of kidney disease = 51.30 ± 28.20, SF-12 physical function = 44.50 ± 9.19, and SF-12 mental function = 50.53 ± 9.07. Demographic and laboratory data of the diabetic and non-diabetic groups are presented in Table Altogether, 2742 CKD patients were included in the current analysis, with a mean age of 48.80 ± 13.66 and a mean eGFR of 54.88 ± 30.55 ml/min/1.73 mP < 0.05). The other dimensions were not significantly different between the two groups, but the score in the diabetic group was lower than that in the non-diabetic group . According to univariate analysis, DM was associated with all five HRQOL dimensions (P < 0.05). Other factors were related to the 3 dimensions. Older age, lower education, longer treatment period, lower eGFR, history of CVD, higher levels of FPG and ACR were associated with lower scores. Multivariable regression analysis revealed that DM was negatively related to dimension S and PCS , although the absolute value of the regression coefficient decreased after adjusting for other factors  with diabetes and without diabetes. Kidney injury was more severe in the diabetic group than in the non-diabetic group. HRQOL scores were significantly lower in the diabetic group in the “symptoms and problems”, “effects of kidney disease” and “SF-12 physical function” dimensions. Furthermore, DM was proved to be negatively associated with HRQOL in CKD patients in this study. Through our findings, we hope that clinicians will be aware of the relationship between DM and the quality of life in CKD patients, and try to improve their quality of life by appropriate intervention in DM.P < 0.05) [Although there was no significant difference in the “burden of kidney disease” or “SF-12 mental function” dimensions, the diabetic group had lower mean scores on all dimension scales compared with the non-diabetic group, which suggested that diabetic patients with CKD suffered a more impaired HRQOL. According to univariate linear analysis, DM was associated with the “symptoms and problems”, “effects of kidney disease” and “SF-12 physical function” dimensions. When adjusted for several specific variables screened from univariate linear analysis, DM was still significantly associated with the dimensions of “symptoms and problems” and “SF-12 physical function”. Our findings were consistent with those of other countries. Two studies containing thousands of CKD participants revealed that DM was associated with low HRQOL in North America ( < 0.05) . In the  < 0.05) , 19. Thi < 0.05) . In addi < 0.05) . TherefoIn the stratified analysis, we found that DM was negatively associated with the scores of HRQOL in both subgroups, but the dimensions and magnitude of correlation were different. In the stage of poor renal function and more complications (stages 3 to 4), the correlation between DM and the quality of life was strengthened in 2 dimensions of “symptoms and problems” and “SF-12 physical Function”. While the correlation between DM and the quality of life was weakened in 1 dimension, “effects of kidney disease”, which may be due to the enhanced negative effects of reduced eGFR and increased or aggravated complications of CKD on the quality of life. A study of 1186 CKD patients in North America also suggested that HRQOL in diabetic patients was lower than that in non-diabetic patients with CKD in stage 3 to 5 . No mattDM and CKD are both global and public health problems . It was Some limitations of the study should be considered. First, when interpreting the results for HRQOL, the personal assessments of health condition are strongly subjective and affected by non-healthy factors, such as cultural aspects and environmental changes. Second, a patient’s knowledge of their diagnosis may affect the perception of health in asymptomatic statements. Third, those excluded from the analysis due to missing values of FPG and scores of HRQOL had difference in some demographic and clinical characteristics, which may introduce selection bias to the study. Fourth, the small sample size in the stratified analysis may affect the results. Fifth, our study had a cross-sectional design. Therefore, the direction of the causal relationship cannot be established.In conclusion, diabetic patients had lower levels of HRQOL than non-diabetic patients among the Chinese CKD population. DM was an independent and negative factor affecting HRQOL in patients with CKD stages 1 to 4. Clinicians should identify DM early in patients with CKD, especially in those whose renal impairment is not attributable to diabetic nephropathy. In addition to controlling CKD and its complications, clinicians should also pay attention to the monitoring and treatment of diabetes in these patients. Developing health care programs for diabetic patients in the early stages of CKD may help patients to lead an active lifestyle and have a relatively high HRQOL in the future.Additional file 1: Table S1. Characteristics of the included and excluded population.Additional file 2: Table S2. The complete case analysis of linear regression between DM and KDQOLTM-36 scales.