Furthermore, each group was divided into a liberal and a restrictive crystalloid group (8 vs. 4 mL/kg/h predicted body weight). Individualised PEEP levels were determined by means of preoperative recruitment manoeuvre and PEEP titration in STP. Participants: Informed consent was obtained from 98 patients scheduled for elective RALP. Interventions: The following intraoperative parameters were analysed in each of the four study groups: ventilation setting  and postoperative pulmonary function (bed-side spirometry). The spirometric parameters Tiffeneau index (FEV1/FVC ratio) and mean forced expiratory flow (FEF25–75) were measured pre- and post-operatively. Data are shown as mean ± standard deviation (SD), and groups were compared with ANOVA. A p-value of <0.05 was considered significant. Results: The two individualised high PEEP groups (mean PEEP 15.5 [±1.71 cmH2O]) showed intraoperative significantly higher PIP, plateau pressure and MP levels but significantly decreased Pdriv and increased LC. On the first and second postoperative day, patients with individualised high PEEP levels had a significantly higher mean Tiffeneau index and FEF25–75. Perioperative oxygenation and ventilation and postoperative spirometric parameters were not influenced by restrictive or liberal crystalloid infusion in either of the two respective PEEP groups. Conclusions: Individualised high PEEP levels (≥14 cmH2O) during RALP improved intraoperative blood oxygenation and resulted in more lung-protective ventilation. Furthermore, postoperative pulmonary function was improved for up to 48 h after surgery in the sum of the two individualised high PEEP groups. Restrictive crystalloid infusion during RALP seemed to have no effect on peri- and post-operative oxygenation and pulmonary function.Objectives: Robotic-assisted laparoscopic prostatectomy (RALP) is typically conducted in steep Trendelenburg position (STP). The aim of the study was to evaluate whether crystalloid administration and individual management of positive end-expiratory pressure (PEEP) improve peri- and post-operative pulmonary function in patients undergoing RALP. Design: Prospective randomised single-centre single-blinded explorative study. Setting: Patients were either allocated to a standard PEEP (5 cmH Randomisation was conducted by the local Centre for Clinical Studies. A randomisation list was generated using SAS 9.4  and the procedure plan (block-wise randomisation with a block length of 8). An envelope was opened by the principal investigator (MP) after the patient had signed the informed consent.2O) or individualised PEEP with administration of either restrictive (4 mL/kg/h predicted body weight [PBW] up to one hour after RALP) or liberal (8 mL/kg/h PBW up to one hour after RALP) crystalloids. The study preliminarily included 104 patients. Six patients were excluded from analysis because of missing data or study protocol violations .The patients were preoperatively randomised into one of the four study groups : standarA standardised anaesthesia protocol for drug administration during RALP was exclusively conducted by three anaesthesiologists throughout the entire study. Drug dosing was based on the calculated PBW (PBW formula: PBW [men] = 50 + 0.91 × [cm of height—152.4] in kg) . Anaesth2O, a peak inspiratory pressure of 40 cmH2O and a ventilation frequency of 6 breaths per min with an I/E of 1:2. For the decremental PEEP titration PEEP was set to 20 cmH2O and decreased stepwise by 2 cmH2O every 3 min. At each PEEP step, the best lung compliance value was observed, and this individual PEEP level was maintained throughout mechanical ventilation during surgery. No RM were employed in the standard PEEP group.The RM was performed in volume-controlled mode and consisted of 10 respiratory cycles with a PEEP level of 22 cmH2 were defined as higher than 92% and those of mean arterial pressure (MAP) as 60 mmHg. Otherwise, FiO2 or noradrenaline concentration was adapted. All patients received volume-controlled ventilation with PEEP according to the levels predefined for the respective group, using an inspiration-to-expiration ratio of 1:1, a basic respiratory rate of 12 and a constant VT of 7–8 mL/kg PBW. At the beginning of RALP, pneumoperitoneum was created by intraperitoneal insufflation of CO2 to a standard value of 15 mmHg with the patient in supine position. Subsequently, each patient was consequently placed in 45 degrees STP. Surgery was exclusively conducted by three urologists. Neuromuscular transmission was monitored with a peripheral nerve stimulator to maintain one twitch of the train-of-four (TOF). Relaxation with rocuronium was finished 45 min before the end of surgery. For extubation, the TOF ratio had to be >0.9 at the end of RALP. Individualised high PEEP values were reduced to 8 cmH2O at the end of surgery after positioning the patient in supine position prior to extubation.During RALP, the target values for SpO® Ventilator . Lung parameters and blood oxygenation were measured in each patient at predefined time points (iO2), minute volume (MV), respiratory rate, tidal volume (VT), peak inspiratory pressure (PIP), plateau pressure, PEEP, dynamic LC and end-tidal CO2. Blood gases were analysed with the radiometer ABL 800 Flex . The following parameters were investigated: pH value, partial pressure of arterial oxygen (PaO2), partial pressure of arterial carbon dioxide (PaCO2), PaO2/FiO2 ratio (P/F ratio), peripheral oxygen saturation (SpO2), arterial oxygen (SaO2) and base excess (BE). Additionally, we calculated the driving pressure (Pdriv) as the difference between plateau pressure and PEEP and the mechanical power (MP) with the following formula: MP (in J/min) =0.098 × VT × RR × (PIP − 0.5 × Pdriv) [All patients were ventilated with the Perseuse points . The fol× Pdriv) ,19.®  with the patient in sitting position at the following four time points: on the day before surgery, 60 min after extubation in the recovery room and on the first and second postoperative day. Each spirometric measurement was observed by two physicians , who had received technical instruction by the manufacturer and had been briefed in using the spirometer by a pulmonologist (ML). The physicians were blinded for the pulmonary function measurement, i.e., they did not know into which group the patients had been randomised. The following parameters were measured with the spirometer: vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in one second (FEV1), the Tiffeneau index (FEV1/FVC ratio), peak expiratory flow (PEF), forced expiratory flow after one quarter of FVC (FEF25), forced expiratory flow after half of FVC (FEF50), forced expiratory flow after three quarter of FVC (FEF75) and mean forced expiratory flow (FEF25–75). Additionally, body weight and brain natriuretic peptide (BNP) were established preoperatively and on the first and second postoperative day. A normal BNP level was defined as less than 35 pg/mL [Spirometry was carried out with the Vitalograph Micro35 pg/mL .1, FEV1/FVC ratio, PEF, FEF25, FEF50, FEF75 and FEF25-75), differentiated between the four different study groups, from the recovery room up to the second postoperative day. In an additional sub-analysis, spirometric parameters of the sum of the two standard PEEP groups were compared with those of the sum of the individualised PEEP groups, or the sum of the two restrictive volume groups with those of the sum of the liberal volume groups. Secondary aims included parameters regarding perioperative ventilation  and blood oxygenation  as well as changes in body weight and BNP.The primary aim of the study was to investigate the dynamics of postoperative spirometric parameters  was targeted to obtain rather robust effect estimates in all four groups for further studies [This study was designed as a pilot study with several primary variables to get insights about postoperative pulmonary function depending on standard or individualised PEEP and on the administration of restrictive or liberal crystalloids. Thus, no a priori sample size calculation could be performed. Because we expected small to medium effect sizes, a sample size of n = 25 per group ) by a biomathematician and statistician (FZ).Data are shown as mean ± SD for continuous variables and as absolute and relative frequencies for categorical variables. All continuous variables were compared between two or more groups by using an analysis of variance (ANOVA). All reported Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.p = 0.25).Out of 104 patients, who had given their informed consent, 98 male patients were eligible for statistical analysis. Patient characteristics, duration of surgery and anaesthesia are listed in 2O (±1.71 cmH2O) and significantly higher plateau pressure and MP levels but significantly lower Pdriv levels than the two standard PEEP groups (5 cmH2O) at all measuring time points during RALP. Perioperative Pdriv levels were lowest in the individualised PEEP group with restrictive crystalloid infusion. Dynamic LC and blood oxygenation measured by the P/F ratio were significantly higher in the two individualised PEEP groups. The gap between PaCO2 and end-tidal CO2 ranged between 3 to 5 mmHg without any significance between the four study groups and the different time points of RALP.The respiratory parameters of the four groups are depicted in driv levels, dynamic LC and P/F ratio during RALP; only at T4 were the MAP values significantly lower in the group receiving restrictive crystalloid infusion than in the group receiving liberal crystalloid infusion .The two groups receiving different crystalloid infusion did not differ in plateau pressure, MP, PEEP and P25, FEF50, FEF75 and FEF25-75) increased again but not reached completely the preoperative values. Patients with individualised PEEP tended to have higher levels, but there were no significant differences between the four groups.The results of pre- and post-operative spirometry are shown in p = 0.014; 2nd day: 76.5% vs. 72.7%, p = 0.021) as well as higher FEF25–75 . Postoperative spirometric parameters were not influenced by restrictive or liberal crystalloid infusion, neither in the four study groups  spirometric parameters  were significantly increased in the sum of patients with perioperatively higher PEEP levels up to the second postoperative day. Secondary findings were: (1) neither restrictive nor liberal crystalloid infusion during surgery had a significant influence on postoperative pulmonary function, and (2) the study groups did not significantly differ in pre-and post-operative BNP levels and body weight.The main findings were: (1) the application of individualised higher PEEP significantly increased plateau pressure, MP, perioperative oxygenation (P/F ratio) and LC and significantly decreased Pdriv) but also in significantly higher calculated MP on the lungs, probably due to the application of significantly higher PIP in the individualised high PEEP groups. The promising idea to combine several variables related to ventilator-induced lung injury (VILI) in the equation of MP [driv and better oxygenation, LC and postoperative spirometric lung function, although these findings should not be overestimated. Nestler et al. found higher PEEP levels, improved blood oxygenation and significantly reduced Pdriv in obese patients undergoing elective laparoscopic bariatric surgery in general anaesthesia, but these differences had not persisted after extubation [2O improves oxygenation in non-obese patients [In this study, individualised higher PEEP levels resulted in significantly better blood oxygenation (P/F ratio) and lung-protective ventilation  in 182 patients undergoing RALP. High amounts of crystalloids were associated with an increased incidence of anastomotic leakage, especially in older patients, but had no effect on the length of hospitalisation .Measurement of circulating levels of BNP is a diagnostic tool for identifying patients with elevated ventricular filling pressure who are likely to develop symptoms of heart failure ,34. STP The strengths of the present study are its prospective randomised single-blinded design and the measurement of pulmonary function up to 48 h after RALP in a large number of patients. Moreover, the study was performed only by a few doctors within a very short time, which allowed a very strict standardisation of the study process and accurate measurements. Taking into account the demanding requirements of mechanical ventilation during STP, we have added MP calculations during laparoscopic surgery to the existing body of knowledge, for the first time. Nevertheless, spirometry is a measurement method that strongly depends on patient cooperation. Considering the exclusion criteria, the generalization of our results to those patients could be limited. Because of the explorative nature of this study and the small sample size in the subgroups, no statement can be made on the effects of liberal or restrictive crystalloid regimens.2O) compared to standard PEEP (5 cmH2O) during RALP showed improved blood oxygenation (P/F ratio) and LC as well as decreased Pdriv, which improved postoperative pulmonary function up to 48 h after surgery in the sum of the individualised high PEEP groups. A preoperative individual PEEP titration to define the best ventilation setting could result into minimize lung injuries during RALP and should be researched in future studies. In our study, restrictive crystalloid infusion during RALP seems to have no effect on peri- and post-operative oxygenation and pulmonary function.Patients with individualised higher PEEP levels (>14 cmH


PaO2)]. This study investigates if ORI can be used to evaluate the impact of two different preoxygenation manoeuvres on the grade of hyperoxia. Two preoxygenation manoeuvres were sequentially evaluated in 41 morbidly obese patients: First, breathing 100% oxygen for 5 min via standard face mask. Second, after achieving a second baseline, 5 min of non-invasive ventilation (NIV) with 100% oxygen. The effect of preoxygenation on ORI compared to PaO2 was evaluated and whether differences in the two preoxygenation manoeuvres can be monitored by ORI. Overall correlation of PaO2 and ORI was significant . However, ORI could not differentiate between the two preoxygenation manoeuvres although the PaO2 values for NIV preoxygenation were significantly higher compared to standard preoxygenation (median 505 mmHg (M1) vs. 550 mmHg (M3); p < 0.0001). In contrast, ORI values did not differ significantly (median 0.39 (M1) vs. 0.38 (M3); p = 0.758). Absolute values of ORI cannot be used to assess effectiveness of a preoxygenation procedure in bariatric patients, mainly because its range of discrimination is considerably lower than the high ranges of PaO2 attained by adequate preoxygenation. Trial registration German Clinical Trials Register: DRKS00025023 .Preoxygenation is a crucial manoeuvre for patients’ safety, particularly for morbidly obese patients due to their reduced pulmonary reserve and increased risk for difficult airway situations. The oxygen reserve index (ORI™) was recently introduced as a new parameter of multiple wavelength pulse oximetry and has been advocated to allow assessment of hyperoxia [quantified by the resulting arterial oxygen partial pressure ( Pulmonary vascular resistance decreases by high values of O2, low partial arterial pressure of CO2 (PaCO2), and increased pulmonary venous pressure [Sufficient preoxygenation is a crucial step prior to induction of anaesthesia to provide safety for patients , 2. Thisolar gas . Apart fpressure . NIV infpressure . WhatevePaO2 of 100 mmHg only 3 ml per 1 L blood). But being directly dependent on the partial arterial pressure of oxygen, this fraction rises during a preoxygenation process [PaO2 is only possible by taking a blood gas sample from an arterial line, which is an invasive manoeuvre, only punctiform and the results come with a certain delay. In daily routine, we are limited to the measurement of peripheral oxygen saturation by pulse oximetry and to defining minimum time frames of preoxygenation.Oxygen is mainly transported being bonded to haemoglobin molecules in the blood. At about 100 mmHg the curve is almost horizontal, meaning the haemoglobin is fully saturated and cannot bind any more oxygen molecules. At normal oxygen levels in the air and normal pressure of the atmosphere only a very small fraction of oxygen is physically dissolved in the blood  was introduced. The ORI is generated by a multiple wavelength pulse co-oximeter that uses the altered background light absorption due to changes in venous oxygen saturation to calculate the ORI using a proprietary algorithm. The ORI is a relative index that quantifies hyperoxemia in a non-invasive manner with a unit-less scale between 0—no hyperoxemia, and 1—maximum measurable hyperoxemia. First data in ranges of moderate hyperoxemia beyond and PaO2 .This study investigates if effectiveness of preoxygenation in morbidly obese patients can be assessed by ORI. Secondly, this study examines, if differences in the effectiveness of preoxygenation via face mask or NIV can be monitored by ORI.This study was performed at the Hamburg-Eppendorf University Hospital from May 2017 until May 2018. We studied patients scheduled for bariatric surgery such as gastric banding and sleeve gastrectomy.The ethical review board of the local authorities  approved the study on 24th January 2017. Inclusion criteria were morbid obesity (body mass index > 35), age over 18 years, and written consent to participate in the study. Exclusion criteria were any pre-existing severe structural lung disease.No patient received any pharmaceutical premedication prior to surgery. After arrival in the operating room, all patients received standard monitoring according to the local protocol for bariatric surgery. This includes 5-lead ECG, pulse oximetry, and invasive arterial blood pressure monitoring via the radial artery. Furthermore, we placed an ORI sensor  on the patients’ ring or middle finger of the non-dominant hand. Possible nail polish was removed beforehand. To shield the sensor from light and reduce the risk of artefacts we covered the finger with the sensor with a double layer of gauze and tape. Patients were asked to keep the arm and finger steady in a relaxed position. All patients were in supine position with a slightly elevated upper body (10–15°).2), and ORI) were measured. Additionally, an arterial blood gas analysis (BGA) was performed to assess arterial oxygen partial pressure (PaO2), arterial CO2 partial pressure (PaCO2), and arterial haemoglobin oxygen saturation (saO2).The study protocol Fig.  comprisePaO2 up to 550 mmHg. The measurements between 550 and 800 mmHg are not clinically validated and are therefore displayed as > 550 mmHg. Standardized and protocolized quality management procedures including calibration were performed daily according to the obligatory codes of action for laboratory devices of the German authorities [For all blood gas analyses the same device (Radiometer ABL90) was used. This analyser has a validated range for PaO2 at M2 was more than 10% higher than the respective value at M0, another 5 min of breathing room air was allowed and M2 was repeated. Then, the second standardised preoxygenation manoeuvre was initiated: Non-invasive ventilation (NIV) was implemented for a period of 5 min using 100% of oxygen, a tight fitted nose-mouth mask strapped to the patients’ head, a positive end-expiratory pressure of 5 mmHg and an assisted spontaneous breathing mode with a support pressure of 8 mmHg . Data (M3) was taken after 5 min.Then, the first standardised preoxygenation manoeuvre was initiated. Over 5 min, 100% of oxygen was applied using a gas flow of 18 L per minute and a tight face mask. At the end of this manoeuvre, all measurements were repeated (M1). This was followed by breathing room air for 20 min to restore baseline (M2). If PaO2: One just before the first incision (M5) and one after 30 min of surgery (M7).After this second preoxygenation the patient was intubated and mechanically ventilated. Two more sets of measurements were taken during the operation to observe the association between ORI and PaO2 and SpO2. Paired t-tests were then used to determine whether M3_2_diff and M1_0_diff differed for these variables. Spearman rank correlation was employed to examine relationships between PaO2 and ORI. The first analysis considers all data points, in the second correlation analysis only the data points with a PaO2 of 100–200 mmHg were considered. Significance level α was 5%. All tests were two-tailed. We also tested how well the PaO2 threshold criteria suggested by Applegate et al. [PaO2 ≥ 100 mmHg and PaO2 ≥ 150 mmHg, respectively) would predict ORI values exceeding 0.24 respectively 0.55 when applied to our data. Data with PaO2 values ≥ 550 mmHg were not included in the analyses to prevent the possible falsifying influence of the ceiling effect due to the limited measuring range. The resulting diagnostic key figures sensitivity, specificity, accuracy as well as positive and negative predictive value are reported. All statistical analyses were done using SPSS, version 27 .This study was designed as an explorative investigation on the new parameter ORI. Since only very limited data on ORI were available at the timepoint of the design, no conventional sample size calculation was performed. Descriptive statistics are presented as mean, standard deviation, median, 1st and 3rd quartile, minimum, maximum and number of observations for continuous variables and as absolute and percent frequencies for categorical variables. Data distributions of continuous variables were assessed by visual examinations of histograms and boxplots. Differences between M1 and M0 (M1_0_diff) and between M3 and M2 (M3_2_diff) were computed for ORI, e et al.  . Patient data are given in Tables PaO2 of 78.1 mmHg (IQR 71.7–88.1 mmHg). ORI was 0 (IQR 0–0). Two patients presented with an ORI > 0, although no additional oxygen was given (ORI 0.03 with a PaO2 97.6 mmHg and ORI 0.4 with a PaO2 of 81.4 mmHg).At baseline (M0), patients presented with a median oxygen saturation of 97% (IQR 95.5–99%) and a 2 increased to 100% (IQR 100–100%). Median PaO2 values increased to 505 mmHg (IQR 447–550 mmHg). Twelve patients showed a PaO2 above 550 mmHg.After oxygenation with 100% oxygen for 5 min the median ORI level rose to 0.39 (IQR 0.27–0.52), values ranging from 0.15 to 1. In parallel, median SpO2 decreased to 97% (IQR 95–98%). PaO2 values decreased to a median value of 76.7 mmHg (IQR 68.9–87.8 mmHg). Only in one patient an additional time of 5 min was necessary to restore baseline. ORI dropped to zero in all patients.After breathing room air for 20 min ORI values returned to zero and in all patients. In parallel, median SpO2 increased to 100% (IQR 100–100%), and PaO2 to a median of 550 mmHg (IQR 550–550 mmHg). At this point 36 of the 41 patients reached PaO2 values > 550 mmHg. Again, median and 1st and 3rd quartile for PaO2 were most likely underestimated.With the NIV preoxygenation the ORI increased to a mean value of 0.38 (IQR 0.28–0.51). Concomitantly, median SpOPaO2 and ORI: Fig. PaO2-values and their respective ORI values , showing a significant correlation between those two variables . Figure PaO2 and ORI in the intended range for ORI of 100–200 mmHg PaO2 .Overall correlation of PaO2 . Red data points indicate ORI values exceeded the 0.24 and 0.55 thresholds, respectively, as suggested by Applegate et al. [PaO2 ≥ 100 mmHg and PaO2 ≥ 150 mmHg, respectively, are also shown. Applying these threshold values within a diagnostic test setting yields the following key figures for detecting ORI > 0.24 based on PaO2 ≥ 100 mmHg: accuracy = 71%, sensitivity = 98%, specificity = 63%, positive predictive value = 46% and negative predictive value = 99%. For detecting ORI > 0.55 based on PaO2 ≥ 150 mmHg, accuracy = 64%, sensitivity = 100%, specificity = 62%, positive predictive value = 8% and negative predictive value = 100%. Note that also a very low ORI can occur at high PaO2 values.Figure e et al.  The corr2 values produced by both preoxygenation procedures did not differ significantly (median 100% for both procedures). PaO2 values reached by NIV preoxygenation were significantly higher compared standard preoxygenation (median 505 mmHg (M1) vs. 550 mmHg (M3); p < 0.0001) as depicted in Table SpO50 mmHg M; p < 0.0PaO2 values compared to standard preoxygenation. We further analysed the respective increases in SpO2, PaO2 and ORI induced by standard preoxygenation and NIV preoxygenation: Standard preoxygenation resulted in a median increase in SpO2 of 3% (IQR 1–4%). The median increase in PaO2 was 431.6 mmHg (IQR 375.3–458.7 mmHg). NIV preoxygenation resulted also in an increase in SpO2 of 3% (IQR 2–5%). PaO2 increased by 471.9 mmHg (IQR 458.5–478.6 mmHg). The median increase in PaO2 was significantly higher in NIV preoxygenation vs. standard preoxygenation (p < 0.0001) and most likely was even higher due to the limitation to 550 mmHg of the measurement of PaO2. In contrast, the increase in SpO2 and ORI did not differ significantly between both procedures.NIV preoxygenation resulted in clinically significant higher The main focus of this study was to assess, if ORI might be clinically useful to quantify the effect of preoxygenation on paO2 in a non-invasive way in morbidly obese patients. Our results do not support this hypothesis. Further, differences in the effectiveness of preoxygenation via facemask, or by NIV cannot be assessed by ORI.PaO2 levels significantly in bariatric patients, and thus, increase the safety margin during airway management [PaO2 values reached with both preoxygenation techniques were considerably higher in our study compared to earlier investigations in obese patients [Our data confirm that both preoxygenation techniques increase the nagement . We furtnagement , 11. An patients , 11. WhyPaO2 levels, thus, effectiveness of NIV preoxygenation was better. ORI levels after preoxygenation, however, did not differ between the standard preoxygenation and the NIV preoxygenation. Further, there was no association between changes in PaO2 and changes in ORI induced by preoxygenation. Thus, ORI did not allow to indicate this different effectiveness.Preoxygenation with NIV resulted in higher PaO2 values of approximately 200 to 250 mmHg the venous saturation reaches a plateau, and the ORI cannot measure any higher values [PaO2 levels above 200 mmHg, and therefore outside the range of sensitivity of ORI, any difference above could not be differentiated by this variable.ORI uses the saturation of venous blood for its algorithm. However, at r values , 13. Recr values , 15. SinPaO2 between 100 and about 200 mmHg was that ORI was repeatedly suggested to be a new parameter to judge preoxygenation before induction of anaesthesia [The reason we performed this study even though the range of ORI was described as being limited to an esthesia , 16. JusPaO2: If ORI was above 0.24 the PaO2 was supposed to be greater than 100 mmHg, and with an ORI of 0.55 the PaO2 was greater than 150 mmHg. Our data supports the conclusion that a certain ORI predicts a minimal PaO2 as shown in Fig. PaO2 the prediction of a PaO2 > 100 mmHg at an ORI of 0.24 seems irrelevant. Even very high PaO2 values were associated with low ORI values. This points out that the ORI and its changes under increases in PaO2 in its present form is inter-individually different. Thus, also estimation of patient individual achievable ORI values under preoxygenation seems not possible. Factors that influence the individual maximum might be all factors that influence peripheral perfusion but that should be subject of another study.Applegate et al.  found a PaO2 < 550 mmHg. Values above 550 mmHg were marked and set as 550 mmHg. This was the case in twelve single measurements at M1 and all but five times in M3. Time points where this was the case, are marked in Table Limitations of this study: The blood gas analyser used in this study was restricted to measurements of PaO2 that are attained by adequate preoxygenation. ORI may be useful as an early indicator of impending return to normoxia from preoxygenation levels, which needs to be proven in future studies. Further, if in particular intra-individual changes of ORI over time might additionally help to characterise phases of deoxygenation should be further investigated.In conclusion, the absolute values of ORI cannot be used to assess the effectiveness of a preoxygenation procedure in bariatric patients. This is mainly because its range of discrimination is considerably under the high ranges of


Dysregulation of compensatory mechanisms to regulate blood pressure (BP) upon postural change is a phenotype of BP variability and an emerging risk factor for cardiovascular outcomes.We assessed postural change in BP (starting 2 min after standing from a supine position), carotid-femoral pulse wave velocity (cfPWV), and markers of hypertension-mediated organ damage (HMOD) in the heart, kidney, and brain in Framingham Third Generation, Omni-2, and New Offspring Spouse Cohort participants. We related vascular measures  with HMOD in 3,495 participants  using multivariable logistic and linear regression models.P-values > 0.05/20 > 0.0025). In multivariable models, greater cfPWV , but not postural change in BP measures , was associated with higher white matter free water using brain magnetic resonance imaging. In multivariable models, greater postural change in pulse pressure was associated with higher urinary albumin-creatinine ratio . No other postural change in BP measure was associated with urinary albumin-creatinine ratio . In sex-specific analyses, higher cfPWV was associated with higher urinary albumin-creatinine ratio in men  but not in women . We also observed marginal to strong effect modification by above vs. at/below median postural change in BP for the association of cfPWV with urinary albumin−creatinine ratio (Bonferroni-adjusted interaction P < 0.001–0.01). Vascular measures were not related to left ventricular mass index or fractional anisotropy .In multivariable-adjusted models, we did not observe significant associations of vascular measures with presence of left ventricular hypertrophy, albuminuria, covert brain infarcts, or white matter hyperintensities (Bonferroni-adjusted Baroreflex dysfunction is associated with greater subclinical kidney damage. Additionally, relations of higher aortic stiffness with greater kidney damage may be modified by associated baroreflex dysregulation. Blood pressure responses to postural maneuvers is a phenotype of blood pressure variability and an emerging risk indicator for hypertension-mediated organ damage (HMOD) and cardiovascular disease (CVD) . Upon stPrior studies revealed that elevated aortic stiffness may contribute to dysregulation of postural changes in blood pressure –7. ElevaWe aimed to assess cross-sectional relations of CVD risk factors with postural change (supine to standing) in blood pressure and the relations of postural change in blood pressure and aortic stiffness with preclinical markers of HMOD of the heart, kidney, and brain. We hypothesize that postural change in blood pressure is associated with preclinical markers of HMOD. Additionally, we hypothesized that the degree of postural change in blood pressure modifies the associations of aortic stiffness with HMOD.n = 42); missing covariate information (n = 92); incomplete tonometry or hemodynamic assessment (n = 171). Written informed consent was obtained from all study participants, and the research protocols were approved by the Institutional Review Board at Boston University School of Medicine.The study sample was drawn from the Framingham Third Generation, Omni-2, and New Offspring Spouse Cohorts, which have been described previously , 13. OmnHemodynamic assessment was performed as previously described , 15. FolWe assessed postural change in blood pressures—MAP, systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse pressure (PP)—as previously described , 11. We We performed brain MRI on participants to ascertain the presence of covert brain infarcts and white matter hyperintensities , 17. We We measured urinary albumin-creatinine ratio (UACR) using spot morning urine samples obtained from participants at the exam visit. We assessed urinary albumin concentration using an immunoturbidimetry assay and measured urinary creatinine using a modified Jaffé method. We defined the presence of albuminuria using sex-specific cutpoints for UACR of ≥17 mg/g for men and ≥25 mg/g for women . UACR is2 for women and >115 g/m2 for men  for the modeling.P < 0.05. CVD risk factors were selected a priori based on literature review and included body mass index, heart rate, fasting glucose, triglycerides, HbA1c, total/high-density lipoprotein cholesterol ratio, hypertension treatment, hyperlipidemia treatment, diabetes mellitus, alcohol consumption (past year), smoking status, prevalent CVD, and prevalent atrial fibrillation.We assessed relations of postural change in blood pressure measures with various CVD risk factors using stepwise multivariable regression models that adjusted for age, sex, and corresponding supine blood pressure; the threshold value for inclusion and removal from the model was We used multivariable logistic regression to analyze the presence of each dichotomous HMOD variable  related to the postural change in blood pressure. Models were adjusted for age, sex, corresponding supine blood pressure, and all CVD risk factors significantly related to any postural change in the blood pressure measures in the stepwise models. Expanded models additionally adjusted for cfPWV. We assessed potential effect measure modification by sex, age (quartiles 1–3 vs. quartile 4), and hypertension treatment by incorporating corresponding interaction terms in the logistic regression models. We tested for non-linear associations using restricted cubic spline models to evaluate associations of postural change in MAP and PP with log odds of covert brain infarcts and white matter hyperintensities in models adjusting for the clinical covariates described above. We placed knots at the 5th, 33rd, 67th, and 95th percentiles of postural change in blood pressures.Furthermore, we assessed the relations of cfPWV and postural change in blood pressure measures with continuous measures of HMOD  using multivariable linear regression adjusted for age, sex, corresponding supine blood pressures, and all CVD risk factors that were significantly related to any measure of postural change in blood pressure in the stepwise models. Supine MAP was a covariate in models where cfPWV was the independent variable of interest. We assessed potential effect measure modification by sex, age (quartiles 1–3 vs. quartile 4), and hypertension treatment by incorporating corresponding interaction terms in the linear regression models. We further assessed potential effect measure modification by postural change in blood pressure (above median change vs. at/below median) on the observed relations of cfPWV with continuous HMOD indicators by incorporating corresponding interaction terms in the statistical models. We estimated Pearson partial correlations to assess associations between postural changes in heart rate and postural changes in blood pressure measures.P < 0.05 were considered statistically significant for the initial cross-sectional risk factor model for stepwise variable selection. For the primary analyses, Bonferroni-adjusted 2-sided P-values  were used to assesses statistical significance to adjust for multiple testing.We performed all analyses with SAS version 9.4 for Windows . Two-tailed We included 3,495 participants  in the analyses. A flow chart for the study is presented in P < 0.001) but not for other HMOD outcomes (P = 0.1) or women (P = 0.53). We did not observe interactions by age or hypertension treatment status for the relation of cfPWV with presence of HMOD outcomes.Relations of vascular measures  with presence of HMOD are presented in outcomes . HoweverP < 0.001) was associated with higher UACR. Other postural change in blood pressure measures were not associated with UACR. We did not observe sex interactions for the association of postural change in blood pressure with continuous HMOD outcomes (P < 0.001), and in sex-specific analyses, higher cfPWV was associated with higher UACR in men  but not in women . In multivariable models, greater cfPWV  was associated with higher brain free water. No other vascular measure was associated with brain free water. Vascular measures were not related to LV mass index or fractional anisotropy. We did not observe interactions by age or hypertension treatment status for the relations of postural change in blood pressure measures and cfPWV with the continuous HMOD outcomes.Relations of vascular measures  with individual continuous measures of HMOD are presented in outcomes . HoweverP < 0.001) and DBP (P = 0.006) and marginally significant interaction above median postural change in MAP (P = 0.01) for the relation of cfPWV with UACR. P < 0.001) and DBP  or above median postural change in PP , higher cfPWV was associated with higher UACR. Interactions by the above median postural change in blood pressures for relations of cfPWV with UACR were attenuated upon further stratification by sex  and cfPWV (reference standard for aortic stiffness) with dichotomous and continuous indicators of HMOD in a sample of middle-aged FHS participants. Differences in postural response in pressure pulsatility were associated with greater subclinical kidney damage, and higher levels of aortic stiffness were associated with higher levels of subclinical kidney damage in men. In addition, higher aortic stiffness was associated with greater subclinical cerebral injury. We observed significant effect modification by the above median postural change in blood pressure measures for the relation of aortic stiffness with subclinical kidney damage. Among participants with postural blood pressure responses above the median for MAP and DBP, but at or below the median for PP, the observed relation of higher aortic stiffness with kidney damage was substantially lower. Our results indicate that differences in baroreflex function, as indicated by a blunted increase in MAP and DBP on standing, are associated with greater kidney damage in the presence of a stiffer aorta.Prior population-based studies suggest that impairment of compensatory mechanisms that regulate blood pressure upon standing is associated with cardiovascular events and adverse outcomes to downstream organs. Although most studies focus on orthostatic hypotension, orthostatic hypertension has been less studied but is emerging as a novel risk factor for CVD events and HMOD , 29–33. 1-adrenergic sensitivity was enhanced in patients with chronic kidney disease , we did not observe significant relations of postural change in blood pressure measures with prevalent LV hypertrophy. Thus, baroreflex dysfunction may be insufficient to indicate early cardiac hypertrophy in younger individuals. Consistent with a previous FHS study , PP normally falls with a concurrent increase in MAP and DBP while SBP remains relatively stable with only a slight increase after standing from a supine position . Althoug disease . Taken tertrophy . HoweverHS study , we did Aortic stiffening reduces impedance mismatch and wave reflection at the aorta-carotid interface. Age-related increase in aortic stiffness is accompanied by only minor changes in the stiffness of muscular arteries , 42. StiHigher aortic stiffness was associated with more subclinical kidney damage in men but not in women. Previous studies showed that progression of kidney damage and severity of kidney disease are greater in men , 48. ThePostural change in blood pressure is easily assessed in the clinic and may be used to refine CVD risk assessment. Elucidation of processes that are associated with variability in postural change in blood pressure may inform the development of novel prevention and therapeutic approaches. For example, the identification of early-onset subclinical indicators and key pathways associated with blunted or exaggerated orthostatic blood pressure response may identify individuals who are at risk for the development of HMOD or CVD. In the present study, we observed significant relations among middle-aged individuals; therefore, assessment of postural change in blood pressure measures may be relevant prior to older age before the clinical manifestation of high aortic stiffness, CVD, and HMOD. Additional studies are necessary to elucidate whether treating individuals with impairment of postural change in blood pressure could mitigate subclinical HMOD and prevent clinical disease.The limitations of our study should be considered. We used a cross-sectional observational study design; thus, we cannot establish causation or temporal relations among postural changes in blood pressure and cfPWV with dichotomous and continuous indicators of HMOD. Longitudinal studies are needed to support the putative mechanisms due to differences in postural change in blood pressure and cfPWV. Presence of atrial fibrillation, overt heart failure, and pacemaker, while rare in our sample, may add to variability in aortic stiffness and blood pressure variables, which may lead to an underestimation of the strength of relations. Although we observed sex differences for the relation of cfPWV with UACR, we did not have the statistical power to resolve putative sex-specific associations for biological interaction of effects of aortic stiffness and baroreceptor activity on kidney damage . We did In a sample of FHS participants, we investigated the inter-relations of postural change in blood pressure, aortic stiffness, and dichotomous and continuous indicators of HMOD. Our findings suggest that differences in baroreflex function are associated with subclinical kidney damage. Additionally, relations of higher aortic stiffness with greater kidney damage may be modified by associated differences in baroreflex function. Additional studies that further examine the inter-relations of aortic stiffness, baroreflex function, peripheral vascular function, and HMOD are warranted.https://www.framinghamheartstudy.org/.The datasets presented in this study can be found in online repositories. The procedure for requesting data from the FHS can be found at The studies involving human participants were reviewed and approved by the Institutional Review Board at Boston University School of Medicine. The patients/participants provided their written informed consent to participate in this study.LC, RV, and GM were responsible for the study’s concept and design. LC, JR, PM, AB, ML, CD, RV, SS, and GM were responsible for acquisition, analysis, or interpretation of data. LC drafted the manuscript. LC, ML, NH, RV, and GM critically revised the manuscript for important intellectual content. ML, JR, RV, SS, and GM provided administrative, technical, or material support. ML, RV, and GM supervised the study. All authors have read and approved the final manuscript.


Background: Chronic kidney disease (CKD) can significantly influence a patient’s nutritional status, leading to malnutrition. Malnutrition is associated with an increase in morbidity and hospital admissions, as well as a decrease in functional status. All these factors impact emotional, physical, and psychosocial health, leading to a lower quality of life (QOL). The aim of the study was to assess the nutritional status and QOL in patients with CKD compared to patients after kidney transplantation and determine what factors influence nutritional status and QOL in this patient population. Methods: The study included 167 patients: 39 pre-dialysis patients—group 1; 65 dialysis patients—group 2; 63 kidney transplant patients—group 3. Patients completed the Kidney Disease Quality of Life questionnaire (KDQoL) and the Mini Nutritional Assessment questionnaire (MNA). Results: A comparative analysis of the QOL of patients in the three study groups showed no statistically significant differences in the overall KDQoL scores. Factors that affected quality of life included the designated group, determined by disease status, MNA score, patient age, and WHR. Nearly 1/3 of patients from groups 2 and 3 were at risk of malnutrition. Conclusions: A systematic assessment of nutritional status and monitoring of QOL should be integrated into the standard management guidelines for CKD patients. Chronic kidney disease (CKD) is associated with a high risk of morbidity and mortality, and presents a significant public health concern, with increasing incidence and prevalence. It is estimated that 600 million people worldwide suffer from CKD, with approximately 4.2 million in Poland . Like anIn addition to a decreased QOL, malnutrition is common in hemodialysis (HD) patients, with prevalence ranging from 18 to 75%, and continues after renal transplant ,3. HemodAs a result, diet is a fundamental aspect in the management of CKD patients, with dietary regimens being the most restrictive of all chronic diseases ,12. DietThe aim of the study was to assess the nutritional status and quality of life in patients with CKD compared to patients after kidney transplantation. The secondary aim was to determine what factors influence nutritional status and QOL in this patient population.This observational study was conducted at the University Clinical Hospital in Wroclaw, Poland between 2018 and 2019. Patients with stage III-IV CKD who were not dialysis-dependent, patients receiving HD for at least 6 months, and patients at least 6 months post-kidney transplantation were included in this study.-Consent to participate in the study;-Age 45–75 years;-Have a diagnosis of chronic kidney disease;-Hemodialysis treatment for at least 6 months;-Kidney transplant (at least 6 months after the transplant).Participant Inclusion criteria:-Transplant rejection within the last six months;-Unwilling to participate in the study.Participant Exclusion criteria:Group 1—39 pre-dialysis patients with stage III or IV CKD (mean age 58.56 ± 8.04);Group 2—65 dialysis patients with stage V CKD ;Group 3—63 kidney transplant patients .The study was conducted in accordance with the Helsinki Declaration and under the ethical and legal supervision of the Bioethics Committee of the Wroclaw University of Health and Sport Sciences, Poland (reference no 26/2017). All participants were informed of the purpose and methods of the study and the ability to withdraw at any time. Patient consent was obtained prior to enrolling in the study.Designated Patient Groups:TM questionnaire is carried out using a scale from 0 to 100 points. The higher the value, the higher the QOL, and the lower the value, the worse the QOL [This questionnaire is used to assess the QOL of patients with kidney disease, including those undergoing renal replacement therapy. It contains twenty-four questions covering a wide range of domains of human functioning in daily, occupational and social life. It is a self-report measure, resulting from a subjective perception of one’s health, functionality, and their QOL as directly related to having kidney disease. Hemodialysis patients additionally rate their satisfaction with the care they receive for HD procedures . Each an the QOL .The kidney disease summary component (KDSC) includes symptom/problem list, effects of kidney disease, burden of kidney disease, work status, cognitive function, quality of social interaction, sexual function, sleep, social support, dialysis staff encouragement, and patient satisfaction. The physical component summary (PCS) and the mental component summary (MCS) scores from the SF-36 questionnaire include physical functioning, role-physical, pain, general health, emotional well-being, role-emotional, social function, and energy/fatigue.The MNA is a validated screening tool, which was originally developed to assess the nutritional status of elderly patients. This scale consists of an abbreviated six-item screening version (MNA-SF) and a full eighteen-item scale (MNA-LF).The full form consists of 18 questions to assess 4 different aspects: anthropometric assessment , general assessment , nutritional assessment  and subjective patient assessment .24–30 points—normal nutritional status;17–23.5 points—risk of malnutrition;<17 points—malnutrition ,19,20.The maximum total score is 30 points, with established cutoff values determining the risk of malnutrition, as seen below:p < 0.05). Variables with significant differences between groups underwent post hoc test (Tukey or Dunn Bonferroni–Holm). Logistic regression and multivariate regression were performed  to indicate which factors have the greatest impact on nutritional status and QOL. Calculations were performed using Statistica 13.3 and PQ Stat 1.8.2. All calculated multivariate regression models were characterized by a high fit (adjusted R2 about 50%) and statistical significance (p < 0.05). The normality of the distribution of residuals was confirmed in all analyses.The Shapiro–Wilk test was used to check the distribution of quantitative variables. Descriptive statistics were calculated. Due to the non-normality of the distribution of some quantitative variables and the qualitative character of some variables, the mean and median were used as a measure of central tendency, and standard deviation (SD) and interquartile range (IQR) as a measure of dispersion. Significance between study groups was determined by one-way ANOVA, Kruskal–Wallis test or Chi-square test. The significance level was  years. Patients were separated into three groups, as noted in the methods. Patient demographics did not significantly differ between the groups, as detailed in p < 0.05). KDCS scores significantly differed between groups 1 and 2 and groups 2 and 3 (p < 0.05), with the highest scores being observed in group 2. There was no statistically significant difference in PCS score between groups. However, it was observed that patients in group 2 scored, on average, 7 points lower than those in group 1 or 3 , as seen in Almost 1/3 of patients in group 2 and 3 had an MNA score indicating risk of malnutrition (MNA < 24). A summary analysis of MNA score showed the highest average score in group 1. Statistically significant differences were found between groups 1 and 2 and 1 and 3 (TM questionnaire (Multivariate regression models were utilized to see which factors influence the different components of the KDQoL-SFionnaire . PCS wasionnaire .MSC was significantly influenced by assigned group (a surrogate for severity of disease), age, and PSC and KDCS levels. MCS scores were highest in group 1 patients, aged over 65 years, with higher PSC and KDCS scores .KDCS was shown to be significantly associated with age, WHR and MSC value. Higher KDCS scores were observed in patients with age less than 65 years, higher WHR and higher MCS scores .A comparative analysis of the QOL of patients in the three study groups showed no statistically significant differences in the overall KDQoL scores. However, in regression analysis, group designation significantly affected KDQoL scores, with group 3 (kidney transplant patients) scoring the highest on average and group 2  scoring lowest. The direct correlation between renal function and perceived QOL is well documented in the current literature. It is observed that, whereas the renal function decreases, patients have a lower assessment of their quality of life ,22,23, wThe physical status is the most affected component of QOL . In our Diet plays an important role in improving the quality of life of dialysis patients. In the case of renal replacement therapy, adherence to an appropriate diet has a major impact on the proper course of dialysis, well-being, the results of certain laboratory tests and the nutritional status of patients ,36. ChroThe total result of the MNA questionnaire was significantly different between the pre-dialysis group and the other groups, with no differences for anthropometric indicators, i.e., body weight, BMI, or WHR. This is probably related to the nutritional habits of patients, as MNA questionnaires ask about the amount and type of meals and products consumed. Hemodialysis and post-transplant patients scored lower, most likely due a stricter adherence to dietary guidelines ,38. Our Depending on the tools used for the diagnosis of malnutrition, up to 80% of CKD patients are malnourished . Up to 6The limitations of this study include non-random sampling and a lack of multicenter involvement, resulting in an inability to generalize results. The MNA test performed is a screening and the results predict risk rather than report incidence of malnutrition. The study was carried out at a single point in time, and does not show the dynamics of changes in the nutritional status of patients. In the future, the study should be carried out at different time points and supplemented with laboratory tests, e.g., serum pre-albumin (mg/dL), serum total iron-binding capacity (mg/dL).CKD is associated with decreased QOL as well as significant morbidity and mortality, all of which are amplified in the setting of malnutrition. Moreover, malnutrition is a strong determinant of PCS score in CKD and kidney transplant patients, in which the physical function is already impacted by kidney dysfunction and treatment protocols. A systematic assessment of nutritional status and monitoring of QOL should be integrated into the standard management guidelines for CKD patients. The early detection of nutritional risk via a periodic monitoring of nutritional status, as well as the implementation of a nutritional intervention program (NIP), are essential for improving outcomes and QOL in this population. Further studies are necessary to establish standardized management guidelines that incorporate regular screening for the early detection of nutritional risk as well as an NIP designed for both the prevention and management of identified malnutrition.


Diabetes mellitus remains the leading cause of end-stage renal disease in most countries in the world. In Ethiopia, renal complications of diabetes may remain unrecognized due to limited diagnostic resources. As a result, the prevalence of chronic kidney disease among adult diabetics in Ethiopia has not been well described. Hence, this study was aimed at assessing the prevalence of chronic kidney disease and associated factors among diabetic patients who attended the federal police hospital diabetic clinic in Addis AbabaA cross-sectional study was conducted among 362 Diabetes Mellitus. Data were collected using face-to-face interviewing questionnaires and analyzed using SPSS version 21.0. Binary logistic regression analyses were performed to identify predictors.The prevalence of chronic kidney disease diagnosed by Cockcroft-Gault equation and Modification of Diet in Renal Disease equation was 14.6% and 7.7% respectively. This finding shows the prevalence of chronic kidney disease among Diabetic patients was low. Age 50–59 years  by Cockroft-Gault equation (CG), age 60–69 years  by Modification of Diet in Renal Disease (MDRD) and  by CG, age 70 years and above  by MDRD and  by CG, BMI  by CG, and previous kidney disease  by MDRD and  C-G equation have a significant association with chronic kidney disease after an adjustment done.The prevalence of chronic kidney disease among Diabetic patients in this study was lower. Age, BMI, and previous recurrent kidney disease were associated with chronic kidney disease. Preventive measures like giving health education and screening of patients with risk factors should get more attention. Chronic kidney Disorder (CKD), a progressive disease, abnormalities of kidney structure and function for greater than 3 months with an estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2 and/ or evidence of kidney damage, including persistent albuminuria - defined as greater than 30 mg of urine albumin per gram of urine creatinine ,5.CKD is a global public health problem with its prevalence estimated to be between 8% and 16%. Despite various measures, the burden of renal disease is likely to escalate since both population age and prevalence of diabetes are projected to increase dramatically . FurtherStudy design and setting: Hospital-based cross-sectional study design was conducted in a federal police hospital, Addis Ababa, from October to December 2017. Federal police hospital is one of the government hospitals in Addis Ababa, Ethiopia, which was established in 1962, under the Ethiopian Federal Ministry of Health. It provides various health services including DM treatment to the police officers and their families. During the study, there were about 1800 diabetic patients enrolled for follow-up care and the patients visited the clinic for follow-up care every 3 months. All systematically selected diabetic patients attending the hospital outpatient diabetic clinic for follow-up during the data collection period were the study population. Diabetes patients greater than 18 years old who were attending the clinic and registered at chronic care were eligible for the study. However, pregnant women were excluded from the study to avoid the effect of gestational diabetes. The sample size was calculated using single population proportion formula by considering the following parameters: 10.4% proportion of chronic Kidney Disease from a previous study . High blood glucose level and Serum cholesterol level were defined as those who has FBS>150mg/dl and cholesterol level>200mg/dl during the study period respectively. Physical exercise was defined as having physical activities greater than 150 min per week. Alcohol consumption was also measured as patients who consumed greater than two alcoholic beverages per day. Former alcohol consumer was defined as those who consume greater than two alcoholic beverages but has not consumed for the last 12 months before the study and current smoker was defined as those who has smoked greater than 100 cigarettes in their lifetime and has smoked in the last 28 days before the study. Ex-smoker was defined as those who have smoked greater than 100 cigarettes in their lifetime but have not smoked in the last 28days before the study. Knowledge of CKD was defined as respondents' understanding of kidney disease symptoms, treatment, management, and risk factors, and those who answered more than 50% of the question were considered as knowledgeable.Data analysis: A STROBE checklist was used to analyze and report data  of the age of study participants was 55.4 (±13.63) years. Fifty-eight percent of the study participants were in the age group of less than 60 years and about 69% were males. More than three fourth (81.2%) of study participants were married. A majority (42.5%) of the study had primary education and more than three fourth (85.4%) had more than 500 Ethiopian birr monthly income  and the prevalence diagnosed by the MDRD equation was 7.7% (n=28). Using the MDRD equation the stages of CKD were diagnosed as; stage 3 were 6.9% (n=25), stage 4 were three individuals, and none on stage 5. Whereas, as per the CG equation, among the 53 individuals, 13.5% (n=49) were on stage 3, four individuals were on stage 4 and none of them were on stage 5. This indicates the prevalence of CKD is higher at stage 3 and none at stage 5.Factors associated with chronic kidney disease: At bivariate analysis age, sex, income, BMI, DM duration, types of medication, history of hypertension, duration of hypertension, cardiovascular disease, previous history of kidney disease, cigarette smoking, alcohol intake, and knowledge were predictors. A multivariable logistic regression analysis; age, BMI, and previous kidney disease were found to be predictors. Attendants whose age was between 50–59 years were 4 times more likely  to develop chronic kidney disease compared to patients whose age was under 50 years by CG equation. Similarly, attendants whose age was between 60–69 years by MDRD  and by CG  were about 6 and 8 times more likely to develop chronic kidney disease respectively when compared to patients whose age was under 60 years. Respondents whose age was 70 years and beyond by MDRD  and by CG  were about 5 and 23 times more likely to develop chronic kidney disease respectively when compared to patients whose age was under 60 years. Patients with high BMI were significantly associated with chronic kidney disease when using the C-G equation. Obese patients were 80% less likely to develop chronic kidney disease than those who were not obese . Those who have been recurrently diagnosed to have any form of kidney disease were 6 and 5 times more likely to develop chronic kidney disease when using MDRD  and C-G equation  respectively (ectively .This study found the prevalence of CKD to be 7.7% and 14.6% by using MDRD and C-G equations respectively. Previous studies conducted in Addis Ababa and southern Ethiopia have shown that CKD prevalence is between 10.4% by MDRD and 19.1% by C-G equation and 18.2% by MDRD and 23.8% by C-G equation respectively. The estimated prevalence of CKD using both equations in the current study is lower than previously conducted studies in Ethiopia . The estAdvanced age groups were found to have a significant association with chronic kidney disease using both MDRD and C-G equations. The finding is consistent with other studies conducted in China and southern Ethiopia , 16. In Being obese was inversely associated with the disease using the C-G equation. This is contrary to the study done in India . The difPrevious recurrent attack of kidney disease was also significantly associated with CKD irrespective of the equation were used. Those who had been diagnosed with a kind of kidney disease previously were found to be more likely to develop current chronic kidney disease compared to those who had never been diagnosed to have kidney disease using both equations. A study done in Tanzania showed an association when the analysis was done using bivariate but was not associated when entered into multivariate logistic regression . Even thThe prevalence of chronic kidney disease in diabetic patients using both equations is high. Age of the patients, having a history of previous kidney disease and BMI were associated with chronic kidney disease. Therefore, alleviating modifiable and preventable factors that lead to kidney disease is recommended. Further, the provision of persistent health education and training for those who are diagnosed to have diabetes mellitus reduces the magnitude of the problem. The study has the following limitations. It was conducted in only one hospital which may affect the generalization of the finding and since the study was a cross-sectional study, the possibility of recall bias may result in underreporting of the results.


NCT03036150) by geographic region.This study aimed to examine the efficacy and safety of dapagliflozin in the Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease (DAPA-CKD) trial  200 to 5000 mg/g were randomized to dapagliflozin (10 mg once daily) or placebo. The primary end point was a composite of a sustained decline in eGFR of ≥50%, end-stage kidney disease or death from kidney or cardiovascular causes. We categorized recruiting countries into 4 broad global regions: Asia, Europe, Latin America, and North America. Of 4304 randomized patients, 1346 (31.3%) were from Asia, 1233 (28.6%) from Europe, 912 (21.2%) from Latin America, and 813 (18.9%) from North America.Adults with chronic kidney disease (CKD) with or without type 2 diabetes, with estimated glomerular filtration rate (eGFR) 25 to 75 ml/min per 1.73 mP = 0.77). Occurrence of serious adverse events (SAEs) was lower among patients randomized to dapagliflozin versus placebo .The relative risk of the primary composite end point was lower in patients randomized to dapagliflozin (relative to placebo) in all regions, with hazard ratios (95% CI) of 0.70 (0.48–1.00), 0.60 (0.43–0.85), 0.61 (0.43–0.86), and 0.51 (0.34–0.76) among patients from Asia, Europe, Latin America, and North America, respectively. There was no effect modification by region (interaction Dapagliflozin reduced kidney and cardiovascular events and prolonged survival in patients with CKD, with and without type 2 diabetes, with no apparent effect modification by geographic region.  In the present study, we investigated whether there were meaningful regional differences in efficacy and safety of dapagliflozin among patients with CKD with and without type 2 diabetes.2 and UACR 200 to 5000 mg/g. Patients with type 1 diabetes, polycystic kidney disease, lupus nephritis, or antineutrophil cytoplasmic autoantibody-associated vasculitis as well as those receiving immunotherapy for primary or secondary kidney disease within 6 months before enrolment were excluded. All eligible patients were required to be treated with a stable maximally tolerated dose of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for ≥4 weeks before randomization unless there was a documented intolerance to these drugs. All participants provided signed informed consent before the start of any study-related procedure. The trial was sponsored by AstraZeneca, and the trial protocol was approved by a central or local ethics committee at each trial site. The trial was registered at ClinicalTrials.gov (NCT03036150).DAPA-CKD was a randomized, double-blind, placebo-controlled multicenter trial conducted at 386 study sites in 21 countries  from February 2017 until June 2020. Manuscripts describing details of the study design and the primary results have been published previously.Eligible participants were randomly assigned to receive dapagliflozin 10 mg once daily or a matching placebo, in line with the sequestered, fixed-randomization schedule. Randomization was stratified by diabetes status and UACR (≤1000 or >1000 mg/g) at baseline. After randomization, in-person study visits were conducted after 2 weeks, 2, 4, and 8 months, and at 4-month intervals thereafter. At each follow-up visit, information on vital signs was recorded, blood and urine samples were obtained, and information on potential study end points, adverse events (AEs), concomitant therapies, and study drug adherence were collected.We broadly categorized participating sites into 4 geographic regions: Asia , Europe , Latin America , and North America .2 confirmed by a second measurement after at least 28 days), or death from kidney or cardiovascular causes. Secondary end points were, in a hierarchical order, the following: a composite kidney end point of ≥50% sustained decline in estimated GFR, kidney failure, or death from kidney disease; a composite cardiovascular end point of cardiovascular death or hospitalization for heart failure; and all-cause mortality. All efficacy end points were adjudicated by an independent event adjudication committee using rigorous prespecified end point definitions.The primary end point was a composite of sustained ≥50% decline in eGFR (confirmed by a second serum creatinine after at least 28 days), the onset of end-stage kidney disease . Potential diabetic ketoacidosis events were adjudicated by an independent adjudication committee.The overall analytical approach and prespecified statistical analysis plan have been previously published.P < 0.05 to indicate statistical significance. We performed all analyses with Stata version 14.2 (Stata Corp).We considered 2-tailed Of 4304 randomized patients, 1346 (31.3%) were from Asia, 1233 (28.6%) from Europe, 912 (21.2%) from Latin America, and 813 (18.9%) from North America. Baseline characteristics of randomized patients stratified by regions are presented in P = 0.8 and 0.4, respectively)  for the primary composite end point were 4.2, 4.4, 5.8, and 4.2 in patients randomized to dapagliflozin and 6.3, 6.7, 9.0, and 8.5 in patients randomized to placebo in Asia, Europe, Latin America, and North America, respectively. ctively) . Resultsctively) . There wSimilar to the primary end point, treatment with dapagliflozin led to a reduction in the incidence of the composite kidney end point, the composite cardiovascular end point, and all-cause death in patients across all regions. For all 3 secondary end points, there was no heterogeneity of benefit on relative or absolute risk reduction by region . SupplemThe number and proportions of SAEs, AEs of interest, and treatment discontinuation due to AEs observed in patients stratified by treatment group and region are presented in For any major international clinical trial, it is unlikely that patients from all participating regions or countries will have the same demographic characteristics, comorbidities, and background therapy. If regional differences are sizable, they have the potential to meaningfully influence the interpretation of clinical trial results vis-à-vis efficacy and safety within regions. In the current analysis, we aimed to determine whether there were regional differences in the effects of dapagliflozin on kidney and cardiovascular end points. We showed consistently favorable effects, despite differences in baseline characteristics and concomitant medication use, with substantial relative and absolute risk reductions of the primary composite end point and 3 secondary end points, including all-cause mortality. The safety profile of dapagliflozin was also similar across regions.2), there was no regional heterogeneity in efficacy for the composite end point of a sustained decline in the estimated GFR of at least 50%, end-stage kidney disease, or death from renal or cardiovascular causes.,In line with our findings, other clinical trials using sodium-glucose cotransporter 2 inhibitors showed health benefits across regions. For instance, in the CREDENCE trial comparing canagliflozin and placebo in patients with type 2 diabetes and CKD  compared with patients from other regions. These regional differences in baseline clinical characteristics may explain the increased incidence of the primary composite end point, secondary kidney composite end point, and all-cause mortality in Latin America and the reduced incidence of the composite cardiovascular end point and all-cause mortality in patients from Asia compared with other regions. Of note, compared with Europeans (a mostly White population), body mass index was lower in patients from Asia, but the prevalence of diabetes was similar. This phenomenon has been well described; the Asian population have a roughly similar risk of type 2 diabetes compared with White people, despite a lower body mass index.,There were substantial regional differences in antidiabetic medication use. Insulin was used more frequently in Latin America and North America. Fewer patients with diabetes in Asia were treated with insulin and/or biguanides, and roughly twice as many patients in Asia were treated with dipeptidyl peptidase-4 inhibitors compared with patients in Europe or Latin America. This may indicate limited access to insulin and biguanides in AsiaThe strengths of the present analyses include the relatively large sample size from 4 major geographic regions, with the collection of detailed information on baseline clinical characteristics. Analysis was prespecified, and data were collected under a single protocol from all target regions. The protocol did not restrict or mandate the use of any cardiovascular or glucose-lowering medications with the exception that angiotensin-converting enzyme-inhibitors and angiotensin receptor blockers be used except when contraindicated. As such, the results are more generalizable across and within the geographic regions studied. There are also several limitations. The definition of regions was based on broad continental geography; only 21 countries were included, with only a few countries in each geographic region, and were largely high and upper-middle-income countries, limiting generalizability. In addition, interpreting differences across regions is difficult because they may reflect several influences other than geography, including race/ethnicity, genetics, cultural differences, diet and lifestyle, type of health care system, economics, and even climate and other environmental factors.In conclusion, despite notable differences in baseline characteristics across regions, dapagliflozin reduced the risk of kidney and cardiovascular disease events and all-cause mortality in all regions, with no evidence of heterogeneity in efficacy or safety. These findings support the use of dapagliflozin in patients with CKD with and without type 2 diabetes across major regions around the world.RCR is a member of the Executive Committee of the DAPA-CKD study and has received grants/contracts from GlaxoSmithKline and Novo Nordisk, consulting fees from Boehringer Ingelheim and Chinook, and payment/honoraria as a speaker or advisor from Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Janssen, and Novo Nordisk. FFH is a member of the DAPA-CKD study executive committee and is a study investigator. She has received personal fees from AbbVie. GMC has received fees from AstraZeneca for the DAPA-CKD trial steering committee, research grants from NIDDK, and support for research staff attending meetings from Amgen; participated in data safety monitoring boards for Bayer and Recor; is on the board of directors for Satellite Healthcare and on trial steering committees for Akebia, Gilead, Sanifit, and Vertez; and holds stock options or stock options with Ardelyx, CloudCath, Durect, DxNow, Miromatrix, Outset, and Unicycive. AML, CDS, and BVS are employees and stockholders of AstraZeneca. JJVM has received payments to his employer, Glasgow University, for his work on clinical trials, consulting, and other activities from AstraZeneca, Cytokinetics, KBP Biosciences, Amgen, Bayer, Theracos, Ionis Pharmaceuticals, Dalcor Pharmaceuticals, Novartis, GlaxoSmithKline, Bristol Myers Squibb, Boehringer Ingelheim, Cardurion, and Alnylam, and has received personal lecture fees from Abbott, Alkem Metabolics, Eris Life Sciences, Hickma, Lupin, Sun Pharmaceuticals, Medscape/Heart.org, ProAdWise Communications, Radcliffe Cardiology, Servier, and the Corpus. PR has received honoraria to Steno Diabetes Center Copenhagen for steering group membership and/or lectures and advice from AstraZeneca, Novo Nordisk, Bayer, and Eli Lilly; advisory board participation from Sanofi Aventis and Boehringer Ingelheim; and steering group participation from Gilead. RDT received funding from AstraZeneca for participating in the steering committee for DAPA-CKD. He has received fees for consultancy from Boehringer Ingelheim, Reata Pharma, and Chinook Pharma. He has received honoraria for lectures from Medscape and Medical Education Resources. He has participated in DSMB or advisory boards for Bayer, Viofor, Akebia, and Otsuka. HSB has received honoraria for lectures from Eli Lilly, Novo Nordisk, and Medscape and received support for congress attendance from Novo Nordisk and AstraZeneca. DCW provides ongoing consultancy services to AstraZeneca and received personal fees from Bayer, Boehringer Ingelheim, Astellas, GlaxoSmithKline, Janssen, Napp, Mundipharma, Reata, Vifor Fresenius, and Tricida. HJLH has received funding/honoraria and consulting fees to his institution for Steering Committee membership and/or advisory board participation from AstraZeneca (DAPA-CKD study), AbbVie, Travere Pharmaceuticals, Janssen, Gilead, Bayer, Chinook, Merck, and CSL Pharma; consulting fees from Boehringer Ingelheim and Novo Nordisk; and honoraria for lectures from AstraZeneca; and has participated in advisory boards for Mitsubishi Tanabe and Mundipharma. All the other authors declared no competing interests.


Multivariate linear regression analysis showed that AIx@75 was positively associated with female sex  6.291, 11.562, p < 0.001), age , mean arterial pressure (MAP) , and was negatively associated with ACEI/ARB  and glucocorticoid . Smoking, eGFR, hemoglobin, and cause of disease were associated with AIx@75 in multivariate linear regression models when considering factors partly. Conclusions: Female, age, smoking, MAP, eGFR, cause of disease, ACEI/ARB, and glucocorticoid were found to be associated with atherosclerosis in CKD patients.Background: Arterial stiffness influences the prognosis of patients with end-stage kidney disease; however, the factors that promote arterial stiffness in chronic kidney disease (CKD) patients remain unknown. We aimed to explore the clinical factors associated with arterial stiffness in CKD. Methods: Between September 2017 and September 2022, all CKD patients treated at the Department of Nephrology, General Hospital of the Chinese People’s Liberation Army, excluding dialysis patients, were screened and their medical records within the last month were collected. Arterial stiffness was measured by the augmentation index (AIx). The correlative clinical factors with arterial stiffness were explored in different linear regression models. Results: 559 patients were included in the study. AIx@75 increased as the deterioration of CKDG1–CKDG5, with values of 1 , 5.5 , 9 , 12 , and 22 , respectively (Z = 63.03,  Chronic kidney disease (CKD) is a global public health problem , represePrevious studies suggested that with the decrease in eGFR, the degree of arteriosclerosis worsens, and the comorbidity or complication such as diabetes mellitus, hypertension, and hyperuricemia are also common in patients with CKD ,5,6,7. HThis single-center cross-sectional study was conducted from September 2017 to September 2022 on adults with CKD who were hospitalized at the General Hospital of the Chinese People’s Liberation Army, excluding patients on dialysis. The inclusion criteria were as follows: (i) age >18 years, (ii) CKD was diagnosed in line with the 2012 KDIGO  guidelines by the investigators prior to enrollment . The excThis study was approved by the Ethics Committee of the General Hospital of the Chinese People’s Liberation Army (No. S2017-133-01). The study was conducted in accordance with the Declaration of Helsinki and all participants were enrolled in the study after providing written informed consent.The information collected included sociodemographic characteristics, medical history, laboratory tests and medication history within the last month. Practicing physicians who were trained in Good Clinical Practice (GCP) collected the above data through a bedside inquiry and medical record system. If there are multiple different records of the same indicator within a month, the results closest to the AIx measure date were recorded. The augmentation index (AIx) was measured using an Endo-PAT 2000 device  by researchers following standard protocols.The subjects were required to fast for 8–12 h before blood sample collection. The following blood biochemical parameters were measured in the blood samples using standard assays: alanine aminotransferase (ALT), aspartate aminotransferase (AST), total protein (TP), albumin (ALB), total cholesterol (TC), triglycerides (TG), high-density lipoprotein (HDL), low-density lipoprotein (LDL), fasting blood glucose (FBG), blood urea nitrogen (BUN), blood creatinine (Scr), blood uric acid (UA), serum calcium concentration(Ca), serum phosphorus concentration (P), potassium (K), serum sodium concentration (Na), serum magnesium concentration (Mg), hemoglobin (Hb), platelet count (PLT), homocysteine (HCY), prothrombin time (PT), plasma activated partial thromboplastin time (APTT), fibrinogen (Fbg), D-dimer (D-Dimer), and C-reactive protein (CRP). The eGFR was calculated using the CKD Epidemiology Society (CKD-EPI) creatinine equation [The Endo-PAT 2000 device  was used to assess the AIx, representing arterial stiffness. All patients underwent testing at a temperature of 21–24 °C in a dimly lit and quiet environment by an investigator with professional training and at least one year of experience according to the operating manual . All pat2 test. AIx and AIx@75 were used to establish univariate linear regression models to screen the relationship between arterial stiffness and other variables in Chinese patients with CKD. Then, AIx@75 was used to explore the dependent variables in multivariate linear regression analysis. p < 0.05 was regarded as statistically significant.All statistical analyses were performed using IBM SPSS 26.0 software. Numerical variables are expressed as the mean ± standard deviation or median (IQR) based on distribution. Categorical variables were expressed as frequencies (%). The demographic, clinical, and laboratory tests were compared between groups according to the staging of CKD using one-way ANOVA, Kruskal–Wallis test, and Pearson χp < 0.05). The levels of ALT, TC, HDL, Hb, PLT, and the proportion of ACEI/ARB, immunosuppressant, and glucocorticoid drug use were decreased with the decrease in eGFR (p < 0.05). More immune nephropathy patients, such as those undergoingIgA nephropathy, showed normal kidney function, while more metabolic nephropathy, such as diabetic nephropathy, with injured kidney function, and at the same time, some patients with both or unidentified.A total of 559 participants were eligible for inclusion. p < 0.05). At the same time, eGFR, ALT, Hb, and use of ACEI/ARB, immunosuppressant, and glucocorticoid were negative associated with Aix and Aix@75 (p < 0.05). Considering the correlative factors with Aix and Aix@75 were consistent, and AIx@75 was adjusted the influence of heartbeats, AIx@75 was used to explore the correlation factors in multivariate linear regression analysis. After collinearity diagnostics, potential relative factors with AIx@75 including female, age, diabetes mellitus, intrarenal arteriosclerosis, smoking, CHD, MAP, ALT, AST, eGFR, Hb, P, Mg, K, Fbg, TC, TG, HDL, immunosuppressant, glucocorticoid, statins, and ACEI/ARB were included in different models of multivariate linear regression analysis, respectively.Univariate linear regression was used to analyze the related factors of AIx and AIx@75 in patients with CKD . Age, feConsidering too many factors should be included in the regression analysis, five multivariate linear regression models on various levels were developed to explore the correlative factors with AIx@75. Model 1 was based on general patient information as independent variables, including female sex, age, smoking, MAP, diabetes, CHD, and intrarenal atherosclerosis. Female sex, age, MAP, and smoking were found positively correlated with AIx@75 in Model 1 . Model 2In this study, we investigated the relationship between AIx@75 and various clinical factors in CKD. In addition to age and female, MAP, eGFR, and the cause of disease were independently associated with arteriosclerosis in CKD. The use of ACEI/ARB and glucocorticoid could change the association between eGFR and the cause of disease with AIx.Arteriosclerosis is an important factor of poor prognosis in end-stage CKD patients. Numerous studies show that CKD progression and atheromatosis progression are closely associated ,11.Studies had shown that central pulse pressure (CAP), AIx, pulse wave velocity (PWV), and carotid and femoral arterial ultrasound were powerful tools for predicting atheromatosis progression in patients with CKD ,12,13In this study, we selected the AIx as noninvasive assessment indicators for arterial stiffness because of its simplicity of operation and portability.The present study found that in glucocorticoid use, Hb was negatively associated with atherosclerosis and etiology was associated with atherosclerosis, unlike previous studies. We found the use of glucocorticoid were negatively associated with atherosclerosis in CKD patients and could change the association between eGFR and the cause of disease with atherosclerosis. So, we considered glucocorticoid maybe decrease atherosclerosis by improving renal function, especially in patients with immune inflammation. The impact of glucocorticoids on atherosclerosis was unclear . ClinicaHb showed a negative correlation with arterial stiffness in the study, while Hb was positively correlated with arterial stiffness in healthy people ,17,18,19Although all of the metabolic relative factors such as diabetes mellitus, hyperlipidemia, and hyperuricemia were not correlated with atherosclerosis, cause of disease was related with atherosclerosis in our study. Patients with metabolic were higher degree of atherosclerosis than patients with immune nephropathy. Elevated glucose level, dyslipidemia, and other metabolic alterations were tightly involved in the almost every step of the atherogenic process . It suggAs in previous studies, atherosclerosis was more severe in females, and eGFR was negatively associated with atherosclerosis. Our study found that female patients had more severe arteriosclerosis than male patients in CKD. Previous studies on healthy people suggest that estrogen has an inhibitory effect on atherosclerosis. The degree of arteriosclerosis in female before menopause was lower than that in men of the same age, while there was no gender difference in arteriosclerosis after menopause . The aveOur study found that arteriosclerosis was negatively correlated with eGFR, which was consistent with previous findings . It was Similar to the general population, atheromatosis progression in CKD is more prevalent among smokers, high levels of MAP, and older patients ,12, and Some limitations should be noted. First, as this is a cross-sectional design, it is difficult to determine the causal relationship between these influences and arterial stiffness. Second, our data came from a single center, which resulted in some selection bias. Third, AIX@75 is a measure of the reflected wave of the terminal artery. However, other indicators of arterial stiffness obtained through the brachial or ankle artery may lead to heterogeneity in arterial stiffness and result in bias.In conclusion, Female, age, smoking, MAP, eGFR, cause of disease, ACEI/ARB, and glucocorticoid were found to be associated with atherosclerosis in CKD.


Patients with asthma (aged ≥12 years) from seven sites across Saudi Arabia participated in this cross‐sectional study. Asthma severity was classified by study investigators, guided by the 2017 Global Initiative for Asthma (GINA) recommendations. Of 511 patients enrolled, 502 patients, treated by respiratory medicine specialists, were analyzed . Most patients had moderate‐to‐severe asthma , were overweight/obese (78.9%), and received full health care reimbursement (83.4%). Asthma was partially controlled/uncontrolled among 64.3% of patients; 62.3% experienced ≥1 severe asthma exacerbation(s), and 60.6% and 41.2% were prescribed ≥3 (overprescription) and ≥10 SABA canisters, respectively, in the 12 months preceding study initiation. Additionally, 21.9% of patients purchased SABA over the counter (OTC), of whom 66.4% purchased ≥3 SABA canisters. Ninety‐seven (88.2%) patients who purchased SABA OTC also received SABA prescriptions, and 80.4% and 56.7% of these were prescribed ≥3 and ≥10 SABA canisters, respectively. Overall, compared with SABINA III, a higher percentage of patients from Saudi Arabia were overprescribed SABA  and purchased SABA OTC , underscoring the need to align asthma treatment practices with current evidence‐based recommendations and regulate SABA OTC sales in Saudi Arabia.Despite near‐universal health care and timely updates to treatment guidelines in Saudi Arabia, asthma control remains suboptimal, warranting deeper exploration of its management practices. This study describes asthma characteristics and prescription patterns of short‐acting β Results from the Saudi Arabia cohort of the SABINA III study demonstrated SABA over‐prescription (≥3 canisters/year) in more than 60% of patients with asthma, substantial over‐the‐counter purchase of SABA, and a high exacerbation burden. Our findings emphasize the need for a fundamental, paradigm shift in prescribing habits with a focus on alignment with current evidence‐based treatment recommendations. Asthma is estimated to affect 339 million people globally and is associated with premature death and a diminished quality of life.In a 2016, population‐based, cross‐sectional study, the validated European Community Respiratory Health Survey questionnaire was administered to adult male and female residents of Riyadh, Saudi Arabia. Participants reported the prevalence of wheezing in the absence of viral rhinitis and physician‐diagnosed asthma at 18.2% and 11.3%, respectively.2‐agonist (SABA) relievers.In 2008, the Saudi Thoracic Society launched the Saudi Initiative for Asthma (SINA) group to tackle the issue of increasing incidence of asthma in the country, with the principal goal of updating management guidelines for health care practitioners who treat Saudi residents with asthma.2‐agonist (LABA), is now the preferred reliever for adults and adolescents at GINA treatment steps 1–2, and for patients with moderate‐to‐severe disease (treatment steps 3–5) who are prescribed ICS‐formoterol maintenance and reliever therapy.Global studies have demonstrated that SABA overuse is associated with an increased risk of asthma exacerbations, incremental health care resource utilization, and even mortality.22.1The SABINA III study methodology has been published previously.2.2Patients aged ≥12 years with a documented diagnosis of asthma, ≥3 consultations with an HCP, medical records containing data for ≥12 months prior to study initiation, and a demonstrated ability to sign informed consent were eligible to participate in the study.Patients with a diagnosis of other chronic respiratory diseases, such as chronic obstructive pulmonary disease, or other acute or chronic conditions, which in the opinion of the investigator would limit the ability of a patient to participate in the study, were excluded.2.32.3.1SABA prescriptions were categorized as 0, 1–2, 3–5, 6–9, 10–12, and ≥13 canisters, with overprescription defined as ≥3 SABA canisters in the 12 months prior to the study visit.2.3.2Other variables included sociodemographic characteristics ; practice type ; asthma characteristics and treatment outcomes 2.3.3The number of severe exacerbations in the 12 months prior to the study visit, based on the American Thoracic Society/European Respiratory Society recommendations and defined as a worsening of asthma symptoms that results in hospitalization, an emergency room visit, administration of intravenous corticosteroids, an OCS prescription for three or more days, or a single dose of an intramuscular corticosteroid,2.4All analyses were descriptive in nature. Continuous variables were summarized by the number of nonmissing values, given as mean (standard deviation [SD]) and median (range). Categorical variables were summarized by frequency counts and percentages.33.1A total of 511 patients were recruited, of whom 502 were included in the analysis. Two patients with an asthma duration of <12 months were excluded; data were missing for six patients; and one patient was likely coded erroneously as being treated by a primary care physician (PCP), rather than a specialist. Thus, all 502 analyzable patients were treated by specialists  or obese (48.6%). Overall, 38.3% of patients had received a university and/or post‐graduate education, while 26.8% had received a primary, secondary, or high school education. Most patients (83.4%) received fully reimbursed health care, while 16.0% were without health care reimbursement. Further, a higher proportion of patients classified with mild asthma versus moderate‐to‐severe asthma had fully reimbursed health care (96.2% vs. 82.0%). Most patients (67.5%) had ≥1 comorbidity and more patients with mild asthma had no comorbidities compared with those with moderate‐to‐severe disease (55.8% vs. 29.8%).Among the patients enrolled by respiratory medicine specialists, mean (SD) age was 47.5 14.8) years, with approximately two thirds (65.1%) aged 18–54 years  asthma duration was 14.8 (11.5) years. Patients classified with moderate‐to‐severe and mild asthma had a mean (SD) asthma duration of 15.4 (11.7) and 9.5 (8.1) years, respectively  of 4.3 (3.3) canisters in the previous 12 months  were prescribed an ICS/LABA fixed‐dose combination as maintenance therapy Table , and alm3.5.2Conversely, only 5.0% of patients were prescribed ICS, with a mean (SD) of 8.6 (6.8) canisters in the 12 months before study initiation Table . This gr3.5.3Overall, 45.2% of patients were prescribed an OCS burst in the 12 months prior to their study visit. Further, 47.1% of patients with moderate‐to‐severe asthma and 28.8% of those with mild disease were prescribed OCS .Additionally, 20.5% of patients were prescribed biologic agents (data not shown). Of these, 67.0% were prescribed omalizumab, 27.2%, mepolizumab, 2.9%, a combination of omalizumab with mepolizumab, and 2.9% received dupilumab.3.6When stratified by treatments prescribed in the 12 months preceding their study visit, most patients prescribed antibiotics 87.4%) experienced ≥1 severe exacerbation, followed by those prescribed short‐term OCS (85.4%), long‐term OCS (78.6%), ICS/LABA fixed‐dose combinations (63.5%), SABA in addition to maintenance therapy (63.4%), ICS (40.0%), and SABA monotherapy ,n = 1778),n = 1096),n = 3066)Of concern, 60.6% of patients from Saudi Arabia were overprescribed SABA. Although these prescription patterns were comparable to those reported in the Gulf cohort  of the SABINA III study where 58.5% patients were overprescribed SABA,Despite the observation that most participants in this study benefited from a medication reimbursement plan, a high proportion of those who purchased SABA OTC obtained ≥3 SABA canisters in the 12 months prior to their study visit. Of additional concern, most patients who purchased SABA OTC also received SABA prescriptions, indicating possession and possible use of an unwarranted quantity by such patients. This behavior may be ascribed to the easy access and ready availability of asthma medication in Saudi Arabia without guideline‐directed evidence for its indication.Of interest, 29.1% of patients in the Saudi Arabia cohort did not receive a prescription for SABA in addition to their maintenance medication, suggesting that alternative, rapid‐onset relievers recommended by SINA, such as a combination of budesonide and formoterolThe high clinical and socio‐economic burden of asthma and widespread SABA over prescription in Saudi Arabia may exist due to several barriers to optimal asthma care reported across different studies. These include patient‐related factors such as lack of education on the disease state and its corresponding levels of severity, guideline‐directed asthma treatment steps,Our study clearly demonstrated a high asthma burden in Saudi Arabia; however, it is not without its limitations. All patients in this study were treated by pulmonologists or other respiratory specialists, and as a result, primary care was not represented. Consequently, our observations potentially may underestimate the countrywide burden of disease and not reflect the full spectrum of asthma care practices in Saudi Arabia. In accordance with this, a cross‐sectional study examining asthma medication patterns in primary care reported SABA use in 90.3% of patients,In conclusion, SABA overprescription (≥3 canisters per year) was widespread, occurring in two thirds of patients in Saudi Arabia. This was considerably higher than that reported in the overall SABINA III population,HA‐J, SW, ASA, AAH, RA, AA, and TD have no conflict of interest to declare. MF and EZ are employees of AstraZeneca. MB was an employee of AstraZeneca at the time the study was conducted.The study was conducted in compliance with the study protocol and Declaration of Helsinki. Local ethics approval was obtained from the King Abdullah International Medical Center Institutional Review Board.MB designed the study. HA‐J, SW, ASA, AAH, RA, AA, and TD contributed to data collection. All authors contributed to data analysis, data interpretation and drafting and reviewing the manuscript.Table S1. SABA prescription/purchase and education level in the Saudi Arabia cohort of SABINA IIIClick here for additional data file.