Early rehabilitation can reduce ventilation duration and improve functional outcomes in critically ill patients. Upper limb strength is associated with ventilator weaning. Passive muscle loading may preserve muscle fibre function, help recover peripheral muscle strength and improve longer term, post-hospital discharge function capacity. The physiological effects of initiating rehabilitation soon after physiological stabilisation of these patients can be concerning for clinicians. This study investigated the feasibility of measuring metabolic demand and the safety and feasibility of early upper limb passive ergometry. An additional comparison of results, achieved from simultaneous application of the methods, is reported.This was an observational feasibility study undertaken in an acute teaching hospital’s General Intensive Care Unit in the United Kingdom. Twelve haemodynamically stable, mechanically ventilated patients underwent 30 minutes of arm ergometry. Cardiovascular and respiratory parameters were monitored. A Friedman test identified changes in physiological parameters. A metabolic cart was attached to the ventilator to measure oxygen uptake. Oxygen uptake was concurrently calculated by the reverse Fick method, utilising cardiac output from the LiDCO™ and paired mixed venous and arterial samples. A comparison of the two methods was made. Data collection began 10 minutes before ergometry and continued to recovery. Paired mixed venous and arterial samples were taken every 10 minutes.2 (p = 0.70).Twelve patients were studied; 9 male, median age 55 years, range (27–82), median APACHE score 18.5, range (7–31), median fraction inspired oxygen 42.5%, range (28–60). Eight patients were receiving noradrenaline. Mean dose was 0.07 mcg/kg/min, range (0.01–0.15). Early ergometry was well tolerated. There were no clinically significant changes in respiratory, haemodynamic or metabolic variables pre ergometry to end recovery. There was no significant difference between the two methods of calculating VOWe report the feasibility of using the reverse Fick method and indirect calorimetry to measure metabolic demand during early physical rehabilitation of critically ill patients. More research is needed to ascertain the most reliable method. Minimal change in metabolic demand supports the safety and feasibility of upper limb ergometry. These results will inform future study designs for further research into exercise response in critically ill patients.http://www.clinicaltrials.gov. Clinicaltrials.gov No. NCT04383171. Registered on 06 May 2020 - Retrospectively registered.  In 2017–2018 there were over 290,000 adult Intensive Care Unit (ICU) patient records in England, of whom 7.4% had a length of stay duration of eleven days and more , 6.A number of studies have reported that the early application of ICU mobility therapy can reduce the number of ventilator days, ICU and hospital length of stay , 8 as weOxygen consumption is a widely used proxy measure for metabolic rate. Within the ICU, whole body oxygen consumption can be determined by using paired arterial and venous blood oxygen content, in conjunction with cardiac output monitoring. (The reverse Fick method). Alternatively, indirect calorimetry techniques provide a minimally invasive assessment of energy consumption, using a metabolic cart, attached to the ventilator measures breath by breath, inhaled and exhaled oxygen and carbon dioxide. . However2). We hypothesize that measuring oxygen consumption during passive exercise in critically ill patients is feasible and will demonstrate minimal metabolic demands on the patient. This study is reported in accordance with the STROBE statement [The primary objective of our study was to assess the feasibility of using the reverse Fick method and indirect calorimetry to measure metabolic demand and to assess the safety and feasibility of passive upper limb cycle ergometry, during the first days of critical illness. A secondary objective analysis will compare simultaneous assessment of the two methods of assessing oxygen uptake . This programme provides a progressive mobility pathway starting with daily passive upper/lower limb exercise sessions by means of an ergometer in addition to their routine physiotherapy. Inclusion criteria for enrolment into the study included: patient being on the EMP pathway of which the criteria were cardiovascular stability (stable vasopressor dose for two hours); stable heart rate (< 140 bpm) and rhythm and the presence of a jugular central venous pressure (CVP) line and arterial line. Exclusion criteria included any prior rapidly deteriorating neuromuscular disease, any upper limb problem precluding cycle ergometry, pyrexia (temp > 38 °C), raised intracranial pressure, patients with poor prognostic outcomes and lack of agreement from clinician or NOK/LR not understanding English. 149 patients accepted onto the EMP were screened for study eligibility.All included patients had monitoring in place that included: electrocardiogram (ECG) set, saturation probe, CVP line and an arterial line. Patients were sedated according to the ICU sedation protocol using a combination of fentanyl, midazolam and/or propofol aiming for a RASS score between − 1 and + 1. Vasopressors were used to maintain a mean arterial blood pressure of > 75 mmHg. Sedative infusion rates and ventilation settings were not changed during the protocol.Patients were ventilated using pressure or volume control modes or support mode using an Engstrom Carestation™ ventilator. Flow volumes were directly measured by a ventilator D-lite™ sensor, which measures pressure difference between two ports and calculates gas/air flow .Patients were positioned in bed, in a semi recumbent position with their arms in the limb supports of the cycle ergometer . Sixty minutes of data was collected. The first 10 minutes were with patients upper limbs positioned in the limb supports and at rest followed by 30 minutes passive upper limb cycling at a frequency of 20 revolutions per minute, and finally 20 minutes with the patients upper limbs left in the limb supports during which the patient was at rest undisturbed. Safety criteria used for patient initiation and continued use of the ergometer was based on the traffic light system recommended from Hodgson et al.  .2 and CO2, respiratory rate (RR) breaths/min, minute volume (MV) mL and tidal volume (VT) mL were measured by the ventilator's E-COVX module. Values for all continuous data were averaged over the five minutes leading up to each 10-minute interval within the 60-minute study period. If any data was missing within those last five minutes the average was calculated by the number of available data within that time frame.Continuous heart rate (HR), blood pressure (BP), heart rhythm and saturations were measured throughout the 60-minute study period for each patient. Continuous cardiac output (CO) L/min, HR (bpm), BP (mmHg), and stroke volume (SV) m/L were monitored by the LiDCO™. The LiDCO™ was calibrated as per manufacturer guidance, prior to patient enrolment. Minute by minute values of inspiratory and expiratory OPaired central mixed venous blood and arterial blood gas samples were taken at 10 minutes prior to ergometry starting, and then at 0, 10, 20 and 30 minutes, during ergometry and again 10 and 20 minutes after ergometry finished.2) was calculated using the equation: DO2 = CaO2 x CO where CaO2  = (1.34 x Hb x SaO2 x 0.01) + (0.023 x PaO2). The value 1.34 is known as Hufners constant and 0.023 is the volume of O2 dissolved per 100 ml plasma per kPa.Oxygen delivery (DO2 production (VCO2) was calculated from values of inspired concentrations of CO2 (FiCO2) and expired concentrations of CO2 (FeCO2) by the E-COVX module via the ventilator using the Bohr equation: VCO2 kPa = FiCO2 – FeCO2. Oxygen uptake (VO2) was calculated by two methods.CO2 mL/min = CO x (CaO2 - CvO2) x10 [Method one: The reverse Fick method uses the measure of CO from the LiDCO™ with paired central mixed venous and arterial blood gas samples: VOvO2) x10 .2 using the E-COVX metabolic module via the ventilator from the value of fraction of inspired O2 (FiO2), expiratory minute volume (MV), expired concentrations of O2 (FeO2) and CO2 (FeCO2) using the equation: VO2 ml/min = MV (FiO2 –FeO2 – FiO2 (FeCO2))/1-FiO2. [Method two: Indirect calorimetry calculated VO/1-FiO2. This is a feasibility study the results of which may be used to power a larger study if appropriate. The study population number was guided by previous work in our unit . All sta2O with a range of 0 to 12 cm H2O . The median resting HR values did not change throughout the exercise protocol (p = 0.60). CO median rest (n = 10) value  did not change statistically throughout the exercise protocol (p = 0.95). There were no significant changes in any of the respiratory variables.Median arterial blood pressure, systolic and diastolic blood pressure did not change significantly throughout the exercise protocol  (n = 9) and did not change statistically from throughout the exercise protocol (p = 0.98)  median rest value was 79.8%, IQR 8.6% and did not change statistically throughout the exercise protocol (p = 0.61). Maximum change of ScvO2 during the session was a 15.7% drop during the first ten minutes of ergometry in one patient but this increased to within 1.8% of its resting levels at the end of the exercise session. VCO2 (n = 10) median rest value was 216.5 mL/min, IQR 105.5 mL/min and did not change statistically throughout the exercise protocol (p = 0.35). Maximum change of VCO2 during the session was a decrease of 38.9% from the median resting value for one patient at the end of the 30-minute exercise session but this increased up to 20.5% from the baseline 10 minutes later  and 160 mL/min, (IQR 127.2 mL/min) from the E-COVX (n = 10) and the reverse Fick method (n = 8) respectively. These did not change statistically throughout the exercise protocol (p = 0.95 and p = 0.84)  such that bias assessment was not explored  have demonstrated improved physical outcomes , 20, 21 As muscle breakdown and deconditioning can be demonstrated within hours of mechanical ventilation there is increasing interest on rehabilitation and muscle training within the ICU, however the benefits of these interventions remain uncertain. , 23. It The examination of metabolic costs of the metabolic demands in response to this type of passive mobilization commenced very early during critical illness is not widely studied. A study by Pires-Neto assessing very early passive cycle ergometry, albeit in the lower limbs also found no significant changes in cardio-respiratory or metabolic parameters . In this2 in response to other passive interventions although two studies report no significant change in VO2, with either passive chair transfer or physiotherapy treatment [2. Although the VO2 calculations via the E-COVX module in this study produced more variable results than the reverse Fick method, the reproducibility of the reverse Fick method needs to be balanced against the invasiveness of the technique. This difference in results is consistent with previously reported poor correlation and reproducibility between different techniques for VO2 assessment [Few studies have examined VOreatment , 30. Oursessment . FurtherIt is important to acknowledge the limitations of this study. The small number of participants (n = 12) and the heterogeneity of these patients with regards to age and diagnosis means extrapolation of these results to all ICU patients is not justified. Technical issues resulted in incomplete data sets. Although the majority of the patients were deeply sedated two patients had a RASS score above − 2, The data from the motomed machine did not indicate if there was any active participation from the patient during the protocol. Although a possibility, such active participation would be expected to result in increases in oxygen uptake which was not seen.Measuring the metabolic demands of upper limb cycle ergometry in critically ill patients appears to be feasible and results in minimal increase in metabolic demands. Our study supports the notion that perceived benefit of early physical rehabilitation may outweigh concerns of adding to the physiological demands during the acute stages of illness. Further research is needed to determine how monitoring patient workload during rehabilitation could be used to personalise rehabilitation strategies during the course of their illness.


Changes in ECG were analyzed according to the occurrence of cardiac arrhythmias and 28-day mortality. Results: 48 patients  aged 18–64 were studied. Intra-cranial pressure correlated with QTc before DC . DC reduced spQRS-T (p < 0.001) and QTc interval (p < 0.01), increased Tax (p < 0.01) and changed STJ in a majority of leads but did not affect QRSax and iCEB. The iCEB was relatively increased before DC in patients who eventually experienced cardiac arrhythmias after DC (p < 0.05). Higher post-DC iCEB was also noted in non-survivors (p < 0.05), although iCEB values were notably heart rate-dependent. Conclusions: ICP positively correlates with QTc interval in patients with isolated TBI, and DC for relief of ICH reduces QTc and spQRS-T. However, DC might also increase risk for life-threatening cardiac arrhythmias, especially in ICH patients with notably prolonged QTc before and increased iCEB after DC.Background: Traumatic brain injury (TBI) is commonly associated with cardiac dysfunction, which may be reflected by abnormal electrocardiograms (ECG) and/or contractility. TBI-related cardiac disorders depend on the type of cerebral injury, the region of brain damage and the severity of the intracranial hypertension. Decompressive craniectomy (DC) is commonly used to reduce intra-cranial hypertension (ICH). Although DC decreases ICH rapidly, its effect on ECG has not been systematically studied. The aim of this study was to analyze the changes in ECG in patients undergoing DC. Methods: Adult patients without previously known cardiac diseases treated for isolated TBI with DC were studied. ECG variables, such as: spatial QRS-T angle (spQRS-T), corrected QT interval (QTc), QRS and T axes (QRS Cardiac disorders are common after traumatic brain injury (TBI) and considered a consequence of so-called brain-heart crosstalk. Cardiac dysfunction occurs in nearly 50% of TBI patients and associates with poor outcome . Common Intracranial hypertension (ICH)-related cardiac disorders were documented nearly 50 years ago ,8. An inTBI-related cardiac disorders associated with abnormal repolarization may result from stimulation/depression of the midbrain and the dorsal pontine regions, and Dorsal Vagal Motor Nucleus (DVMN) ,18. An iDecompressive craniectomy (DC) is commonly performed to reduce intracranial hypertension (ICH) refractory to medical treatment ,20. It hThe aim of the present study was to analyze the effect of decompressive craniectomy on electrocardiographic variables in TBI patients. We hypothesized that rapid decrease in ICP and improved cerebral blood flow following DC might correct ICH-related disorders in electrocardiographic abnormalities and cardiac function.This prospective, observational study was conducted in accordance with the Declaration of Helsinki and applicable regulatory requirements approved by the Institutional Review Board and the Bioethics Committee of Medical University at Lublin, Poland (KE-0254/26/2019). Informed consent was obtained from patients’ legal representatives, as all enrolled patients were unconscious or/and sedated at the moment of the inclusion in the study.Adult patients who were treated for severe isolated TBI (classified according to the Glasgow Coma Score (GCS) and Rotterdam computed tomography score (CTS) care system ), and whFor the entire duration of the ICU stay, relevant demographic, clinical and laboratory data along with daily assessment of fluid balance, sepsis-related organ failure assessment (SOFA) score, and advanced hemodynamic monitoring variables (obtained with EV1000) were registered in an electronic database. Data on mortality was collected on day 28.2), fronto-temporal electroencephalography, peripheral saturation (SpO2) with hemoglobin in level and Pleth Variability Index (PVI). Intracranial pressure management was based on the latest Brain Trauma foundation guidelines [2O. Blood potassium concentration was measured five times per day and eventually corrected using continuous infusion of potassium and magnesium mixture. Fluid administration and vasopressors (norepinephrine) were titrated to obtain SrO2 higher than 50% and mean arterial pressure (MAP) higher than 80 mmHg.Our monitoring and treatment techniques have been previously described . Arteriaidelines . Hyperos20, and respiration rates according to the carbon dioxide levels. Ventilatory parameters were set to maintain values of end tidal carbon dioxide (EtCO2) between 35–40 mmHg, oxygen reserve index (ORI) 0.0–0.1 and pulse oximetry (SpO2) 97–100% saturation, respectively. The mixture of gases was monitored with a SpaceLabs monitor . All patients received continuous infusion of balanced crystalloids to maintain MAP above 80 mmHg. Intravascular volume status and fluid responsiveness were controlled with Pleth Variability Index (PVI) using the Masimo device. In patients not responding to fluid therapy, a continuous infusion of norepinephrine  was used. Tachycardia was treated with the ultra-selective beta-1-blockerlandiolol . After surgery completion, all patients were transferred to the ICU.Total intravenous anaesthesia (TIVA) was used for decompressive craniectomy in all patients. General anaesthesia was induced and maintained with the continuous administration of fentanyl  and propofol . Muscle relaxation was obtained with a single bolus of 0.1 mg/kg body weight vecuronium bromide , which was titrated to maintain an adequate level of muscle relaxation. The depth of anaesthesia was controlled with Patients Sedation Index (PSI) measured by Masimo Root. Anaesthesia was maintained throughout the procedure using a mixture of air (60%) and oxygen (40%), and all subjects were ventilated using intermittent positive pressure ventilation. The following ventilation parameters were applied: tidal volume (6–8 mL/kg body weight) plateau pressure < 30 cm Hax, Tax, STJ and Ta, were obtained directly from the Cardiax commercial software. For detection of the end of T wave, QT interval and calculation of QTc, the Cardiax software utilizes a median beat related “global QT interval” algorithm similar to that described by Xue [Surface12-lead resting ECGs with derived vectorcardiograms (VCGs) were recorded using a Cardiax device . The recordings at each time period were automatically averaged to a single median beat, and transformed into three orthogonal leads X, Y and Z according to the inverse Dower method ,25. The d by Xue . The indd by Xue . The ECGt-test was used for variables with normal distribution. Categorical variables were compared using the χ2 and Fisher exact test, or χ2 with Yates correction when applicable. For variables with non-normal distribution, the Wilcoxon signed-rank, Mann-Whitney-U, Kruskal-Wallis ANOVA and post-hoc Dunnett’s multiple comparison tests were used. Linear regression analysis was performed by using the Pearson’s test for variables with normal distribution and the Spearman’s test for variables with non-normal distribution. Multiple stepwise regression analysis was performed to estimate the potential influence of various factors on changes in spQRS-T angle, QTc, QRSax, Tax and STJ. The following independence parameters were entered into the model: dose of norepinephrine, plasma osmolality and ICP. A p < 0.05 was considered significant.The Shapiro-Wilk test was used to test the normality of the distribution of the results. Means and standard deviations (SD) were calculated, and the Student’s unpaired Sixty-two consecutive adult patients without previous cardiac history admitted to the intensive care unit for isolated TBI between January 2019 and December 2019 were considered for inclusion in the study. Fourteen underwent emergency DC just after the admission to hospital, before the admission to ICU, and those patients were excluded due to lack of sufficient cardiac evaluation. Finally, 48 patients  aged 18–64 were included . Fifteenp < 0.05). Intra-cranial pressure correlated with QTc calculated with Bazett formula before DC . However, the significant correlation was lost when QTc was calculated with either the Fridericia or Framingham formulas. After decompressive craniectomy, spQRS-T was reduced, Tax increased and QTc interval was shortened  and with QTc after DC . Plasma osmolality inversely correlated with QRSax before and after DC . Multivariable regression showed that iCEB significantly depended on HR and dose of norepinephrine before DC .Changes in the STJ segment were noted in the following leads: II, III, aVF and V6 . There wp < 0.05). Decompressive craniectomy did not change iCEB in patients who survived 28 days, whereas iCEB increased after surgery in non-survivors  died due to brain death before 28 days of treatment. Two underwent DC during the 24 h after the admission to the ICU, 6 between 24 and 48 h of treatment and five between 48 and 72 h of treatment. Independent of the correction formula, the QTc was significantly prolonged before DC in non-survivors . Independent of the correction formula, QTc was significantly higher in patients with atrial fibrillation before DC , as well as after DC . Decompressive craniectomy did not differentially affect iCEB in patients with versus without atrial fibrillation, but iCEB was significantly higher before DC in patients with episodes of atrial fibrillation observed within a few days after DC .Atrial fibrillation was noted in 10 patients within a few days after DC and was significantly more frequent in patients who did not survive the 28-days of treatment  are common in many diseases, increases above 100° definitively increase the risk for sudden cardiac death ,36,37. A1- and β2-adrenoreceptor agonists, increases iCEB [The index of cardiac-electrophysiological balance measured as QT interval divided by QRS duration has been put forward as a derivative of the cardiac wavelength λ (effective refractory period × conduction velocity) ,15. In hses iCEB ,15. Imposes iCEB . In the ses iCEB . Based oDespite its novel findings, the present study also had several limitations. First, we did not analyze the effect of anesthesia on ECG and derived vectorcardiography variables. It has been documented that some anesthetics prolong the QTc interval and some, such as propofol, shorten it . Second,The effect of DC on ECG has not been previously systematically studied. The present study showed that DC shortened QTc interval and reduced spQRS-T angle. Higher values of iCEB were also noted in patients with cardiac arrhythmias, although the increases were heart rate-dependent. Additionally, QTc interval prolongation was statistically significantly correlated with elevations in ICP. Our observations further document cardiac disorders in TBI patients without previously known cardiac diseases, and further confirm the phenomenon of brain-heart interaction. However, larger studies are required to corroborate the effects of DC on ECG findings, cardiac function and outcomes.


Disturbed blood flow, characterized by high retrograde and oscillatory shear rate (SR), is associated with a proatherogenic phenotype. The impact of disturbed blood flow in patients with heart failure with reduced ejection fraction (HFrEF) remains unknown. We tested the hypothesis that acute elevation to retrograde and oscillatory SR provoked by local circulatory occlusion would increase endothelial microparticles (EMPs) and decrease brachial artery flow-mediated dilation (FMD) in patients with HFrEF.Eighteen patients with HFrEF aged 55 ± 2 years, with left ventricular ejection fraction (LVEF) 26 ± 1%, and 14 control subjects aged 49 ± 2 years with LVEF 65 ± 1 randomly underwent experimental and control sessions. Brachial artery FMD (Doppler) was evaluated before and after 30 min of disturbed forearm blood flow provoked by pneumatic cuff (Hokanson) inflation to 75 mm Hg. Venous blood samples were collected at rest, after 15 and 30 min of disturbed blood flow to assess circulating EMP levels .P < 0.001), but blood flow patterns and EMPs had no differences (P > 0.05). The cuff inflation provoked a greater retrograde SR both groups (P < 0.0001). EMPs responses to disturbed blood flow significantly increased in patients with HFrEF (P = 0.03). No changes in EMPs were found in control subjects (P > 0.05). Disturbed blood flow decreased FMD both groups. No changes occurred in control condition.At rest, FMD was lower in patients with HFrEF compared with control subjects (Collectively, our findings suggest that disturbed blood flow acutely decreases FMD and increases EMP levels in patients with HFrEF, which may indicate that this set of patients are vulnerable to blood flow disturbances. Disturbed blood flow, characterized by high retrograde and oscillatory shear rate (SR), plays a proatherogenic role across the vascular endothelium . ArteriaHeart failure with reduced ejection fraction (HFrEF) is a complex syndrome, characterized by peripheral vasoconstriction, as a result of an elevated sympathetic nervous system  and reniMicroparticles are cell-derived vesicles up to 100 nm released after activation or apoptosis of the endothelium or blood cells types . SpecifiIn this study, we sought to determine the effects of disturbed blood flow on the release of EMPs and endothelial function in patients with HFrEF. We hypothesized that (1) acute elevation in retrograde and oscillatory SR would increase circulating EMPs and (2) would decrease FMD in patients with HFrEF.All experimental procedures and measurements conformed to the Declaration of Helsinki and were approved by the Research Committee of the Heart Institute (SDC: 4374/16/040), the Human Subject Protection Committee at the Clinics Hospital of the University of São Paulo Medical School (CAEE 57991116.4.0000.0068). All patients provided written informed consent before enrollment.2) ≤ 20 mL kg–1 per min. The exclusion criteria were myocardial infarction within 3 months, unstable angina, acute HF, pacemaker, pulmonary disease, chronic renal disease, peripheral neuropathy, history of stroke, untreated hypo/hyperthyroidism, body mass index (BMI) > 30 kg/m2, or history of smoking. Screening for the study consisted of a complete medical history questionnaire, followed by physical examination that included biochemical blood analysis, resting blood pressure (BP) measurement (sphygmomanometry), a resting electrocardiogram, anthropometry , cardiac function test (echocardiogram), and cardiopulmonary exercise testing.A total of 32 subjects (18 patients with HFrEF and 14 age-matched controls) were included in the study. All patients had been on stable heart failure medications for >3 months, had LVEF ≤ 40%, New York Heart Association functional class I–II, optimal medical therapy, and peak oxygen uptake , and 15 and 30 min (during inflation of the cuffs). Finally, after an interval of 10 min, the FMD was performed again. The control session consisted of the same protocol; however, the cuffs were not inflated to produce disturbed blood flow.Left ventricular ejection fraction (LVEF) was determined by two-dimensional echocardiography by Simpson’s biplane method. All parameters, LVEF, LV end-diastolic diameter (LVEDD), LV end-systolic diameter (LVESD), LV end-systolic volume (LVESV), and LV end-diastolic volume (LVEDV) were evaluated by an echocardiographer .O2) and carbon dioxide production were determined by means of gas exchange on a breath-by-breath basis in a computerized system . O2 peak was defined as the maximum attained 2O (V-slope) or the point at which the ventilatory equivalent for oxygen and end-tidal oxygen partial pressure curves reached their respective minimum values and began to rise  with the ramp protocol, increasing from 5 to 25 W per minute, based on the clinical status of the patients . Oxygen  to rise . RespiraBefore and after intervention , we measured brachial artery FMD, in accordance to the guidelines , 2019. FAfter 10 min of quiet resting, a 30-min intervention to induce disturbed blood flow or normal flow (control) was conducted. Then a pneumatic cuff (Hokanson) was placed around the left forearm and inflated to 75 mm Hg, and a second proximal cuff was positioned 3 cm distal from the axilla and inflated to 40 mm Hg to partially occlude venous flow from the arm. For normal flow measures, the cuff was placed on the same arm, but it was not inflated. Mean SR and the pattern of SR  were recorded by 60 s at three different time points, 0 (before the inflation of the cuffs), and 15 and 30 min (during inflation of the cuffs).+/CD42b– were determined by flow cytometry , as previously described  and during  experimental and control sessions. The endothelial microparticle populations CD31escribed . Briefly–1⋅). But the FMD was normalized by SRAUC until peak vasodilation (peak diameter). FMD reliability was evaluated through the comparison of FMD value (pre intervention) between days. The intraclass correlation coefficient was 0.91 (P < 0.05), and the coefficient of variation was 5.5%.The Doppler ultrasound video signal was encoded real-time and captured at a frequency of 30 Hz. The video files were compatible with commercial automated edge-detection and wall-tracking software , which was used for offline analysis. The initial phase of the software analysis consisted of identifying regions of interest on the optimal portion of the brachial artery image and its blood velocity spectra. R-wave gaiting function was applied to continuously assess brachial artery diameter or blood velocity. FMD was calculated as the percentage rise of this peak diameter from the preceding baseline diameter. After deflation of the cuff, the cumulative SR was determined by a 3-min period through the area under the curve  and artery diameter (in cm) . For calculations of antegrade and retrograde SR, antegrade and retrograde mean blood velocities were used, respectively. In addition, oscillatory SR index, a variable that estimates the magnitude of oscillation in the vascular bed was calculated as IRetrograde shearI/. The vascular and EMPs response to experimental sessions are presented as baseline and maneuver (the peak between time points 15 and 30 min). The delta changes at peak were from baseline.Shear rate was calculated as four times the ratio between mean blood velocity  post hoc tests were applied when significant F-values were found. Data are presented as mean ± standard error of the mean, percentage, or absolute delta. Significance was set at P ≤ 0.05. All analyses were performed using STATISITICA 12.0 software.The Shapiro–Wilk test was used to verify data distribution, and the Mauchly test was used to verify sphericity. The normality and sphericity assumptions were not violated. The Student paired 2peak, and LVEF than control subjects had (P < 0.05). In addition, HFrEF patients had higher glucose, LVDD, LVSD, and creatinine compared with control subjects . The estimated glomerular filtration rate was similar between groups (P = 0.14). All patients were clinically stable, based on normal jugular venous pressure, and absence of orthopnea, body weight gain, pulmonary congestion, hepatomegaly, or lower limb edema. The control subjects were not currently taking any medications, and the relevant medications used by the patients with HFrEF are reported in Heart failure with reduced ejection fraction patients and control subjects were well matched for age, sex, other physical characteristics and BP and heart rate . HFrEF pP > 0.05). Brachial artery FMD % was lower in patients with HFrEF compared with control subjects (P < 0.05). EMPs were similar between groups (P > 0.05).Blood flow patterns, FMD, and EMPs at rest are shown in P < 0.001; P > 0.05). Anterograde SR similarly increased during the experimental session in patients with HFrEF and control subjects  released from the endothelium into the circulation in response to activation or apoptosis of endothelial cells . They haIn the present study, disturbed blood flow was conducted by forearm cuff inflation at 75 mm Hg for 30 min. This maneuver has been used to manipulate the SR patterns in conduit peripheral arteries . We obseThe exact cellular mechanisms of EMPs release induced by disturbed blood flow are not well established. However, have been shown that several pro-inflammatory and oxidative substances, such as tumor necrosis factor (TNF-α), angiotensin II and reactive oxygen species may contribute for this process . As hearIt is well known that patients with HFrEF have endothelial dysfunction . To our Because disturbed blood flow increased EMPs in patients with HFrEF, a greater reduction in the FMD of these patients would be expected. Surprisingly, this was not the case. The reduction of the FMD was similar between patients with HFrEF and age –matched controls. Explanations to this response are outside the scope of our study. However, we speculate that there is a maximum reduction in maneuver-induced endothelial function. Of note, the values for FMD after maneuver were similar between the groups.Increased EMP levels and reduced endothelial function are associated with an increase in the risk of mortality in patients with chronic heart failure . In our Our study has some limitations. The sample size of our study was relatively modest and should be interpreted with caution. But the results were consistent between and within individuals. The clear dose-response relationship between the independent and dependent variables provides powerful evidence that our findings are robust. Therefore, it is unlikely that a larger number of subjects would have significantly changed the findings of the study. We did not evaluate endothelium-independent function via nitroglycerin, an exogenous donor of NO. Previous studies have shown that stimuli [e.g., mental stress  and physCollectively, our findings suggest that disturbed blood flow acutely decreases FMD and increases EMP levels in patients with HFrEF, which may indicate that this set of patients are vulnerable to blood flow disturbances.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Research Committee of the Heart Institute (SDC: 4374/16/040), the Human Subject Protection Committee at the Clinics Hospital of the University of São Paulo 101 Medical School (CAEE 57991116.4.0000.0068). The patients/participants provided their written informed consent to participate in this study.TS and AS conceived experimental designs, performed experiments, interpreted results, and drafted the manuscript. DF, CM, HR, and NR conceived experimental designs, interpreted results, and edited the manuscript. GA, GF, PB, and ML performed experiments and edited the manuscript. CN interpreted results and reviewed/edited the manuscript. MA conceived and designed the study, interpreted results, and reviewed/edited the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


We would like to thank Braber et al.  for thisThis was for instance shown in the SYNTAX RCT (CABG vs PCI in multivessel disease), in which only a small percentage of the patients presented to the Heart Team was eventually randomised in the study . In addip-value <0.1 in the univariate analysis for the multivariate analysis per outcome, as is explained in the method section of our article. Variables in the multivariable model that did not affect the outcome with p > 0.05 were successively excluded from the model, which resulted in a final model of significant variables influencing the outcome and correcting for them. We created a different model per outcome and subsequently corrected for the significantly different variables from baseline. For example, if age, diabetes and previous CABG had a p-value <0.1 in the univariate analysis, these variables were included in all multivariate analyses. If age was not a significant variable in the multivariate analysis for myocardial infarction, it was excluded from the model for that outcome, resulting in a correction for diabetes and previous CABG for the outcome ‘myocardial infarction’. We agree with Braber et al. that variables such as cancer, neurologic disorders (e.g. dementia) and frailty are interesting and important to correct for. However, in order to do so, a prospective registry should be performed.Braber et al. also indicated that our method of correction for confounders at baseline was confusing. Therefore, we would like to explain that we included all baseline variables with a The trials mentioned by Braber and colleagues  comparing PCI with CABG have their own limitations with regard to the elderly population at hand. The BARI trial, performed in 1995, investigated percutaneous transluminal balloon angioplasty and is therefore not applicable to this discussion . In addiLastly, we share the opinion that PCI is progressively improving and becoming more effective in the treatment of coronary artery disease. In addition, antiplatelet treatment continues to improve and is being tailored to specific patient characteristics, thereby reducing complications of PCI, such as stent thrombosis but also bleeding in the elderly population. That was one of the reasons for our contemporary analysis. Despite improved antithrombotic therapy for PCI patients, the results of our observational study did not substantiate a more favourable outcome after PCI compared with CABG. We do, however, agree with Braber et al. that this difference may not be due to the failure of PCI, but due to the PCI patients in our study being frailer and having more comorbidities than the CABG patients.


However, it is unknown whether there is a change in dysbiosis across the stages of diabetic chronic kidney disease. We investigated a cross-sectional study of patients with early and late diabetes associated chronic kidney disease to identify possible microbial differences between these two groups and across each of the stages of diabetic chronic kidney disease. (2) Methods: This cross-sectional study recruited 95 adults. DNA extracted from collected stool samples were used for 16S rRNA sequencing to identify the bacterial community in the gut. (3) Results: The phylum Firmicutes was the most abundant and its mean relative abundance was similar in the early and late chronic kidney disease group, 45.99 ± 0.58% and 49.39 ± 0.55%, respectively. The mean relative abundance for family Bacteroidaceae, was also similar in the early and late group, 29.15 ± 2.02% and 29.16 ± 1.70%, respectively. The lower abundance of Prevotellaceae remained similar across both the early 3.87 ± 1.66% and late 3.36 ± 0.98% diabetic chronic kidney disease groups. (4) Conclusions: The data arising from our cohort of individuals with diabetes associated chronic kidney disease show a predominance of phyla Firmicutes and Bacteroidetes. The families Ruminococcaceae and Bacteroidaceae represent the highest abundance, while the beneficial Prevotellaceae family were reduced in abundance. The most interesting observation is that the relative abundance of these gut microbes does not change across the early and late stages of diabetic chronic kidney disease, suggesting that this is an early event in the development of diabetes associated chronic kidney disease. We hypothesise that the dysbiotic microbiome acquired during the early stages of diabetic chronic kidney disease remains relatively stable and is only one of many risk factors that influence progressive kidney dysfunction. The human gut harbors a complex community in excess of 100 trillion microbial cells that constitute the gut microbiota. They form a dynamic and symbiotic ecosystem that is in constant interaction with the host metabolism influencing nutrition, physiology, and immune function . The micDiabetes and associated micro and macrovascular complications have reached pandemic proportions, with a global prevalence of 463 million . More thSeveral studies have reported compositional change in intestinal microbiota in humans with diabetes compared to control subjects , and exaClostridium spp. and Bacteroides spp. [Clostridium species in CKD [Research in experimental animal models of chronic kidney disease (CKD) ,15 and ides spp. . It is ks in CKD . This ‘uA further hallmark of intestinal dysbiosis is the reduction of beneficial saccharolytic microbial families, such as Prevetoellaceae, that produce short-chain fatty acids such as butyrate. These short-chain fatty acids help maintain the integrity of the intestinal barrier, and are reduced in individuals with CKD compared to healthy subjects . IndividDespite the disease burden, the pathophysiologic mechanisms underpinning the progression of diabetic CKD are poorly understood. Diabetic CKD is characterised by hypertension, albuminuria, and progressive decline in kidney function, measured as a change in the estimated glomerular filtration rate (eGFR). The role of the gut microbiome in the progression of diabetic CKD has emerged as an area of scientific interest . Individ2), 2 (eGFR 60–89 mL/min/1.73 m2), 3a (eGFR 45–59 mL/min/1.73 m2), 3b (eGFR 30–44 mL/min/1.73 m2), 4 (eGFR 20–29 mL/min/1.73 m2), and 5 (eGFR < 20 mL/min/1.73 m2). The risk of death from any cause, cardiovascular events, or hospitalization increases exponentially from Stage 3b onwards [This prospective, cross-sectional study recruited 95 adults, over a 6 month period, at the time of their outpatient endocrinology clinic visit. The patients consented to providing a stool sample for DNA isolation, in addition to their routine blood tests at the outpatient visit. These patients had diabetes with varying stages (stages 1–5) of chronic kidney disease. Patients were divided into 2 distinct groups: ‘early CKD’ and ‘late CKD’. The early diabetic CKD group was defined as participants with diabetes who had stage 1, 2, or 3a CKD, while the late diabetic CKD group was defined as participants with diabetes who had stage 3b, 4, or 5 CKD. Diabetes-associated chronic kidney disease is the preferred terminology encompassing the range of histological kidney lesions that may be observed . CKD is  onwards .Data collection occurred only at one time point and included information on blood pressure, medical comorbidities, duration of diabetes, the stage of CKD, and its associated complications, medications, and pathology results. Anthropometric data and stool samples were collected on the day of the clinic visit while the remainder of the patient’s information was gathered via access to the Austin Health’s electronic medical record. All of this selected information was then entered into a database specific for this research study for subsequent analysis. There were 70 participants in the early diabetic CKD group and 25 in the late group. Participants provided written informed consent and the study was approved by the Human Research Ethics Committee of Austin Health, Victoria, Australia  and the Human Research Ethics Committee of Deakin University, Australia. The procedures followed were in accordance with the Helsinki Declaration of 1975, as revised in 2013.Following collection by the donor in a 50 mL specimen container, samples were aliquoted approximately 0.5–1 g into smaller 1.5 mL Eppendorf tubes before freezing at −80 °C for future DNA extraction.® DNA Stool Mini Kit  according to the manufacturer’s protocol. DNA quantification and purification was assessed using a Qubit fluorometer (Invitrogen). DNA extractions from the stool aliquots were performed at the completion of patient recruitment.DNA was extracted using the Qiagen QIAampPCR amplification and sequencing was performed by the Australian Genome Research Facility . PCR amplicons were generated using the primers and conditions outlined in Paired-ends reads were assembled by aligning the forward and reverse reads using PEAR (version 0.9.5) . PrimersThe categorical variables for the patient characteristics were tested using Fisher’s Exact and the continuous variables were tested with Wilcoxon-signed rank test.Data were pruned to remove representatives classified to Archaea (N = 4), Chloroplast (N = 42), and 22 unassigned OTUs implemented in the package ‘phyloseq’ in the R statistical program version 1.26.1 . We alsoboxplot command in base R. Because our data have potential outliers and were not normally distributed, differences between sample group means were tested with the non-parametric Kruskal-Wallis test, using the command kruskal.test [We calculated the number of observed OTUs and compared the alpha diversity (within the sample) of individuals grouped by the CKD stage using the Shannon Index , which akal.test .adonis command from the package ‘vegan’ [p-values <0.05.For beta diversity (between samples), we used a log transformation of data scaled to read depth per sample and then calculated and plotted weighted UniFrac , which p ‘vegan’  to perfo ‘vegan’ . ResultsClinical and Biochemical Characteristics2 in the early diabetic chronic kidney disease group , and 24.48 mL/min/1.73m2 in the late diabetic chronic kidney disease individuals . This reached statistical significance with a p value < 0.001 (Wilcoxon Signed Rank Test). The mean age in the early CKD group was significantly younger at 66.24 years compared with 72.68 years in the late CKD group . The proportion of the 95 recruited patients in each stage of diabetic CKD is illustrated in After sample quality control, data were available for 95 patient samples. The clinical and biochemical characteristics of the 95 study population are shown in p value = 0.70, The beta diversity indices are used to describe ecological diversity between microbial community samples. The beta diversity of the gut microbiome did not significantly differ between early versus late groups of diabetic CKD individuals or between each of the stages of diabetic CKD when compared with another  or between each of the stages of diabetic CKD when compared with another  of bacterial operational taxonomic units (OTUs) identified to the taxonomic level of phylum in the gut microbiome of individuals with different stages of CKD disease were represented by the phyla Bacteroidetes and Firmicutes. The phylum Firmicutes was the most abundant and its mean relative abundance was similar in the early  and late  CKD group, accounting for 45.99 ± 0.58% in early CKD and 49.39 ± 0.55% in late CKD. Likewise, the mean relative abundance for phylum Bacteroidetes was similar in early diabetic CKD accounting for 42.86 ± 1.40% and 41.20 ± 1.12% in the late diabetic CKD group A. At theFaecalibacterium, Bifidobacterium, Bacteroides, and Akkermansia, which are known to be negatively associated with type 2 diabetes [Prevotella in the family Prevotellaceae showed no significant difference in relative abundance in either early or late diabetic CKD  to a more pathogenic proteolytic fermentation pattern. Although the mechanisms for dysbiosis in diabetes are less clearly understood, it has been shown that individuals with diabetes generally exhibit reduced bacterial diversity characterised by a reduction of butyrate-producing bacteria such as Faecalibacterium prausnitzii and Roseburia intestinalis together with an increase in opportunistic pathogens [Diabetic CKD is a multi-systemic disease process with complex pathophysiological processes. Indeed the cause-consequence relationship between such a dynamic pathological process and associated changes to intestinal microbiota is difficult to differentiate. Factors known to be responsible for the dysbiosis in CKD include increased intestinal barrier permeability secondary to an inflammatory and uraemic milieu associated with CKD and subsequent translocation of pathogenic bacteria and bacterial endotoxins from the gut lumen into the bloodstream due to this increased gut permeability . A majorathogens .The ability to isolate gut dysbiotic causality due to diabetes associated CKD alone, remains a clinical challenge due to the presence of multiple comorbidities such as hypertension, obesity and vascular disease. Furthermore, therapeutic strategies in diabetic CKD include medications and dietary restrictions which as described above, can independently affect the gut microbiome ,45. DespIn particular, the gut microbiome differences between healthy individuals and those individuals with diabetic CKD have been documented ,23,46. WFaecalibacterium, Bifidobacterium, Bacteroides, and Akkermansia [Ruminococcus in individuals with type 2 diabetes [2, and a low GFR subgroup, defined as GFR ≤ 7 mL/min/1.73 m2 [The data has shown that the gut microbiome of individuals with early and late diabetic CKD and across all stages 1–5 of diabetic CKD are similar. Consistent with the literature , we haveermansia  are presdiabetes , also shdiabetes , were prdiabetes  examined/1.73 m2 . Whilst Our data has shown that the average relative abundance of bacterial phyla and family across stages 1–5 of diabetic CKD were mostly similar A,B. ThisPrevotella strains are classically considered to be commensal bacteria due to their extensive presence in the healthy human body. Prevotella is a genus with high genetic diversity within and between species, which could explain its abundance in human healthy microbiota [A distinct gut microbiome with reduced Prevotellaceae families has been associated with CKD . Consistcrobiota . As desccrobiota , maintaicrobiota , and redcrobiota . Similarcrobiota .In our study, there was no demonstrable difference in the operational taxonomic units (OTUs), at any of the taxonomic levels across all stages of diabetic CKD suggesting that dysbiosis appears early in diabetic CKD and persists through to the late stages of the disease thus raising the question of what role gut dysbiosis plays in the progression of diabetic CKD. We postulate that dysbiosis is one of a number of factors that may influence progression of diabetic CKD. Comorbid conditions such as hypertension, diabetes, and vascular disease, together with proteinuria and genetics are some of the contributors to the pathogenesis of chronic kidney disease . More reIt is known that in gut dysbiosis, pathogenic bacteria overgrow and secrete increased amounts of lipopolysaccharides, peptidoglycans, and bacterial DNA into the host circulatory system which are detrimental to intestinal permeability . ConsequDiabetes occurs very commonly and is globally present in pandemic proportions  while diOne of the limitations of this study is its small sample size, especially the presence of only 25 patients with the late stages (3b–5) diabetic CKD resulting in a potential loss of the ability to recognise microbial trends. One of the reasons for this is that the study subjects were selected from an outpatient endocrine clinic, where there is a lesser propensity to see more advanced renal dysfunction. We acknowledge that the inherent problem of a small sample size in the late CKD group together with our large number of covariates, would result in a limited statistical power to detect microbiome differences as well as imprecision of the effect estimate and an elevated false positive rate. Other limitations include the cross-sectional nature of this study cohort, which meant that patient samples were collected at only one time point and not studied longitudinally. Furthermore, our data set did not contain information on antibiotic usage, which is known to have an impact on gut microbiome composition. Another significant limitation is that the dietary habits of the participants were not recorded which will invariably affect the outcome of results. There was also no healthy group, however, as described previously, the microbiome between healthy and diseased group has been well characterised and was not the purpose of this study.Future directions in this area of research should include a longitudinal study of a larger number of patients in each of the stages of diabetic CKD (1–5), with a focus on the predominant form of Type 2 diabetes with information inclusive of dietary intake and medications, especially pertaining to antibiotic use.This study raises some unexpected yet interesting questions about the microbiome in individuals with diabetes and varying kidney dysfunction. We know from current literature that there is a significant difference in the gut microbiome between healthy people and those individuals with diabetic CKD. However, within the limitations of this study, we did not observe a significant change in the microbiome across any of the six stages of diabetic CKD. We propose that once patients achieve a state of dysbiosis in early diabetic CKD, this dysbiosis remains relatively the same and could be considered a susceptibility risk factor, which together with other risk factors , influence the progression to late stage diabetic CKD.Bifidobacterium, Bacteroides, Faecalibacterium, and Akkermansia in relation to type 2 diabetes showed a similar relative abundance between early and late CKD groups, as did the positively associated Ruminococcus. We hypothesise that the dysbiotic microbiome acquired during the early stages of diabetic CKD remains relatively static and is only one of many risk factors that influence progressive kidney dysfunction. These findings warrant a further examination in larger patient cohorts followed longitudinally over time with multiple sampling and clinical data inclusive of information on dietary intake and medications. Only then will it be possible to robustly test whether the dysbiotic microbiome composition remains the same or significantly changes with the progression of diabetic chronic kidney disease.In conclusion, the data arising from our cohort of individuals with diabetes associated with CKD show a predominance of phyla Firmicutes and Bacteroidetes. The families Ruminococcaceae and Bacteroidaceae represent the highest abundance, while the beneficial Prevotellaceae family was reduced in abundance. The most interesting observation is that the relative abundance of these gut microbes does not change across the stages (1–5) of diabetic CKD, suggesting that this is an early event in the development of diabetes associated CKD. The negatively associated genera


The aim of this study was to determine the effect of rotational axis position (RAP and thus g‐gradient) during short‐arm human centrifugation (SAHC) upon cardiovascular responses, cerebral perfusion and g‐tolerance.g, 1.7 g and 2.4 g.In 10 male and 10 female participants, 10 min passive SAHC runs were performed with the RAP above the head (P1), at the apex of the head (P2), or at heart level (P3), with foot‐level Gz at 1.0 We hypothesized that movement of the RAP from above the head  towards the heart might reduce central hypovolaemia, limit cardiovascular responses, aid cerebral perfusion, and thus promote g‐tolerance.Moving the RAP footward towards the heart decreased the cerebral tissue saturation index, calf circumference and heart rate responses to SAHC, thereby promoting g‐tolerance.Our results also suggest that RAP, and thus g‐gradient, warrants further investigation as it may support use as a holistic spaceflight countermeasure.g, 1.7 g and 2.4 g. Cerebral tissue saturation index , calf circumference , heart rate (HR) and digital heart‐level mean arterial blood pressure (MAP) were continuously recorded, in addition to incidence of pre‐syncopal symptoms (PSS). ΔCC and ΔHR increases were attenuated from P1 to P3 . In addition, ΔcTSI decrements were also attenuated  and PSS incidence lower in P3 than P1 (P < 0.05). A positive linear relationship was observed between ΔCC and ΔHR with increasing +Gz, and a negative relationship between ΔCC and ΔcTSI, both independent of RAP. Our data suggest that movement of RAP towards the heart (reduced g‐gradient), independent of foot‐level Gz, leads to improved g‐tolerance. Further investigations are required to assess the effect of differential baroreceptor feedback (i.e. aortic–carotid g‐gradient).Artificial gravity (AG) through short‐arm human centrifugation (SAHC) has been proposed as a holistic spaceflight countermeasure. Movement of the rotational axis position (RAP) from above the head towards the heart may reduce central hypovolaemia, aid cerebral perfusion, and thus promote g‐tolerance. This study determined the effect of RAP upon cardiovascular responses, peripheral blood displacement , cerebral perfusion and g‐tolerance, and their inter‐relationships. Twenty  healthy participants (26.2 ± 4.0 years) underwent nine (following a familiarization run) randomized 10 min passive SAHC runs with RAP set above the head (P1), at the apex of the head (P2), or at heart level (P3) with foot‐level Gz at 1.0  The aim of this study was to determine the effect of rotational axis position (RAP and thus g‐gradient) during short‐arm human centrifugation (SAHC) upon cardiovascular responses, cerebral perfusion and g‐tolerance.g, 1.7 g and 2.4 g.In 10 male and 10 female participants, 10 min passive SAHC runs were performed with the RAP above the head (P1), at the apex of the head (P2), or at heart level (P3), with foot‐level Gz at 1.0 We hypothesized that movement of the RAP from above the head  towards the heart might reduce central hypovolaemia, limit cardiovascular responses, aid cerebral perfusion, and thus promote g‐tolerance.Moving the RAP footward towards the heart decreased the cerebral tissue saturation index, calf circumference and heart rate responses to SAHC, thereby promoting g‐tolerance.Our results also suggest that RAP, and thus g‐gradient, warrants further investigation as it may support use as a holistic spaceflight countermeasure. Immediately upon standing from the supine position, blood pressure remains unaltered at certain locations within the arterial, venous and other fluid‐filled compartments of the body, termed hydrostatic indifference points   of +2.4 Gz via short‐arm human centrifuge (SAHC) leads to significant improvements in subsequent standing orthostatic tolerance  since the hydrostatic pressure rises continually from head to foot when the rotation axis occurs above the head outside the body, but rises in both directions away from the rotation axis when it occurs within the body Fig. . As a reThus the aim of the study was to investigate the effect of three standardised RAPs and the head‐to‐heart and heart‐to‐foot hydrostatic component (g‐gradient) of blood pressure upon the cardiovascular responses, peripheral blood displacement , cerebral perfusion and g‐tolerance, in addition to the relationship between peripheral blood displacement, and both heart rate (HR) and cerebral perfusion with respect to g and RAP.Declaration of Helsinki, including registration with the German Clinical Trial Registry (DRKS), and was approved by the Ethics Committee of the North Rhine Medical Association in Düsseldorf, Germany (Ref: 2015381). All participants gave written informed consent to participate in the study.The study conformed to the −2; Table Twenty 10 male) healthy normotensive, non‐smoking participants  and low density lipoprotein (LDL)); haematology (blood count); urine analysis ; resting electrocardiogram (ECG); an exercise test to verify aerobic fitness; a standing test to assess orthostatic tolerance; and a complete medical history. Female participants had to test negative on a urine‐based pregnancy test before each session. Prior to testing, each participant was familiarized with all aspects of the study, including the methodology, personnel involved and the SAHC Fig. A.grey shaded area, Fig. Participants underwent nine (following a familiarization run) passive 10 min short‐arm centrifugations on the unique :enviFuge SAHC at the German Aerospace Centre  over two experimental sessions on separate days (2 months apart) with rest phases of at least 25 min between each of the five runs per day  was used to determine the absolute ratio of oxy‐ and deoxy‐haemoglobin. Taking into account participant frontal cranium thickness, estimated according to age and sex, the cerebral tissue saturation index (cTSI) was deduced , was quantified using strain gauge plethysmography  positioned around the calf midpoint  of each participant.et al. Continuous beat‐by‐beat HR via a standard three‐lead electrocardiogram  and mean arterial finger blood pressure (MAP) was recorded with a Finometer . The Finometer finger cuff was placed around the third finger of the right hand and fixed by a sling at the level of the fourth intercostal space (i.e. heart level). Finometer BP measurements were corroborated with absolute arterial BP measurements obtained by an automated sphygmomanometer  prior to starting each profile. Stroke volume (SV) and total peripheral resistance (TPR) was estimated from the arterial BP waveform using the Modelflow method  when one (or more) of the following was observed: (i) reduction of HR and BP > 15 s; (ii) nausea, paleness, dizziness; and (iii) participant requested run termination  of 0.05, power (1 ‐ β) of 0.80 with an average effect size (d) of 0.05, a power calculation, using G* Power  function using the following criteria: (i) physiologically plausible limits; and (ii) maximal percentage of change in relation to the standard deviation of the signal. Data were resampled at 4 Hz (piecewise cubic spline interpolation) as long as >95% of data were valid  yielding 15 complete sets of data for further analysis. Summary data are presented as means ± standard deviation (SD) unless otherwise stated. Mean 2 min changes (delta) from the mean of the final 5 min of the 10 min baseline immediately before each corresponding centrifuge run were analysed.Data are presented as mean 2 min changes (delta) from the mean of the final 5 min of the 10 min baseline immediately before each corresponding centrifuge run.lme4  in question, against the model without that effect.R  and vs. P3), one‐way analyses of variance were conducted, followed by post hoc tests (Tukey's honestly significant difference) to determine effect location . Chi‐squared testing was employed to evaluate the frequency of PSS+ classification during runs at each position across all g‐levels .To reduce complexity of the models, secondary analysis was performed with data both averaged for each 2 min increment of centrifugation and compared for differences arising due to position at that moment. To evaluate the differences induced (e.g. P1 P < 0.05). All parameters were significantly affected by g‐level, and all but CO were affected by position (Table P < 0.05). As there was a significant effect of g‐level on all parameters, for clarity the figures only show P3 and P1 +2.4 Gz data as P2 responses were consistently around the midpoint between those of P1 and P3 across the entire centrifuge run .Significant changes were observed in all measured cardiovascular variables except MAP where there was a strong trend for time (i.e. centrifugation)  reductions were significantly attenuated from the fourth minute until the end of the ramp‐down phase between P1 and P3 at +2.4 Gz  and away from ‘classical centrifugation’ (P1) resulted in significant attenuation of HR Fig. A and MAP < 0.05; Fig. P < 0.05) higher during the entire centrifugation phase in P1 vs. P3, and then lower in P1 (vs. P3) (7.05 ± 2.92 mmHg to −1.94 ± 0.98 mmHg) in the first minute following ramp‐down as no rebound was evident  acceleration was greatest in the final minute of centrifugation in both P1 and P3; albeit significantly less in the latter  lower at P3 vs. P1 across the +Gz levels  the effect of three standardised RAPs and the head‐to‐heart and heart‐to‐foot hydrostatic component (g‐gradient) of blood pressure upon the cardiovascular responses, peripheral blood displacement , cerebral perfusion and g‐tolerance, in addition to the relationship between peripheral blood displacement, and both HR and cerebral perfusion with respect to g and RAP. Specifically, we sought: (i) to determine physiological differences to positive and negative heart‐to‐head g‐gradients by measuring cerebral perfusion, systemic cardiovascular responses and the emergence of pre‐syncopal symptoms indicative of g‐intolerance; and (ii) provide a better insight for future artificial gravity research by characterizing the third variable in human centrifugation studies . The main findings were that a reduced or negative heart‐to‐head g‐gradient significantly attenuated the reduction in cerebral perfusion and central hypovolaemia, the acceleration of HR and indicators of g‐intolerance.et al. In P1, the fluid shifts and overall cardiovascular loading is comparable to that of upright standing ; and secondary blood shifts due to acceleration gradients throughout the entire system. Even if a baroreceptor remains unaffected at the onset of centrifugation by being located at the centre of rotation, the g‐gradient will redistribute blood causing local pressure changes, which will initiate secondary reflex cardiovascular responses. The effects of altered pressure gradients when RAP is changed are demonstrated in Fig. et al. Delta calf circumference was unchanged by position in the initial stages of centrifugation (up until minute eight) whilst ΔcTSI was significantly lower at +2.4 Gz in P1 than P3 from the fourth minute onwards. This finding suggests that cerebral perfusion was attenuated earlier than significant peripheral fluid shifts indicated by ΔCC, presumably due to a varied peripheral vascular response to early orthostatic stimulation  all increased as a function of g‐level, as hypothesized based on previous findings , changes with each position despite a comparable +Gz level at the feet Fig. . It is ket al. Significant attenuations of g‐induced changes in cerebral perfusion, central hypovolaemia and systemic cardiovascular response occurred at P3, the most striking of which was ΔHR. Interestingly, it has been postulated that the hydrostatic gradient between the carotid and aortic baroreceptors is a potent determinant of HR responses to orthostatic challenge  due to fluid shifts and of course the reduction in flow may have negatively affected NIRS signal quality . Furthermore, this study did not measure local pressure or volume changes during centrifugation; pressure changes were calculated from referring g‐profiles. Speculation regarding pressure receptor stimulation and arterial/venous HIP locations has been inferred based upon studies of the cardiovascular responses to postural changes  independent of foot‐level Gz, reduced the orthostatic challenge leading to improved g‐tolerance. However, the role of peripheral blood displacement remains unclear. Our results suggest that RAP, and thus g‐gradient, warrants further investigation, specifically the effect of differential baroreceptor feedback (i.e. aortic–carotid g‐gradient) as reduced cardiac filling may effect haemodynamic regulation during and immediately following SAHC.Our results demonstrate that SAHC g‐gradient is a critical factor in determining the haemodynamic responses to centrifugation in addition to g‐level magnitude and duration. However, moving the axis of rotation to the level of the heart probably decreases the potential orthostatic training benefits of SAHC in microgravity, although this, and its effect on the efficacy of AG on other physiological systems, also warrants further investigation.No conflicts of interest, financial or otherwise, are declared by the authors.CL performed the experiments; CL and JR analysed the data; CL, DAG, NG, EM and JR conceived and designed the research; CL, DAG, AB, HHS, NG interpreted the results of the experiments; CL, DAG, AB, HHS, EM, JR and NG edited and revised the manuscript; CL,DAG, AB, HHS, EM, JR and NG approved the final version of the manuscript.CL received a Helmholtz Space Life Sciences Research School (SpaceLife) PhD scholarship. SpaceLife was funded in equal parts by the Helmholtz Association (grant no.: VH‐KO‐300) and the German Aerospace Centre .Statistical Summary DocumentClick here for additional data file.


Excessive secretion of PTH can cause primary hyperparathyroidism (PHPT). Parathyroidism is highly prevalent in postmenopausal women and is often associated with secondary osteoporosis. PA and PHPT are common endocrine system diseases. However, studies have shown a link between the RAAS and PTH, indicating a positive relationship between them. In this review, we explore the complex bidirectional relationship between the RAAS and PTH. We also point out possible future treatment options for related diseases based on this relationship.The renin-angiotensin-aldosterone system (RAAS) is the regulatory system by which renin induces aldosterone production. Angiotensin II (Ang II) is the main effector substance of the RAAS. The RAAS regulates blood pressure and electrolyte balance by controlling blood volume and peripheral resistance. Excessive activation of the RAAS is an important factor in the onset of cardiovascular disease and the deterioration of this disease. The most common RAAS abnormality is primary aldosteronism (PA). Parathyroid hormone (PTH) is a peptide secreted by the main cells of the parathyroid gland, which promotes elevated blood calcium (Ca Primary aldosteronism (PA) is often accompanied by primary hyperparathyroidism (PHPT) . In gene2+) and promote Ca2+ entry into cells, increasing vasoconstriction and raising blood pressure  excretion, and blood volume and blood pressure. The RAAS has an important influence on cardiovascular hemodynamics and the development and progression of cardiovascular disease  contains multiple peptides, Ang II is the major active metabolite and acts on many different tissues and organs. Ang II promotes vasoconstriction and sympathetic enhancement and increases renal tubular reabsorption of sodium, leading to decreased blood flow and increased vascular resistance. Almost every organ system in the body responds to Ang II . Imprope+ excretion, retains water, and increases fluid volume , AT1R antagonists, and MRAs . RAS inh2+  on the surface of parathyroid cells (2+ (PTH is an 84 amino acid single-stranded peptide hormone secreted by the chief cells of the parathyroid gland. The active form of PTH (pth1-84) is inactivated via liver and kidney metabolism  . The sec2+ . When thecreases . This reid cells –54. The ells , which acts on the vitamin D receptor (VDR) to promote the intestinal reabsorption of Ca2+ and Pi, thereby increasing serum Ca2+ and Pi concentrations , 602+ inParathyroid adenoma, hyperplasia, or cancer can secrete excessive amounts of PTH, causing PHPT . PHPT isBlood pressure and biomarkers of RAAS have been shown to have circadian rhythms in humans ; this ci2+ concentration  or end-stage renal failure . A . A −10 M−8 M  patients, observing no activation of the RAAS, and only found a weak positive correlation between PTH and PRA . A studyOther studies have revealed a link between PTH1R and PRA. In the spontaneous hypertensive rat model driven by somatic human PTH1R (hPTH1R) gene expression, the overexpression of hPTH1R increases PRA, but the blood pressure remains unchanged . InteresPTH receptor antagonists have been demonstrated to eliminate the secretory effect of PTH on aldosterone . Parathy2+ will cause an increase in PRA ..2D3 (2+ As reviewed above, the interaction between RAAS and PTH-Calcium metabolism may be indirectly influenced by secondary factors such as electrolytes, blood pressure, and renal function. However, the direct interaction between the two systems is predominant. Further research is needed to investigate the complex interactions between PTH and RAAS and to assess whether PTH measurements can contribute to the diagnosis of PA. Elucidating the relationship between the RAAS and PTH has important clinical significance and future implications for the treatment of patients with PA or PHPT. RASIs might decrease PTH levels and improve these symptoms. MRA may reduce PTH-induced increases in the fracture rate in PA patients. However, the effect of MRA on PTH in patients without PA is unclear. MRAs may be a promising, novel, and inexpensive therapeutic option for PA patients with elevated PTH levels. Further studies are needed to investigate more medications that mitigate cardiovascular or skeletal diseases mediated by aldosterone and PTH.L-QY: manuscript writing and approving final version of manuscript. M-HZ: study conduct, data analysis, and manuscript writing. FX, XL, YW, Q-SX, and BG: data analysis. All authors: reviewed the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Significance. One of the modern trends in medical diagnostics is based on metabolomics, an approach allowing determination of metabolites which can be the specific features of disease. High-resolution gas spectroscopy allows investigation of the gas metabolite content of samples of biological origin. We present the elaboration of a method of studying diabetic and non-diabetic biological samples, prepared as pellets, by terahertz (THz) high-resolution spectroscopy.Aim: The main idea of the work is studying the content of thermal decomposition gas products of diabetic and non-diabetic dried blood plasma and kidney tissues for revealing the set of gas-markers that characterized the diabetes by the THz high-resolution spectroscopy method.Approach: We present an approach to study the diabetic and non-diabetic blood plasma (human and rats) and kidney tissues (rats), using high-resolution spectroscopy based on the non-stationary effect of THz frequency range. The methods of preparing the blood and kidney tissue samples as pellets and of vaporizing the samples were developed.Results: The measurements of rotational absorption spectra of vapors at heating the pellets prepared from blood and kidney tissue were carried out in 118 to 178 GHz frequency range. The absorption lines appearing in spectra of the sample vapors were detected and identified. The molecular contents of thermal decomposition products differed for non-diabetic and diabetic samples; e.g., main marker is acetone appearing in the diabetic blood (human and rats) and in the diabetic kidney tissue.Conclusions: Our paper illustrates the potential ability for determining the metabolite content of biological samples for diagnostics and prognosis of diseases for clinical medicine. One of the new approaches opening new possibilities in diagnostics and treatment of various diseases is metabolomics. Metabolomics is a field of science that investigates the final and intermediate metabolic products of a biological system . The metabolomics can reveal the metabolites which can be the specific features of disease and can play a large role in diagnosis and prognosis for a disease. The media, containing the final and intermediate metabolic products in the human organism and useful for revealing the metabolites associated with diseases and pathologies, are exhaled breath, blood, urine, saliva etc.,One of the socially important diseases threatening to the quality of life of people is diabetes. Diabetes mellitus type 2 was previously a disease of middle age, but now it is diagnosed in adults, young people, and children. The results of metabolomic investigations of blood and urine samples of diabetes patients from 18 years as well as children from 1 to 13 years old are presented in Human Metabolome Database (HMDB).,The development of chronic kidney disease is a major complication of diabetes mellitus. Although the determination of glycated albumin is the common approach to the screening, kidney damage may start long before clinically significant changes in urine albumin appear. Considering the multifactorial pathogenesis of chronic kidney disease, various markers have been considered for its screening.The spectroscopic approach can provide the information about content of the biological samples which can be used for medicine diagnostics. The terahertz (THz) frequency range is very important for studying gases, liquids, and tissues of living organisms. There are some reviews devoted to applications of methods of THz frequency range, including THz time-domain spectroscopy, THz reflectometry, and THz imaging for biology and medicine.THz time-domain spectroscopy allows detecting the spectra, where the absorption coefficient or refraction index has some spectral features corresponding the presence of some biomolecules  in the samples or their various concentrations.The molecular absorption spectroscopy and in particular THz gas spectroscopy is a very promising approach for investigations of multicomponent gas mixtures of various origins.,The level of acetone in samples of exhaled breath and urine taken from the diabetes patients (12 people) was measured using a terahertz range spectrometer with phase-shift keying of the acting radiation. Experiments were done in collaboration with Almazov National Medical Research Centre. The measurements were carried out at the acetone absorption lines with central frequencies of 150.537 and 151.647 GHz. The measurements were carried out without heating. Simultaneous analysis of the samples of exhaled breath and urine of diabetes patients revealed that the acetone level in the urine was much higher than in the exhaled breath, in some cases an order of magnitude higher.The results of THz high-resolution gas spectroscopy investigations of blood plasma of patients and rats  as well as the rat’s kidney tissue  dried and pressed to pellets are presented. The tissues or blood plasma of living organisms, without any preparation, must be investigated immediately after sampling. Preparation as pellets allows investigation after a sufficiently long time after blood sampling or kidney biopsy.22.1Venous blood from patients with type 2 diabetes mellitus and conditionally healthy participants were collected at the Endocrinology Department of Almazov National Medical Research Centre; the center provides medical care for diabetic patients. Three patients and two participants were male, age-matched (39 to 43 years old). All experimental protocols used in this investigation were reviewed and approved by the patients and participants and the Use Commission of the Medical Centre. Venous blood was collected in the morning after 8 to 12 hours of fasting in a tube with the anticoagulant The study was also carried out with Wistar male rats at the age of 8 weeks and weight 180 to 200 g, according to the protocol of experimental studies approved by the Animal Care and Use Commission of the Institute of Experimental Medicine Almazov National Medical Research Centre. The glucose level in animals of the experimental group was Test samples were frozen at a temperature of The lyophilized samples powder was weighed  and then placed in a steel press-mold. Using a laboratory presses  at a certain molding pressure, the blood plasma pellets and kidney pellets were obtained. Each crystal of pellets contains a certain percentage of fats (triglycerides), proteins , and fibrinogen—all of them normal or glycated (in the diabetic case). The pellets of samples from the control group hereinafter are referred as “non-diabetic pellet” and the pellets of samples from the diabetic group hereinafter are referred as “diabetic pellet.”2.2High-resolution THz spectroscopy based on non-stationary effects allows analyzing the component composition of gas and vapor multicomponent gas mixtures. Spectrometers provide sensitivity close to the theoretical limit with a resolution limited only by the Doppler effect and can record fast processes. The sensitivity is preserved even with a substantial decrease in gas pressure and is approximately 0.2 ppb in the scanning mode for some gases . In addition, it enables determining the component composition of a gas mixture with high reliability.,A study of the thermal decomposition products of pellets was carried out using the method of THz non-stationary gas spectroscopy of the 118 to 178 GHz range. The spectrometer uses a phase-locked loop for automatic control of the frequency of the backward wave lamp and phase shift, registration in the time-domain, averaging, and processing of the spectroscopic transition signal. The device registers a signal in the time domain. Samples’ vapor was analyzed using the following procedure. Pellets were placed into a test tube, using vacuum pumped, gradually heated a test tube (up to 240°C) and the resulting mixture of thermal decomposition products of the sample was let into the measuring cell. A data file usually includes recordings of a selected or of the total operating range of the spectrometer. Therefore, substances can be identified by absorption lines appearing in the total spectrum of the sample and the dynamics of concentrations in a mixture can be traced by comparing several data files. Substances were identified by searching them in open-source mw, mmw, and THz databases.3With our THz-TDS systems, we measured pellets transmission in the spectral range of 0.2 to 1.4 THz,,Plasma vapor substances, such as carbonyl sulfide (OCS), sulfur dioxide , methanethiol , sulfur dioxide  in the blood protein composition. Methionine is an essential amino acid that is not synthesized in human organism. It is obtained from the food and is a source of sulfur for cysteine biosynthesis. When sulfur amino acids were heated up to temperatures of about 240°C, methanethiol and ethylene sulfide (methionine decomposition) were detected in the mass spectrum of these substances.4The molecular content of human and rat blood plasma and rat kidney tissue during thermal decomposition of the samples was studied with using the THz high-resolution spectrometer. The method of preparing the biological samples as pellets was presented. This method gives the possibility of storing and transportation of samples.The high-resolution gas spectroscopy allows to determine the content of multicomponent gas mixtures of any origin, including biological with trace concentrations of gas components.Acetone was detected in diabetic blood plasma samples. Information about the difference of content of diabetic and healthy blood plasma of men and rats and diabetic and healthy rat kidney tissues was obtained from absorption rotational spectra of vapors. The use of THz high-resolution spectroscopy provides a qualitative analysis of component content of samples of vapors of blood and kidney tissues pellets. The possibility of carrying out the quantitative estimations of concentrations of important diabetes gas-markers depending on the state of patients should be studied in further investigations.


Sunitinib is a standard treatment for metastatic renal cell carcinoma (RCC). Currently, the data available on the effects of sunitinib on endothelial dysfunction, metabolic changes, and cardiovascular (CV) risk factors are limited, and we aimed to evaluate these aspects in patients with RCC after a short period of treatment.Patients affected by metastatic RCC were enrolled and evaluated before starting sunitinib (T0) and after 40 days of treatment (T1) by the flow‐mediated dilation (FMD), carotid intima media thickness (IMT), ankle‐brachial pressure index (ABI), and 24‐hour proteinuria. We also assessed serum metabolic and nutritional parameters at T0 and T1.P = .002), FMD (P = .001) and in fasting plasma glucose levels (P = .04), as well as an increase in plasma insulin (P < .001), HOMA‐IR (P < .01), and serum total cholesterol levels (P = .01). Moreover at T1 we found a significant increase in systolic and diastolic blood pressure (P ≤ .001) and 24‐hour proteinuria (P < .001) compared to baseline, whereas no changes in IMT and ABI were detected.Twenty patients , with a mean age of 61.4 ± 12.0 years, were studied. Overtime, we observed a reduction in estimated glomerular filtration rate  from sunitinib administration. Our data suggest to oncologists to perform a strict follow‐up in this clinical setting. We obtained written consent from each patient before the enrolment. We performed an observational prospective study on clinically stable patients affected by metastatic RCC treated with sunitinib, at the Divisions of Nephrology and Oncology, Policlinico Umberto I, Sapienza University of Rome, Italy. Taking into account that some studies showed the development of the most common side effects after a median of 4 weeks from sunitinib initiation in patients with RCC,All the patients received sunitinib, orally, at recommended dose of 50 mg/d for 4 weeks each 6 weeks. In case of grade 2 or 3 toxicity according to National Cancer Institute‐Common Toxicity Criteria, therapy was planned to be continued at a reduced dose (37.5 or even 25 mg/d) or suspended.2.1The inclusion criteria included age >18 years and <80 years, WHO performance status 0‐2 and life expectancy ≥12 weeks, patients with metastatic RCC in whom the treatment of choice was sunitinib and patients signing the informed consent form.2.2The exclusion criteria included the use of corticosteroids, the presence of heart failure, severe cardiovascular disease, liver failure or chronic liver disease, chronic kidney disease 4/5 stage KDOQI (eGFR < 30 mL/min), unstable or uncompensated respiratory disease. We also excluded pregnant or breastfeeding patients, and those with missing clinical data.2.3Blood was collected in the morning after an overnight fasting (≥12 h). The estimated glomerular filtration rate (eGFR) was calculated with the abbreviated modification of diet in renal disease formula (MDRD).2.4The BP measurements were carried according to the British Hypertension Society guidelines,2.5Intima media thickness was calculated using a machine Toshiba Aplio xV  with a 5‐ to 12‐MHz linear transducer, as described previously.2.6The FMD was assessed using the same Toshiba Aplio xV following a standardized protocol according to the Celermajer method.2.7P < .05 was considered significant. Data management and analysis were performed using IBM® SPSS® Statistics 17 for Windows® software .Shapiro‐Wilk test  was used to determine if the data set was well‐modeled by a normal distribution. All continuous variables were expressed as mean ± standard deviation and categorical variables were expressed as numbers (percentage). Not‐normally distributed variables were described using median . One‐way ANOVA or Wilcoxon signed‐tank test were performed to determine differences between groups, as appropriate. Binomial test or chi‐squared test was used for the comparison of categorical data. All comparisons were two‐sided and a 33.12) of 60.47  (Table 2) of 24.05 ± 2.32. Five patients (25% of our cohort) were affected by arterial hypertension and only one patient (5%) by chronic heart failure (NYHA class 1).Patient characteristics at baseline are indicated in Table 3.2During the study period, eight patients (40%) reduced sunitinib dosage from 50 mg/d to 37.5 mg/d due to the development of side effects including mucositis, hand‐and‐foot syndrome, anemia and diarrhea.P = .002), and fasting plasma glucose levels (TableP = .04); in parallel, we found a significant increase in plasma insulin levels (P < .001) (Table P < .01) (Table After 40 days T1) from the initiating dose of sunitinib, we observed a significant reduction, compared to baseline, in eGFR ( from theP = .001)  values with respect to baseline  vs 9 ; P < .0001) (Table P = .001) (Table P < .001)  (Table Moreover we found a significant increase compared to baseline in systolic blood pressure (SBP) P < .000 Table 1P < .0001) Figure . We also4Sunitinib is a standard treatment for metastatic RCC.In this study, we observed an increase in SBP, DBP, and proteinuria, representing indicators of renal damage and endothelial dysfunction. In addition, we observed a significant worsening of renal function with a reduction of FMD, which is an early marker of endothelial dysfunction.Güneş et alEndothelial dysfunction determined by anti VEGF seems to be primarily responsible for vascular, renal and cardiac damage,Thijs et alLankhorst et alOur results indicate, after sunitinib administration, a significant reduction in fasting plasma glucose levels in non‐diabetic patients, although remaining within the normal range and without documenting hypoglycemic and/or symptomatic events. Our observation is in line with the those reporting a significantly decreased plasma glucose concentrations, only in patients with diabetes during sunitinib administration.Some case reports documented an improvement in glycemic control in diabetic patients during TKIs treatment or a significant decrease in plasma glucose levels in diabetic and nondiabetic patients after sunitinib treatment that resulted almost always reversible after drug discontinuation.Agostino et alLouvet et alMoreover recent studies reported additional side effects with TKIs, including changes in thyroid, bone, and gonadal functions, fetal development, and adrenal function.Our study has several limitations including the small number of RCC patients. We included patients treated with antiplatelet, antihypertensive therapies and with lipid‐lowering molecules potentially affecting the results here obtained. Additional data are necessary to clarify the underlying mechanisms responsible for renal, cardiovascular and metabolic negative effects in cause‐effect studies.In conclusion, the modifications observed overtime after sunitinib treatment in terms of markers of early endothelial dysfunction, blood pressure, as well as in glucose/insulin metabolism and proteinuria might increase the cardiovascular risk in RCC patients treated with sunitinib. Larger studies are mandatory to confirm our results. However, a strict metabolic and cardiovascular follow‐up in this setting is recommended especially in order to manage these targeted therapies safely.The authors declare no conflict of interest.SL designed research, conducted research, analyzed data, and wrote the paper. MIA conducted research, analyzed data, and wrote the paper. SM conducted research, and reviewed the paper. APM reviewed the paper. An.Ma. collected the data. AG analyzed data and performed statistical analyses. GI collected the data. RC collected the data. MP collected the data. AM designed research, analyzed data, and wrote the paper.