Furthermore, we report our experience with long-term follow-up of positive subjects. We screened more than 170,000 newborns and 22 males were confirmed to have a GLA gene variant, with an incidence of 1:7879 newborns. All patients were diagnosed with a variant previously associated with the later-onset phenotype of FD or carried an unclassified variant (four patients) or the likely benign p.Ala143Thr variant. All were asymptomatic at the last visit. Although lyso-Gb3 is not considered a reliable second tier test for newborn screening, it can simplify the screening algorithm when its levels are elevated at birth. After birth, plasma lyso-Gb3 is a useful marker for non-invasive monitoring of all positive patients. Our study is the largest reported to date in Europe, and presents data from long-term NBS for FD that reveals the current incidence of FD in northeastern Italy. Our follow-up data describe the early disease course and the trend of plasma lyso-Gb3 during early childhood.Fabry disease (FD) is a progressive multisystemic lysosomal storage disease. Early diagnosis by newborn screening (NBS) may allow for timely treatment, thus preventing future irreversible organ damage. We present the results of 5.5 years of NBS for FD by α-galactosidase A activity and globotriaosylsphingosine (lyso-Gb Initially, a fluorescent method with 4-methylumbelliferyl-D-galactopyranoside as a substrate was used . Later, From September 2015 until March 2021, the DBS from 173,342 newborns were collected consecutively by the Regional North East Italy expanded neonatal screening program. The DBSs were assayed for the enzymes deficient in FD and three other lysosomal diseases . Written informed consent was obtained from a parent. Proof of informed consent is available upon request. According to the NBS protocol, samples were collected between 36 and 48 h of life on the same card used for the other NBS tests; a second sample was required for premature newborns  and for sick newborns . DBS were analyzed on the day they were received, and the DBS cards were stored at −20 °C in plastic bags for at least five years after analysis. All analyses were performed in compliance with institutional review board guidelines.3 using the LC-MS/MS method with a cut-off value of 1.3 nmol/L. This cut-off was established from the analysis of 253 anonymous healthy adult blood donors (n = 133) and pediatric patients (n = 120), and the 97.5 th percentile was considered [α-GAL A enzyme activity was determined simultaneously with acid α-glucosidase (deficient in Pompe disease), β-glucosidase (deficient in Gaucher disease), and α-L-iduronidase (deficient in mucopolysaccharidosis type I) using a multiplex MS/MS assay . Assay results were obtained after overnight incubation and enzyme activity was expressed as micromoles of substrate hydrolyzed per hour of incubation per liter of blood (µmol/L/h). Samples with low activities for several enzymes were repeated due to a suspected preanalytical error. For IDUA activity, an initial cut-off of 3.76 µmol/L/h was established using 0.2 multiples of the median (MOM); this was reset to 2.3 µmol/L/h after the first 9 months of screening . Samplesnsidered .3 measurement, and molecular analysis. Moreover, the mothers of confirmed newborns underwent GLA molecular testing. α-GAL A enzyme activity in lymphocytes was measured initially using a fluorometric method and more recently using a MS/MS assay. lyso-Gb3 was measured in plasma samples using LC-MS/MS technology, as described in [GLA gene was sequenced using Next Generation Sequencing technology on genomic DNA isolated from peripheral leukocytes. Variants were classified according to published clinical reports and public databases including the International Fabry Disease Genotype-Phenotype Database and The Fabry Working Group Genotype Phenotype Database [Confirmatory testing included α-GAL A enzyme activity in peripheral lymphocytes, plasma lyso-Gbribed in . The GLADatabase ,50,51.3 was monitored as a specific marker of the disease. Patients were monitored every 12 months, with clinical evaluation: angiokeratomas, hypohidrosis, gastrointestinal symptoms, limb pain, kidney , and cardiac (electrocardiogram) assessments. Plasma lyso-GbGLA gene, with an incidence of one in 4068 males. The only female newborn with a measured low DBS α-GAL A activity was negative at molecular testing. Regarding the ethnicity of the 22 positive neonates, four were of African origin, two were of Asian origin, and the others were Caucasian. Patients #13 and #20 and patients #16 and #21 were brothers. None of the patients had a family history of a previous FD diagnosis or manifestations strongly suggestive of FD . The clinical, biochemical, and molecular features of the patients are presented in All results of the NBS program for FD are summarized in n = 22, mean 1.54 µmol/L/h, SD 0.88). After confirmatory testing, we found that the α-GAL A enzyme activities of males with known pathogenic GLA variants ranged from 0.63 to 1.88 µmol/L/h , whilst in males carrying unclassified GLA variants or the p.Ala143Thr variant, it ranged from 0.87 to 3.45 µmol/L/h . This difference was statistically significant .The α-GAL A enzyme activities in DBS ranged from 0.63 to 3.45 µmol/L/h  carrying known pathogenic variants  associated with the later-onset form of FD, four carrying previously unclassified GLA variants, four with the p.Ala143Thr variant, and one carrying a haplotype considered to be benign patient #5). Among our patients, the most common variant was p.Ala143Thr (four patients), followed by p.Asn215Ser (three patients). This latter is a known pathogenic variant found in association with the later-onset cardiac form of FD . Among o, while t3 testing in 2016, and tested 17 out of the 22 positive newborns. The values ranged from 0.22 to 2.7 nmol/L . Levels were abnormal in five newborns , among the 12 tested patients carrying a known later-onset variant . No patient carrying unclassified or likely benign variants had abnormal levels of DBS lyso-Gb3 at birth . This difference was not statistically significant , but this is likely due to the small number of samples. However, an inverse linear correlation was found between DBS α-GAL A activity and DBS lyso-Gb3 at birth (r = −0.28).We started DBS lyso-Gb3 in all neonates  and it ranged from 0.12 to 2.98 nmol/L . It was above the cut-off in 11/21 patients, nine of which had a known pathogenic variant. lyso-Gb3 was only slightly increased in patient #1 (p.Ala143Thr variant) and in patient #16 , whilst the highest values were observed in patients with the known pathogenic variants p.Asn215Ser, p.Arg363His, and, interestingly, in patient #10 (p.Arg356Gly), which is listed as a likely later-onset form in the International Fabry Disease Genotype-Phenotype Database [p = 0.061, according to Student’s t-test). However, an inverse linear correlation, stronger than the one between DBS α-GAL A activity and DBS lyso-Gb3, was found between DBS α-GAL A activity and plasma lyso-Gb3 at first visit (r = −0.41).At the first visit, we evaluated plasma lyso-GbDatabase . The mea3 level was 1.19 nmol/L SD 1.06 (range 0.35–3.91 nmol/L), with slightly elevated values in 17 patients at the latest visit (85%). Interestingly, plasma lyso-Gb3 levels increased in most children  than in individuals carrying unclassified variants or the variant p.Ala143Thr . This difference was statistically significant . The p.Asn215Ser variant appeared to be associated with greater increase. Of note, all three patients with this variant had a value of 1 nmol/L at birth, with values increasing with age. The older patient had a value of 3.91 nmol/L at the age of 4.5 years.None of the patients showed clinical or biochemical abnormalities at the first visit. All patients participated in regular follow-up except patients #5 and #14, who were lost to follow-up because parents refused additional medical examinations. A summary of clinical and biochemical features at the first visit and during follow-up is reported in Here, we report our results from more than five years of NBS for FD in northeast Italy, based on the determination of α-GAL A enzyme activity in DBS using a multiplex MS/MS assay.GLA variants were identified in 22 males, 13 of which were known pathogenic variants previously reported in association with a later-onset phenotype. One was a benign haplotype, four were unclassified variants, and four carried the p.Ala143Thr variant whose pathogenicity is debated. The four patients with the p.Ala143Thr variant did not appear to have classic FD, based on the clinical picture and biomarkers. Thus, the overall incidence of α-Gal A deficiency was of 1 in 7879 , while the frequency of pathogenic variants was 1 in 6883 males. This incidence was similar to those detected in our previous pilot study, conducted from September 2015 to January 2017 on about 40,000 births  [GLA variants were found  and only one had a mutation known to cause the classic phenotype [n = 14,600). Moreover, only one patient had a known pathogenic variant, while 25/37 carried benign variants [GLA splicing variant (IVS4 + 919G > A) (82% of patients) [In the last 5.5 years, we screened 173,342 newborns  for FD, which is the largest study reported to date in Europe. ewborns) . Moreoveewborns)  but simihenotype . The incvariants . Conversvariants , which iatients) ,42. All GLA variants including large and small gene rearrangements, splicing defects, and missense or nonsense variants. In contrast, most mildly affected atypical hemizygotes usually bears missense variants that express residual α-GAL A activity. However, most Fabry patients have private variants and attempts to predict the clinical phenotype based on the type or location of a variant may prove difficult. Moreover, the influence of modifier genes or other genetic factors on phenotype severity may be confounders since individuals with the same GLA variant may occasionally have variable phenotypes including within the same family. Thus, the clinical severity of private missense variants detected in Fabry families with few, or only young patients, is difficult to predict and requires more extensive clinical information from unrelated patients with the same FD genotype [The lack of knowledge about the long-term course of the disease, especially for later-onset forms, complicates the establishment of clear correlations between genotype and phenotype in FD. Affected hemizygotes with the classic disease manifestations and no detectable α-GAL activity are associated with a variety of genotype . Furthergenotype ,54. 3 and lyso-Gb3 [3 during follow-up. Plasma lyso-Gb3 was higher in the patient with p.Ala143Thr plus the intronic unclassified variant ; however, it was lower than the lyso-Gb3 levels in patients carrying known pathogenic variants . In our opinion, the α-GAL A activity and the lyso-Gb3 levels detected in the four babies with the genetic variant p.Ala143Thr are in favor of a likely benign classification of this variant. The high frequency of this variant in the gnomAD database (5.06 × 10−4) is also in favor of a benign variant relatively frequent in the European population  [Among the 12 different variants that we found , there were 11 missense variants and one intronic splicing variant. The most frequent variant (p.Ala143Thr) was found in four patients  and is more frequent in the Caucasian population. In a previous Italian study, three of six positive males carried this variant , and a slyso-Gb3  and no slyso-Gb3 ,57. Howelyso-Gb3 . Our patalleles) .p = 0.003).Among the pathogenic variants, we found a high frequency of the mutation p.Asn215Ser , associated with very low enzyme activity in DBS . This variant is reported in patients with predominant cardiac involvement . Other v3 values correspond to the upper limit of the normal range (0.43 nmol/L), questioning pathogenicity of this variant. Patient #15 carried two variants (p.Gly116Ala) and the likely benign p.Ser126Gly and several benign intronic variants. He has no signs of disease at age 2.5 years, but plasma lyso-Gb3 level is slightly elevated (0.92 nmol/L), so that further follow-up visits are requested. Finally, two brothers (patients #16 and #21) carried the p.Leu286Val variant. The first brother is asymptomatic at two years of age, and has a plasma lyso-Gb3 value that corresponds to the upper limit of normal range (0.43 nmol/L), while the second brother is a newborn. We will continue to monitor them. Because FD can undergo silent progression without evident clinical manifestations, especially with later-onset forms, we believe that long-term follow-up is important. Indeed, Hsu et al. demonstrated that cardiac damage could progress in silence, even when it becomes severe and irreversible  [All patients were monitored, except for two who did not want to come back to the hospital periodically. Because all our patients carried variants associated with the later-onset form or unclassified variants, we decided to follow them up every 12 months. The follow-up included clinical, instrumental, and biochemical assessments: the search for angiokeratomas, limb pain, hypohidrosis, gastrointestinal symptoms, renal, and cardiac evaluations  . We deteibrosis) , whilst ibrosis) . We alsoibrosis) ,62.3 and lyso-Gb3 accumulation. We have provided constant psychological support to the parents from diagnosis and during follow-up, especially to the mothers because this X-linked disease could be a major psychological burden on them [Currently, after five years of NBS and follow-up, none of our patients with predicted later-onset forms (mean age at last visit: 3 years) have symptoms or signs of FD. However, further investigations are needed to find the best way for early detection of clinical manifestations in patients with unclassified and later-onset variants. This would allow us to establish an appropriate timing for specific treatments and avoid potential organ damage due to Gb on them . The par3  is the N-deacylated form of Gb3 that has been proposed as a specific biomarker for FD [3 can be measured in plasma or DBS by LC-MS/MS technology, as we have demonstrated [3 in a large cohort of Fabry patients (n = 71) where we observed high levels in males with the classic phenotype and mild-to-moderately elevated levels both in males with the later-onset phenotype and in heterozygous females with the classic phenotype [3 begins in utero [3 in DBS from neonates identified by NBS for FD. We found that only five patients, all with a later-onset pathogenic variant, had abnormal DBS lyso-Gb3 at birth, among the 17 tested newborns (of which 12 carrying a pathogenic variant), indicating that a normal result cannot exclude FD and, therefore, cannot be used as a second tier test. At the first visit, plasma lyso-Gb3 was abnormal in 11/21 patients, nine of them with a later-onset variant, one carried the p.Ala143Thr variant, and one had the unclassified p.Leu286Val variant. Interestingly, patient #10 had a very low α-GAL A activity (0.73 µmol/L/h) accompanied by the highest level of plasma lyso-Gb3 that we found in our neonates (2.98 nmol/L). He carries the p.Arg356Gly variant, considered likely associated with a later-onset phenotype. Moreover, we found an inverse linear correlation between DBS lyso-Gb3 /plasma lyso-Gb3 and DBS α-GAL A activity at birth/first visit . This finding suggests that lower enzyme activity corresponds to a higher storage from birth. Although a normal DBS lyso-Gb3 value cannot rule out FD, its use as a specific marker in the diagnostic process is still valid. However, we believe that the use of lyso-Gb3 as a second-tier test in newborn screening programs needs further evaluation. Biomarkers and biochemical follow-up show Lyso-Gbr for FD . Lyso-Gbnstrated . Recentlhenotype . Storagein utero ,65; ther3 levels were above the cut-off, the newborn must be referred directly to a Pediatric Unit without requiring a second DBS. Moreover, biomarkers play an important role during follow-up. A recent case report showed that lyso-Gb3 may be elevated in the first days of life and that it increases significantly during infancy in patients affected by a classic (severe) form of FD [3 gradually increased with age, suggesting that there may be a progressive and insidious storage, even in milder forms , three carried the p.Ala143Thr variant , and three carried unclassified variants   and patients with unclassified variants or the p.Ala143Thr variant at last visit, but this difference was not statistically significant in the neonatal period. Of note, we found that all patients carrying the p.Asn215Ser variant  had plasma lyso-Gb3 levels above the cut-off at birth. These values progressively increased and, interestingly, the highest value was found in the oldest patient (3.91 nmol/L at 4.5 years), suggesting progressive and insidious storage, even in an asymptomatic child. However, all our patients carrying unclassified variants had normal lyso-Gb3 at birth and it remained in the normal range in three of four patients at the last visit. Only in case #15, carrying one previously unreported variant in cis with the likely benign p.S126G variant, showed a mild increase in plasma lyso-Gb3 (0.92 nmol/L). Nevertheless, we believe that further studies are needed to assess the exact value of lyso-Gb3 in neonates carrying unclassified variants. Whether a slight increase in lyso-Gb3 has any clinical significance has not been proven and also warrants further studies.In light of our five-year-experience with NBS for FD, we propose a new screening algorithm  that is rm of FD . In our er forms a. At thel range) a,b. A stThe high incidence of later-onset forms has raised ethical issues regarding the conduct of a NBS program. Detection in the newborn period may have a negative psychological impact on parents and carries the risk that these children, defined as “patient-in-waiting”, are labelled and overmedicated. Moreover, it increases the costs for diagnostic laboratory testing and follow-up visits . HoweverMoreover, their identification allows physicians to perform cascade genotyping in at risk family members and identify undiagnosed relatives . Further3 as a second-tier test in NBS for FD, our experience confirms, as previously reported [3, when elevated in DBS, makes the application of the diagnostic algorithm easier  the significance of mildly elevated plasma lyso-Gb3; (2) the absence of a reliable second-tier test to reduce the recall rate; (3) poor detection of heterozygous females; (4) the clinical interpretation of unclassified and uncertain genetic variants; and (5) the impact of early diagnosis on patients with later-onset forms. Our overall experience in NBS for FD is positive, and the project is moving forward with the aim of gaining a better understanding of the disease and better care for the patients. Our study confirms that NBS for Fabry disease is feasible through the measurement of α-GAL A enzyme activity in DBS and should be evaluated for inclusion in the national NBS program. Biomarkers like lyso-Gb


FAN1 gene, which encodes the FANCD2/FANCI-associated nuclease 1.3Karyomegalic interstitial nephritis  is a very rare autosomal recessive inherited systemic disease caused by germline pathogenic variants in the KMIN was first described in 1974 in a young woman with liver carcinoma and interstitial nephritis with dysplastic tubules.FAN1 gene were recently identified in patients with KIN with FAN1 linking CKD to defective DNA repair in tubular cells.FAN1 pathogenic variant.,,,Germline pathogenic variants in the 2 in the eastern South Pacific and including ≈280,000 inhabitants (Polynesians ≈90%). The 12 affected patients from 5 families were homozygous for the FAN1 c.2120G>A, p.(W707X) pathogenic variant, previously identified in 2 siblings without reported consanguinity and of Maori descent from New Zealand.Here, we report the high prevalence of KMIN in French Polynesia, a large territory covering 188 islands spread over 4167 kmFAN1. In the 8 tested patients, genetic analysis identified a recurrent homozygous FAN1 c.2120G>A, p.(W707X) variant that was classified as pathogenic according to the American College of Medical Genetics and Genomics (ACMG) guidelines as it leads to a premature termination codon in the exon 8 of FAN1, which contains 15 exons, and it is absent in individuals from the Genome Aggregation Database (gnomAD), v2.1.1, whereas it has been identified in several patients with KMIN.KMIN was identified in 12 Polynesian patients born in islands from various archipelagos of the French Polynesia . Diagnos2 (interquartile range 3–62). Kidney presentation consisted of CKD with absent or mild tubular proteinuria (<1 g/d) and bland urinalysis. Four patients had hypertension, and none had electrolyte disorder. Renal ultrasonography (US) showed bilateral renal atrophy in 7 patients (58%), whereas kidney size was normal in the others. None had renal cyst or malformation. Kidney biopsy (n=7) showed typical features of tubulointerstitial nephropathy. Glomeruli were normal except for glomerulosclerosis in the fibrosis area. Interstitial fibrosis with atrophic tubules and tubular dilatation was common. Karyomegalic cells were observed in all samples with massively enlarged nuclei  (Median age at recognition of the kidney disease was 32 years (interquartile range 18–56) . At diagal size) . No vira2 (–1.5 to –11 mL/min per 1.73 m2). Two patients received kidney transplantation without relapse of the kidney karyomegaly.Eight patients (75%) developed end-stage kidney disease, including 5 before 40 years of age. The oldest patient reached end-stage kidney disease at the age of 71 years. From the diagnosis of kidney disease, the median yearly decline of eGFR was –7 mL/min per 1.73 mThree patients had recurrent upper airways infection , 5 developed at least 1 episode of pneumonia or bronchiolitis and 3 developed lung tuberculosis. KMIN had a primary pulmonary presentation in 3 patients. The main computed tomographic scan abnormalities were pleural thickening, bronchiectasis, and lung fibrosis .n=3) did not show overt karyomegalic cells or liver fibrosis. The pancreas was normal.All the patients had nonicteric cholestasis  and 2 had elevation of aspartate- and alanine-aminotransferases. No patient developed portal hypertension or liver failure. Liver ultrasonography was normal in all, but magnetic resonance imaging showed nonobstructive segmental stenosis of the choledochus or intrahepatic biliary ducts in 3 and 2 patients, respectively. Liver biopsy (n=3) was normal, as well as bone marrow examination (n=1). No patient developed solid or hematologic cancer.One patient receiving chronic renal replacement therapy developed severe hypertrophic cardiomyopathy with features of karyomegaly on heart biopsy. Two patients had hypothyroidism, including one with antithyroglobulin antibodies. Retinal examination , pathogenic variant with a heterozygous status developed CKD or abnormal urinalysis, suggesting that they theoretically can be considered as potential living kidney donors for their relatives. One individual developed a nonicteric cholestasis related to nonalcoholic steatosis. One male patient developed cholangiocarcinoma. None developed colon carcinoma or other cancers.No individual carrying the ad 1648 and genealogical tree suggested that the founder effect occurred before ad 1800  pathogenic variant  but also the identification of KMIN in families in whom the disease was identified in only 1 generation, both suggesting that this variant spread in the Polynesian population. Consistently, among 7 patients awaiting for kidney transplantation because of end-stage kidney disease of unknown origin (no kidney biopsy) and not related to the 5 families described here, genetic testing for the FAN1 p.(W707X) pathogenic variant was positive in 1 individual with a heterozygous status. Thus, the FAN1 p.(W707X) pathogenic variant is frequently identified in Polynesian individuals and also present in New Zealand,The structure of the family 1 pedigree with unrelated individuals necessarily heterozygous for the In this study, we identified KMIN as a frequent disease in French Polynesia, a territory located in southwest Pacific and characterized by insularity. Twelve patients from 5 families  were identified compared with fewer than 60 cases described to date in the world . Because CKD and its usual risk factors  are highly prevalent in French Polynesia, and kidney biopsy is not systematic, incidence of KMIN was likely underestimated in our study.FAN1 p.(W707X) pathogenic variant in French Polynesia probably occurred before ad 1800. Interestingly, this variant was also identified in 2 brothers of Maori descent born in New Zealand,FAN1 pathogenic variants described to date are unique to each family.,FAN1 haplotypes of these Maori patients and those included in our series could not be performed. Last, our study clearly demonstrates how rare inherited diseases or genetic variants can be over-represented in area characterized by a small-sized population and insularity.By analyzing the genealogical tree of a large family with KMIN, we could show that the founder event that subsequently led to the spreading of the FAN1 founder pathogenic variant in French Polynesians also furnished a unique opportunity to address the respective roles of genotype and environment in the severity scaling of KMIN. As previously described, most patients with KMIN will reach end-stage kidney disease, but age at dialysis onset varied from 27 to >70 years, even in the same family and despite a common FAN1 genotype.in vitro findings showing that FAN1-deficient cells have hypersensitivity to DNA damages and that environmental genotoxins promote kidney fibrosis in patients with KMIN.,FAN1 variations in donors but not to exclude those with heterozygous status.The identification of a frequent Extra-kidney phenotype was more homogeneous, especially for liver involvement that was almost constant and lung phenotype that was symptomatic in 10 of 12 patients. Lung and ear, nose, and throat phenotypes were poorly specific and characterized by frequent infection during infancy. Bronchiectasis and interstitial lung diseases were common, but sometimes only detectable using chest computed tomographic scan, highlighting the need of careful phenotyping facing kidney disease with tubulointerstitial presentation. Whereas severe kidney failure was the rule, no patient developed chronic lung or liver failure. Chronic cholestasis was frequently observed and associated with severe pruritus in one of our patients, but karyomegalic cells were rarely seen within the liver. KMIN should be searched for using kidney biopsy in patients with CKD of unknown origin and concomitant cholestasis or bronchiectasis.Finally, among the individuals with a homozygous or heterozygous status for the FAN1 variation, none developed solid cancer, as previously described.S3FAN1 pathogenic variant with a founder effect that occurred more than 200 years ago. The heterogeneity of the glomerular filtration rate slope despite a common genotype supports the role of modifying genetic factors or environment and genotoxins in FAN1-related nephropathy.In summary, we report here the high incidence of karyomegalic interstitial nephritis in French Polynesia owing to a recurrent All the authors declared no competing interests.SF, PT, LG, and RD designed the study; LG and SF collected and analyzed the data; MB, CD, LG, and DSL performed genetic analyses; HS performed kidney pathology; SF, DSL, and LG wrote the manuscript; all the authors approved the final version of the manuscript.


There were significantly lower concentrations of MMP-1, MMP-2, MMP-3, and osteocalcin in SPK subjects. Among the analyzed biomarkers, only logMMP-1, logMMP-2, and logMMP-3 concentrations were associated with log HbA1c. Multivariate stepwise backward regression analysis revealed that MMP-1 and MMP-3 variability were explained only by log HbA1c. Normal glucose metabolism achieved by SPK is followed by the favorable profile of circulating matrix metalloproteinases, which may reflect the vasoprotective effect of pancreas transplantation.It is not fully elucidated whether the restoring of normal glucose metabolism after successful simultaneous pancreas-kidney transplantation (SPK) improves vascular wall morphology and function in type 1 diabetic (T1D) patients. Therefore, we compared arterial stiffness, assessed by pulse wave velocity (PWV), carotid intima-media thickness (IMT), and biomarkers of arterial wall calcification in T1D patients after SPK or kidney transplantation alone (KTA). In 39 SPK and 39 KTA adult patients of similar age, PWV, IMT, circulating matrix metalloproteinases (MMPs) and calcification biomarkers were assessed at median 83 months post transplantation. Additionally, carotid plaques were visualized and semi-qualitatively classified. Although PWV and IMT values were similar, the occurrence of atherosclerotic plaques (51.3 vs. 70.3%,  Simultaneous pancreas and kidney transplantation (SPK) is the treatment of choice in patients with type 1 diabetes (T1D) and end-stage renal disease. This procedure results in improved T1D patient survival as compared to kidney transplant alone (KTA) ,3. MoreoThe matrix metalloproteinases (MMPs) family is a bundle of zinc-dependent proteases that are involved in the degradation and hydrolysis of extracellular matrix components . Their aThe present study aimed to compare arterial stiffness, intima-media thickness, and several arterial wall calcification biomarkers as well as calcium-phosphate metabolism parameters in T1D patients long-term after SPK or KTA.Here, we present the results of cross-sectional study in kidney transplant recipients, performed in two Polish transplant centers (in Katowice and Wrocław) between 2014 and 2018. The study protocol was approved by Bioethics Committee of the Medical University of Silesia in Katowice (KNW/0022/KB1/151/12), and each participant gave informed consent. No organs/tissues were procured from prisoners. All procedures were performed in accordance with the relevant guidelines and regulations. Clinical data were obtained from a database of transplant centers and from original medical records.n = 39) or KTA (n = 39), with a minimum post-transplant follow-up period of 12 months, were enrolled into the study, as described previously [p = 0.06).Two groups of T1D patients after SPK , bacterial infection within 1 month preceding the study, diagnosis of cancer or liver cirrhosis, apparent noncompliance, and additionally any type of antidiabetic medication currently used in SPK recipients.The exclusion criteria  were as In all patients, the kidney was transplanted on standard basis, and in SPK recipients, the pancreatic graft was placed intraperitoneally with systemic drainage of venous blood and enteric drainage of pancreatic juice.Carotid ultrasound examination was performed using a Siemens machine  equipped with a 4.0–9.0 MHz linear transducer. The evaluation comprised the common, internal, and external carotid arteries and the carotid bifurcation on each side. The common carotid artery IMT was measured proximal to the carotid bulb, omitting visible plaques. The results from three separate measurements on each side were then averaged. Additionally, at each examined location, the vessels were carefully evaluated concerning the presence of plaques, which were classified based on the following simplified scale: 0, no lesions; 1, non-calcified lesions; 2, at least one calcified lesion; 3, some calcified lesions; and 4, carotid bulb heavily covered with calcified lesions. The final plaque score was equal to the higher score obtained for both sides .Arterial stiffness measurements were performed in the morning, after at least 15 min of rest in the supine position, using a non-invasive tonometer  placed over the carotid and femoral arteries . Pressur1c), serum creatinine, lipids, calcium, and phosphate were routinely measured during standard visits in the out-patient clinic. Additionally, blood samples were collected from each patient in a closed system into tubes containing citrate and ethylenediaminetetraacetic acid (EDTA). The tubes were allowed to remain standing for 30 min at room temperature, then they were centrifuged  and finally preserved at −70 °C.The concentrations of blood-glycated hemoglobin (HbAEnzyme-linked immunosorbent assays (ELISA) using commercially available kits were applied for: plasma concentration measurements of fetuin A  of 0.1 ng/mL, intra-assay variation <3.6%, inter-assay variation <6.3%), high-sensitivity C-reactive protein—(CRP) , osteoprotegerin (OPG) , matrix metalloproteinase 9 (MMP-9) , fibroblast growth factor-23 (FGF23) , and soluble α-Klotho . Plasma 25-hydroxylated vitamin D (25-OH-D) (LoQ 3 ng/mL) and intact parathyroid hormone (PTH) levels were assessed by electrochemiluminescence method (ECLIA) using commercially available kits in Cobas E411 analyzer  with inter-assay coefficients of variability of <7.8 and <6.5%, respectively.Plasma levels of matrix metalloproteinases , osteocalcin (OC), and osteopontin (OP) were measured using multiplex Bio-Plex kits , in accordance with the manufacturer’s instructions. Median bead fluorescence readings were taken using the Bio-Plex 200 System with high PMT (High RP1) setting and analyzed with Bio-Plex Manager version 6.1.0.727 .Blood pressure (BP) was measured at the beginning of study: three times in the sitting position at the arm without arterio-venous fistula. Patients with BP values above 140/90 mmHg or those who received antihypertensive medication were diagnosed as hypertensive.Vitamin D status was categorized by commonly used cut-offs and definitions of serum 25-OH-D: the values below 10 ng/mL were categorized as severely deficient, between 10 and 19.9 ng/mL as deficient, between 20 and 29.9 ng/mL as insufficient, and those with values equal to or above 30 ng/mL as sufficient 25-OH-D concentrations .The kidney graft function was measured using eGFR calculated according to MDRD formula.https://www.r-project.org) (accessed on 3 August 2021). The level of statistical significance was set at p value below 0.05. All tests were two-tailed. Imputations were not performed for a few missing clinical data. Nominal and ordinal data were expressed as percentages, whilst interval data were expressed as mean value ± standard deviation (SD) in case of normal distribution or as median with lower and upper quartile (1-3Q) in case of data with skewed or non-normal distribution. The distribution of variables was evaluated by the Shapiro–Wilk test, and the homogeneity of variances was assessed by Levene test.Statistical analysis was performed using Statistica 13.3 PL for Windows , StataSE 12.0 , and R software , log10(CRP), HDL, and log10(TG). Cook–Weisberg test and Cameron and Trivedi’s decomposition test were used to test the residuals for heteroscedasticity as well as the violation of skewness and kurtosis assumptions in linear regression. The correlation between variables was assessed either with Pearson linear correlation coefficient or Spearman rank correlation coefficient, depending on data distribution.In order to assess the relationship between variables, linear regression was used. Multivariate models for the variability of MMP-1, MMP-2, MP-3, and OC included potential independent variables selected on the basis of univariable regression analyses, i.e., eGFR, log1c levels. In addition, the proportion of patients with HbA1c in the reference range for healthy individuals (below 5.5%) was significantly higher in SPK than in KTA group . Patients in SPK group had higher eGFR values. Of note, SPK patients were more frequently receiving tacrolimus-based, steroid-free regimens , especially calcified lesions , in the SPK subjects. Nevertheless, IMT and PWV values were similar in both groups  were significantly older  and were characterized by greater IMT (Me: 0.8 (1-3Q: 0.7–0.9) vs. Me: 0.7 (1-3Q: 0.6–0.7) mm; p < 0.001) than the subjects without calcified lesions. Additionally, they were more likely to use statins . Of note, the difference in median HbA1c concentration (Me: 50 (1-3Q: 38–66) in SPK vs. Me: 42 (1-3Q: 33–60)% in KTA; p = 0.08) and eGFR  between the study groups did not reach statistical significance. Similarly, there was no significant difference in OC levels between these groups (Me: 2268 (1-3Q: 1253–3525) vs. 1339 (1-3Q: 828–3034) pg/L, p = 0.31). There was a significant positive correlation between increasing plaque score and age . The subjects with plaque score ≥ 3 were more likely to use statins (N: 12 (52.2%) vs. 11 (20.7%); p < 0.01). Nevertheless, there was no significant association between plaque score and eGFR and OC, metalloproteinases, or HbA1c levels.The patients with calcified lesions .Of all the analyzed biomarkers, only log MMP-1 , log MMP1c . In addi1c . Of note1c, whereas OC variability only by eGFR  in SPK recipients as compared with KTA patients, which potentially may reflect the beneficial changes in the vascular wall related to the normalization of glucose metabolism. Importantly, multivariate analysis confirmed the independent association of HbA1c and MMP-1, MMP-2, and MMP-3 plasma levels, confirmed by multivariate analysis for MMP-1 and MMP-3. This indirect evidence supports the expected improvement in vascular wall metabolism related to normal glucose metabolism control in SPK patients.It has been postulated that restoring of normoglycemia after successful SPK transplantation should be followed by favorable effect on the vascular system, which will compensate the increased risk of surgical and infectious complications, including death, related to combined organ transplantation. However, taking into account the advanced vascular wall damage already present at the time of transplantation as a consequence of several decades of diabetes and subsequent uremia, the expected vascular improvement after SPK is difficult to demonstrate in cohort studies. Additionally, the lack of such evidence can also be explained by non-optimal metabolic efficiency in a significant proportion of transplanted pancreas, which may result from their fragmentary thrombosis and even more often from weight gain and increasing insulin resistance after transplantation ,25. In lMMP-2 and MMP-9 are considered to be main enzymes that degrade collagen type IV, the key component of extracellular matrix that determines the structure of vessels and glomerular base membranes . Previou1c level. Although plasma osteocalcin levels were shown to be significantly lower in SPK patients, it was attributed to better kidney graft function and lower serum PTH concentration but not to HbA1c blood level in this group. To date, the only study in small insulin-independent SPK cohort reported mildly elevated osteocalcin levels in 45% of the patients, with similar association with PTH [When considering the potential association between the metabolism of glucose and established biochemical markers of vascular calcification, none of them turned out to be associated with HbAwith PTH . Previouwith PTH . On the with PTH . Nonethewith PTH .The main limitation of this study is its low number of participants. However, we included all eligible SPK patients attending our out-patient clinic who gave their consent to participate in the research. Additionally, we recruited the KTA group based on two transplant centers due to the low number of T1D patients in whom KTA was performed. Moreover, in the effort to improve the study groups match in comparison to our original analysis , especiaThe list of study limitations is longer. At the time of the study, we have noted significant differences in immunosuppression regimens and lipid levels between the examined groups that may interfere with the study results. In fact, patients in SPK group were exclusively treated with tacrolimus-based, predominantly steroid-free regimens, whereas a relevant part of KTA patients were treated with cyclosporine A and prednisone. As both tacrolimus and steroids affects glucose metabolism, the net effect of immunosuppressive regimen on vascular wall damage is at least partially balanced. Furthermore, the independent effect of lipid levels on circulating MMPs was not supported in multivariable analyses, which suggests that their influence is smaller than that of the normal glucose metabolism restored with SPK.In conclusion, in our study we demonstrated that SPK recipients are characterized by a favorable profile of circulating matrix metalloproteinases in comparison to KTA subjects with T1D. This potential vasoprotective effect of SPK transplantation seems to be mediated mainly by the normalization of glucose metabolism.


Selective phosphodiesterase (PDE) inhibitors are a class of nonsteroid anti-inflammatory drugs for treating chronic inflammatory diseases. Modulation of systemic and airway inflammation is their pivotal mechanism of action. Furthermore, PDE inhibitors modulate cough reflex and inhibit airway mucus secretion. Roflumilast, a selective PDE4 inhibitor, has been extensively studied for the efficacy and safety in chronic obstructive pulmonary disease (COPD) patients. According to the mechanisms of action, the potential roles of PDE inhibitors in treating chronic respiratory diseases including severe asthma, asthma-COPD overlap (ACO), noncystic fibrosis bronchiectasis, and chronic cough are discussed. Since roflumilast inhibits airway eosinophilia and neutrophilia in COPD patients, it reduces COPD exacerbations in the presence of chronic bronchitis in addition to baseline therapies. The clinical studies in asthma patients have shown the comparable efficacy of roflumilast to inhaled corticosteroids for improving lung function. However, the clinical trials of roflumilast in severe asthma have been limited. Although ACO is common and is also associated with poor outcomes, there is no clinical trial regarding its efficacy in patients with ACO despite a promising role in reducing COPD exacerbation. Since mucus hypersecretion is a result of neutrophil secretagogue in patients with chronic bronchitis, experimental studies have shown that PDE4s are regulators of the cystic fibrosis transmembrane conductance regulator (CFTR) in human airway epithelial cells. Besides, goblet cell hyperplasia is associated with an increased expression of PDE. Bronchiectasis and chronic bronchitis are considered neutrophilic airway diseases presenting with mucus hypersecretion. They commonly coexist and thus lead to severe disease. The role of roflumilast in noncystic fibrosis bronchiectasis is under investigation in clinical trials. Lastly, PDE inhibitors have been shown modulating cough from bronchodilation, suppressing transient receptors potential (TRP), and anti-inflammatory properties. Hence, there is the potential role of the drug in the management of unexplained cough. However, clinical trials for examining its antitussive efficacy are pivotal. In conclusion, selective PDE4 inhibitors may be potential treatment options for chronic respiratory diseases apart from COPD due to their promising mechanisms of action. Phosphodiesterase (PDE) is an enzyme involved in the pathogenesis of chronic inflammatory diseases and degenerative diseases, for instance, asthma, chronic obstructive pulmonary disease (COPD), psoriatic arthritis, atopic dermatitis, and dementia of Alzheimer. PDE hydrolyzes substrates, nucleotide cyclic adenosine monophosphate (cAMP), and cyclic guanosine monophosphate (cGMP) to inactive metabolites as adenosine-5-monophosphate (5-AMP) and guanosine-5-monophosphate (5-GMP), respectively . The inhcAMP is a key secondary messenger for intracellular signaling processes . cAMP pr+ cell infiltration from the bronchial biopsy  document  for beinRoflumilast has been investigated for clinical effects on COPD patients with specific phenotypes such as COPD with frequent exacerbations and chronic bronchitis despite maximized treatment and specific comorbidities, for instance, effect on obesity, metabolic diseases, and cardiovascular diseases. This drug also has a potential mechanism in other conditions associated with COPD, for instance, COPD with small airway diseases and pulmonary hypertension. Roles of roflumilast and PDE4 inhibitors in these COPD patients are shown in 1 improvement. Also, the add-on benefit of roflumilast to combination therapies, for instance, ICS/LABA or ICS/LABA/LAMA, has been investigated systematically. The efficacy of therapies for reducing exacerbations was a major concern in COPD with superexacerbations (≥3 times a year) (The efficacy of roflumilast for reducing exacerbation was demonstrated in controlled studies . This be a year) . Since m a year) . Besides a year) . Further a year) . As prevBody mass index (BMI) is considered the prognostic marker of COPD mortality . SarcopeSmall airway fibrosis is one pathophysiological change in COPD apart from chronic mucus hypersecretion and pulmonary emphysema . Small aCardiovascular disease is a common cause of mortality in COPD patients. The more symptomatic COPD may underly by the occult cardiovascular diseases and low-grade systemic inflammation. A previous study has shown that roflumilast treatment is safe in terms of cardiovascular side effects . Apart f2) and may not convey the clinical benefit on OSAH in obese COPD patients with OSA.The increase in body fat in obesity is associated with the increase in tongue fat contributing to upper airway obstruction, which is associated with obstructive sleep apnea (OSA). The prevalence of OSA in COPD is varied . BesidesChronic hypoxemia is a key driver for the development of pulmonary hypertension (PH) associated with chronic lung diseases. Prevalence of COPD associated with PH is not uncommon and varied according to the degree of airflow obstruction, the definition of PH, and the method of diagnostic assessment . The magThe current evidence of roflumilast’s effect on chronic sinusitis has been investigated. The therapeutic roles of roflumilast in allergic rhinitis were examined for decades . RoflumiThe inhaled formulation of a PDE4 inhibitor has been investigated in patients with asthma and COPD. The aims are to improve their tolerability and maximize therapeutic effect . InhaledAsthma coexisting with upper airway disease has been emphasized as united airway disease . Rhinosiin vitro model. The effects of rolipram (specific PDE4 inhibitor), milrinone (specific PDE3 inhibitor), and zaprinast (specific PDE5 inhibitor) were investigated in rabbit maxillary sinus and trachea. The different selective PDE inhibitors exhibited the differential effect on ciliary beat frequency (CBF) in rabbit sinus and trachea  in patients with chronic inflammatory airway disease coexisting with chronic sinusitis. The 8-week treatment of ibudilast improves sputum and postnasal drip symptoms regardless of the previous macrolide and corticosteroid treatment. The putative mechanisms are reducing glycoprotein secretion and stimulating bronchial ciliary movement .The selective PDE1 or PDE4 inhibitor or dual PDE inhibitors (PDE3/4) raise the intracellular level of cyclic nucleotides in airway epithelial cells. Consequently, they may be the potential target in the development of new inhaled mucokinetic drugs. Further studies are needed for examining the cilia-modulating properties of PDE inhibitors .1 from allergen challenge compared with that of placebo after 2 h allergen challenge. However, early asthmatic responses to allergen challenge were not significantly reduced by the single dose of roflumilast  is a hallmark of asthma pathophysiology. The modulation of BHR is the target of asthmatic treatment. The prevention of allergen-induced early- and late-phase asthmatic reactions (EAR and LAR) is the hallmark of antiasthmatic drug efficacy, for instance, ICS and roflumilast. Previous studies have shown that roflumilast attenuates early- and late-phase asthmatic reaction after allergen challenge in different fashions. Single-dose orally administered roflumilast reduced the decrease in FEVlumilast . Furtherlumilast . Also, rlumilast . Howeverlumilast .ex vivo experiment has shown that ME1414 reduced lipopolysaccharide (LPS)-stimulated TNF-a release as well as LTB4 from the whole blood of asthmatic patients  is a reproducible and reliable physiologic surrogate for testing asthma drugs, roflumilast also improves other clinically relevant physiologic parameters, for instance, peak expiratory flow rate (PEFR) representing large airway function. The FVC improvement in roflumilast represents the reduction of the degree of air trapping as the effect of an orally ingested drug on small airways (1) and asthma symptoms in mild-to-moderate asthmatic patients compared with both low-dose beclomethasone and montelukast . Moreover, adding roflumilast to ICS/LABA or ICS/LABA/LAMA has shown the benefit of COPD exacerbation reduction as mentioned previously. The combined oral PDE4 inhibitor including roflumilast to ICS needs more studies examining the synergistic effect of PDE4 inhibitor and ICS on asthma and clinical efficacy.The reason underlying the paucity of clinical studies regarding PDE4 inhibitors in asthma is the comparable efficacy of PDE4 inhibitors to ICS therapy. In addition, prominent side effects of roflumilast, the selective PDE4 inhibitor, warrant the clinical utility in asthma. One way is the ICS that is the major or cornerstone treatment of asthma. Despite this, the oral leukotriene modifier is comparable to ICS in asthma treatment . In addiRoflumilast has potential roles for being an asthmatic controller as mentioned previously. The position of the drug in add-on therapy to ICS or ICS-containing regimens is shown in There is an interest in the characteristics or clinical traits of patients with the diagnosis of both asthma and COPD. Due to the lack of a well-accepted and precise definition of ACO, it is problematic to define the population in clinical trials of ACO. Hence, the treatments of ACO are extrapolated from asthma and COPD studies. COPD patients presenting with blood or systemic eosinophilia have demonstrated the clinical response to ICS for the reduction in an exacerbation. Also, management of severe asthma patients requires phenotypic treatment and monoclonal antibodies . Roflumi1 to LAMA or ICS/LABA in COPD and increasing FEV1 in asthma has been shown in clinical trials. Also, the improvement of FEV1 and the modulation of AHR have been shown in roflumilast-treated patients with asthma. To date, there is no definite evidence of the clinical benefit of roflumilast in ACO patients. In a bronchial biopsy study that examined the anti-inflammatory effects of roflumilast on patients with COPD, in comparison with placebo, roflumilast was associated with a significant reduction in eosinophils in the bronchial biopsy and significant reductions in both absolute and differential eosinophil cell counts in induced sputum. However, peripheral blood eosinophil counts were not affected  score after 52 weeks of roflumilast treatment . HoweverRoflumilast and other selective PDE4 inhibitors exhibit definite therapeutic roles in patients with COPD and possible roles in other chronic airway diseases. The mechanisms of roflumilast and drugs in this class are the modulation of the airway and systemic inflammation. However, the heterogeneity of airway inflammation including eosinophilic and neutrophilic is a treatment target for these anti-inflammatory drugs. They modulate airway inflammation in both asthma and COPD and improve airway function in both bronchodilator and nonbronchodilator effects. To date, roflumilast is the only PDE4 inhibitor approved for the treatment of COPD with chronic bronchitis phenotypes in patients who suffer from exacerbations. However, its role is limited by being added to backbone COPD treatment in terms of long-acting bronchodilators with or without ICS. The possible therapeutic role in severe asthma and ACO is promising but a large-scale study to support clinical use is needed. Furthermore, roflumilast has a clinical effect on extrapulmonary manifestation including metabolic derangement in COPD patients by reducing fat mass and glycemic control. The therapeutic opportunity in chronic airway inflammatory airway diseases including noncystic bronchiectasis and modulation of chronic persistent cough is promising and under clinical investigation. To sum up, roflumilast and PDE4 inhibitors may be classified as broad-spectrum oral anti-inflammatory treatment of chronic airway diseases. Preclinical studies elucidating the mechanisms of action are important as are the well-designed clinical studies examining the clinical efficacy of these drugs in chronic airway diseases other than COPD.


Furthermore, with respect to the end of omalizumab treatment, the score of sino-nasal outcome test-22 (SNOT-22) significantly decreased after therapy with benralizumab (p < 0.05). Conclusion. The results of this real-life study suggest that the pharmacologic shift from omalizumab to benralizumab can be a valuable therapeutic approach for allergic patients with severe eosinophilic asthma, not adequately controlled by anti-IgE treatment.Background. The wide availability of monoclonal antibodies for the add-on therapy of severe asthma currently allows for the personalization of biologic treatment by selecting the most appropriate drug for each patient. However, subjects with overlapping allergic and eosinophilic phenotypes can be often eligible to more than one biologic, so that the first pharmacologic choice can be quite challenging for clinicians. Within such a context, the aim of our real-life investigation was to verify whether allergic patients with severe eosinophilic asthma, not adequately controlled by an initial biologic treatment with omalizumab, could experience better therapeutic results from a pharmacologic shift to benralizumab. Patients and methods. Twenty allergic patients with severe eosinophilic asthma, unsuccessfully treated with omalizumab and then switched to benralizumab, were assessed for at least 1 year in order to detect eventual changes in disease exacerbations, symptom control, oral corticosteroid intake, lung function, and blood eosinophils. Results. In comparison to the previous omalizumab therapy, after 1 year of treatment with benralizumab our patients experienced significant improvements in asthma exacerbation rate ( Severe asthma includes several phenotypes driven by complex cellular and molecular pathogenic networks defined as endotypes ,2,3. In Hence, IgE, blood eosinophils and FeNO are currently considered as useful biomarkers of type 2 asthma, being also utilized to guide the choice of the most appropriate biological therapy for severe disease . Indeed,Omalizumab is a humanized monoclonal antibody which specifically binds to the two Cε3 domains of the constant region of human IgE, thus preventing their interactions with both high affinity (FcεRI) and low affinity (FcεRII/CD23) IgE receptors ,26. TherMepolizumab is a humanized IgG1/κ monoclonal antibody which selectively ligates IL-5, thus inhibiting its interaction with the α subunit of the IL-5 receptor (IL-5Rα) . Both RCDifferently from mepolizumab, the humanized IgG1/κ monoclonal antibody benralizumab specifically binds through the Fab fragments to IL-5Rα, thereby impeding its occupancy by the natural ligand IL-5 ,44,45. ATherefore, on the basis of the above considerations, we decided to evaluate, within a real-life context, the potential benefits of a therapeutic shift to benralizumab, implemented in allergic patients with severe eosinophilic asthma, not satisfactorily controlled by a previous treatment with omalizumab.We performed a real-life, retrospective, multicenter study including adult outpatients (≥18 years old) with severe persistent allergic and eosinophilic asthma, uncontrolled despite the add-on biological treatment with omalizumab, and thus switched to benralizumab. These subjects referred to five Respiratory and Allergology Units of Southern Italy . All enrolled patients met the European Respiratory Society (ERS)/American Thoracic Society (ATS) criteria that define severe uncontrolled asthma .2-adrenergic agonists (LABA) combinations, eventually associated with long-acting muscarinic antagonists (LAMA). Such patients had total serum IgE levels included within the range of 30–1500 IU/mL, as required by the Italian Drug Agency (AIFA), and they were also characterized by SPT positivity versus perennial aeroallergens. Therefore, omalizumab was prescribed and administered every 2 or 4 weeks, according to body weight and serum IgE levels. After a treatment period of at least 12 months, patients were shifted to benralizumab because of their unsatisfactory clinical response to anti-IgE therapy. We chose such a relatively long period of initial treatment, because it has been interestingly observed that the onset of a late response to omalizumab can be experienced by some patients even 48 weeks after starting anti-IgE therapy [At baseline , all 20 patients, also including 9 subjects complaining of chronic rhinosinusitis with nasal polyps (CRSwNP), exhibited high blood eosinophil counts and experienced frequent asthma exacerbations and an inadequate symptom control, thus needing high dosages of inhaled corticosteroids (ICS)/long-acting β therapy . Therefo therapy . Omalizu2-agonist (SABA) rescue medications, as well as prednisone intake, asthma control test (ACT) score, forced expiratory volume in the first second (FEV1), and blood eosinophil counts were recorded at baseline, after at least 12 months of omalizumab therapy (pre-shift), and at least 12 months after the first injection of benralizumab. Moreover, the sino-nasal outcome test-22 (SNOT-22) questionnaire was administered to patients with allergic CRSwNP. SPT was judged to be positive when the wheal area was equal to or larger than that one caused by histamine. Spirometry was performed according to ATS/ERS guidelines [The main aim of this real-life investigation was to evaluate the effects of benralizumab on clinical, functional, and laboratory parameters in patients with severe type 2 asthma previously treated with omalizumab. The numbers of asthma exacerbations and hospitalizations, the use of short-acting βidelines .2. The mean age of asthma onset was 31.40 ± 14.34 years. Mean baseline FEV1 was 62.47 ± 13.84% of predicted value. Baseline patient characteristics are summarized in We enrolled 20 patients, including 13 females and 7 males, with a mean age of 52.85 ± 9.39 years, and a mean BMI of 23.47 ± 3.54 Kg/mThe present observational study met the standards of Good Clinical Practice (GCP) and the principles of the Declaration of Helsinki. All recruited patients signed a written informed consent. Our study was also carried out in agreement to what decided by the local Ethical Committee of Calabria Region .p-value lower than 0.05 (two-sided) was considered to be statistically significant.Prism Version 9.1.2  was used to statistically analyze study results. Median values with interquartile range (IQR) were used to express skewed data distributions, while normally distributed data were expressed as mean ± standard deviation (SD). The normality of data distribution was checked using Anderson–Darling and Kolmogorov–Smirnov tests. Dunnett’s multiple comparison test and Friedman test were used to compare variables, when appropriate. A p < 0.0001) (p < 0.01) (p < 0.01) after treatment with omalizumab (pre-shift period), and zeroed after at least one year of add-on therapy with benralizumab (p < 0.001) (p < 0.0001), and after add-on treatment with omalizumab , respectively (p < 0.001) after at least 12 months of add-on therapy with benralizumab, respectively  . The dec < 0.01) . This re< 0.001) . The meaectively . It was ectively . In partp < 0.0001) (p < 0.05). Moreover, in 9 patients also complaining of CRSwNP, the SNOT-22 score decreased from the mean baseline value of 58.44 ± 17.87 to 53.89 ± 15.93 after omalizumab treatment (p < 0.05), and to 43.44 ± 19.91 after benralizumab therapy (p < 0.01), respectively (p < 0.05) between the two SNOT-22 scores calculated after treatments with omalizumab and benralizumab, respectively (The median ACT score increased from 12.00 (7.00–15.00) at baseline to 20.00 (17.25–23.75) during treatment with benralizumab ( 0.0001) . A signiectively . We alsoectively . 1 enhanced from the baseline measurement of 1.71 ± 0.46 L at baseline to 2.18 ± 0.63 L after benralizumab therapy (p < 0.01). Mean pre-bronchodilator FEV1 also significantly increased with respect to pre-shift  assessment, characterized by a mean value of 1.81 ± 0.48 L (p < 0.05) (p < 0.0001). The decrease of median blood eosinophil number was statistically significant even with respect to the time point of pre-switching biological therapy (p < 0.0001), corresponding to the end of treatment with omalizumab (The mean pre-bronchodilator FEV < 0.05) . Finallyalizumab .The recent advances in the rapidly evolving scenario of the biological treatment of severe asthma have provided, during the last few years, an increasing number of valuable therapeutic options. Such a relevant progress makes it possible, in many cases, to tailor the biological therapy on the basis of the specific sub-phenotype expressed by each patient with severe type 2 asthma ,23,55. AIn particular, benralizumab significantly decreased the annual number of asthma exacerbations not only in comparison to baseline, but especially with respect to the effects of omalizumab, whose therapeutic action was quite modest thus not allowing a clinically relevant prevention of exacerbations, which was subsequently achieved after switching to benralizumab. Differently from omalizumab, benralizumab was indeed able to reduce asthma exacerbations much more than 50%, which is the threshold suggested by the British National Institute for Health and Care Excellence (NICE) as a reliable clinical goal to be pursued by anti-asthma therapies . This imWith respect to omalizumab treatment and in addition to the positive impact on the annual asthma exacerbation rate, benralizumab also elicited other clinical improvements, especially regarding symptom control. Indeed, our patients were characterized by a poor control of asthma symptoms, expressed by a quite low baseline ACT score, which modestly and not significantly enhanced after omalizumab treatment, whereas benralizumab induced an increase which resulted to be significant not only with respect to baseline, but also versus omalizumab therapy. In particular, after switching from omalizumab to benralizumab, our patients reached the crucial ACT score of 20, which reflects an adequate asthma control . In real1: 62% pred). The initial treatment with omalizumab induced a scanty and not significant FEV1 change, which was overwhelmed by the subsequent therapy with benralizumab, responsible for a significant FEV1 increase amounting after 1 year to more than 400 mL with respect to baseline, and to more than 300 mL when compared to the end of omalizumab treatment (pre-switching), respectively. Such a remarkable improvement of bronchial obstruction, provided by benralizumab, is probably due to the powerful anti-eosinophil activity of this drug. Although the relationship between blood and sputum eosinophil levels is still debated, and with regard to this context there is disagreement in scientific literature, a recent reliable study has clearly shown that blood eosinophils are an excellent predictor of sputum eosinophilia in patients with uncontrolled asthma [In regard to lung function, at baseline our patients were characterized by a relevant airflow limitation (mean pre-bronchodilator FEVd asthma . TherefoTaken together, the results of the present real-life study strongly suggest that a subset of allergic patients with severe eosinophilic asthma, unresponsive to an initial add-on treatment with omalizumab, can greatly benefit from a subsequent biological therapy with benralizumab. This therapeutic shift was allowed by the phenotypic features of our patients, belonging to a group of subjects who express high levels of multiple biomarkers of type 2 asthma, including serum IgE and blood eosinophils . Of courOf course, omalizumab remains the first drug selection for uncontrolled atopic asthmatics ,20, whosIn conclusion, we think that the main strength of our real-life experience is based on the demonstration of the effectiveness of the pharmacologic shift from omalizumab to benralizumab, detected in allergic patients with severe eosinophilic asthma. These results are very interesting, because the effects of the above therapeutic switching are largely unexplored in atopic subjects with difficult-to-treat type 2 asthma. On the other hand, similar to other real-world investigations, our present study has some limitations including the relatively low number of enrolled patients, as well as the lack of randomization and placebo control.


Bedside measurements of critical closure pressure (Pcc) and mean systemic circulation filling pressure (Pmsf) were utilized to evaluate the response to esmolol in septic shock patients, in relation to the vascular waterfall phenomenon and body oxygen supply and demand.This prospective observational self-controlled study included patients with septic shock, newly admitted to the intensive care unit, between August 2019 and January 2021. Pcc and Pmsf, along with the heart rate and other hemodynamic indicators were observed and compared before and 1 h after esmolol IV infusion.2, P < 0.001), a significant increase in stroke index (SI) , and a significant decrease in heart rate (HR) . After 1 h of treatment with esmolol, patients had a significant increase in Pcc . The difference between Pcc and Pmsf before and after treatment was statistically different . After heart rate control with esmolol, the patients had a significant increase in the body circulation vascular resistance indices (RIs) . There was an increase in ScvO2 in patients after treatment with esmolol, but the difference was not statistically significant , while Pcv-aCO2 was significantly lower  and patients had a significant decrease in blood lactate levels .After 24 h of initial hemodynamic optimization, 56 patients were finally enrolled. After start of esmolol infusion, patients had a significant decrease in cardiac index (CI) , without affecting MAP, CVP, Pmsf and arteriovenous vascular resistance, and improve the balance of oxygen supply and demand in the body. The early clinical management of patients with septic shock depends on the hemodynamic management and optimization. The pathophysiological characteristics of septic shock include a waterfall-like inflammatory response, which is often accompanied by sympathetic hyperactivation, continuously elevated catecholamine levels, myocardial depression, vascular hyporesponsiveness and autonomic nerve dysfunction –3. In adThe phenomenon of "vascular waterfall", hemodynamic state of collapsible vessels, different from classic Poiseuille law and similar to waterfalls in nature, has been studied since the 1960s –7. In coCC and PMSF is a good breakthrough opportunity to connect the macrocirculation and microcirculation.Based on that, blocking the side effects caused by high catecholamine levels helps to improve the prognosis of patients with septic shock , 12. EsmConsequently, by explaining the pressure gradient between arteriolar closure pressure Pcc and the mean venous filling pressure Pmsf at the level of small veins, vascular waterfall phenomenon is an important discovery in the study of the microcirculation system, and with the further research of many scholars this phenomenon can be measured stably and reliably. In recent years, more and more studies have been conducted to explore and explain related circulation problems by measuring vascular waterfall, which is an important bridge between the study of macrocirculation and microcirculation . Therefo2, and Intrathoracic Blood Volume Index (ITBVI > 850 mL/m2). Diagnostic process of septic shock included the following: for patients with infection or suspected infection, if their sequential organ failure assessment (SOFA) score was ≥ 2 or doctors suspected sepsis, we further evaluated whether there is an evidence of organ dysfunction; if the patient's SOFA score was ≥ 2 or the new score was ≥ 2, it was diagnosed as sepsis. Septic shock was diagnosed if patients with sepsis still needed to maintain blood pressure MAP ≥ 65mmhg or blood lactate levels > 2 mmol/L after sufficient fluid resuscitation.The study, which adopts a prospective observational method, enrolled patients with septic shock, newly admitted to the intensive care unit (ICU) of the Department of Critical Care Medicine, Chengdu Third People's Hospital, between August 2019 and January 2021. Patients diagnosed with septic shock according to the Sepsis-3 criteria [2 and GEDVI > 700 mL/m2 and ITBVI > 850 mL/m2), adequate sedation and analgesia for less than 36 h, length of stay in the ICU less than 48 h, surgery or re-operation within 48 h after admission to ICU, and pregnancy.Exclusion criteria were previous treatment with β blockers before or within 24 h of ICU admission, severe valvular disease, congenital heart disease or cardiomyopathy, severe pulmonary bullae or spontaneous pneumothorax, need for inotropic agents or severe cardiac dysfunction , and informed consent was obtained from patients or their next of kin.2 and GEDVI > 700 mL/m2, ITBVI > 850 mL/m2; MAP > 65 mmHg; central venous oxygen saturation (ScvO2) ≥ 70%; and urine output > 0.5 mL/kg/h. (2) Respiratory support therapy: Mechanical ventilation was performed in volume control mode  with a target tidal volume of 6 to 8 ml/kg or less. (3) Sedation and analgesia: Dexmedetomidine or midazolam was used for continuous intravenous infusion sedation, fentanyl or butorphanol was used for analgesia; (4) Others: Rational use of antibiotics to fight infection, insulin control of blood sugar, dynamic monitoring of blood lactic acid level, maintaining acid–base electrolyte balance, etc.Within 24 h from admission to the ICU, the patients received the primary treatment according to the following scheme: (1) Hemodynamic therapy with shock resuscitation immediately after the patient was admitted to the ICU. Hemodynamic treatment objectives were: CI > 3 L/min/m24 h after admission to ICU, patients whose heart rate was more than 95 beats/min after hemodynamic optimization and needed norepinephrine (≥ 0.10 μg/kg/min) to maintain blood pressure began to receive intravenous esmolol  to control heart rate. The loading dose was 0.25–0.5 mg/kg  and the maintenance dose was 0.05 mg/kg/min, IV (intravenous pumping), which was dynamically adjusted by the doctor in charge according to the heart rate and the changes of the disease. 24 h after the patient enters the ICU, the target heart rate was controlled at 80–94 bpm until he leaves the ICU .2O. The ventricular output (VO) curve and venous return (VR) curve were constructed for the 4 pairs of CO, MAP values and CO, CVP values obtained from the 4 plateau pressures. A linear regression line was fitted through these data points. When the flow velocity was zero, the cutoff values of the pressure axis were Pcc and Pmsf, respectively [Through continuous sedation at the bedside until the patient until no spontaneous breathing for 12 s, steady-state CO, CVP and MAP were measured over the last 3-s of 12-s inspiratory hold maneuvers at plateau pressures of 5, 15, 25 and 35 cmHectively , 17.2), dosage of norepinephrine and urine output per hour were observed and recorded before and 1 h after esmolol treatment . During the observation period, the patient was no longer treated with fluid resuscitation, and only the necessary drugs were given to maintain infusion. The systemic vascular resistance index (RIs) was defined as RIs = (MAP-CVP)/CI; arterial vascular resistance index (RIa) = (MAP-Pcc)/CI; venous vascular resistance index (RIv) = (Pmsf-CVP)/CI. Vascular waterfall was confirmed in cases of Pcc > Pmsf.CVP, MAP, HR, GEDVI, ITBVI, extravascular lung water (EVLWI), cardiac stroke volume index (SI), CI, ScvO2, Pcc, Pmsf, VO curve slope, VR curve slope, blood lactate level (Lac), central venous-to-arterail carbon dioxide difference (Pcv-aCOx ± s). The data before and after treatment with esmolol were compared by a paired-sample t test. The least square method was used to fit the linear regression of Pcc and Pmsf. Differences with a P value of less than 0.05 were considered statistically significant.Statistical analyses were performed using SPSS 22.0 . The measurement data are presented as mean ± SD  to maintain MAP > 65 mmHg, and had a GEDVI > 700 mL/m2/L, P < 0.001), arterial RIa , venous RIv  and RIa + RIv  did not change significantly compared to before treatment  in patients before and after esmolol treatment. Although after esmolol treatment systemic RI was significantly higher than before treatment (18.25 vs. 15.14 mmHg·min/mP < 0.001), while SI, Pcc and Pcc-Pmsf were significantly increased . The decrease in CI was mainly due to a decrease in heart rate after esmolol treatment . Esmolol did not affect the levels of MAP  and CVP . Simultaneously, before and after esmolol treatment, patients' PiCCO volume indexes GEDVI , ITBVI  and EVLWI  were not changed either.After heart rate control with esmolol, patient CI decreased significantly , while Pcv-aCO2 was significantly decreased  and patients had a significant decrease in blood lactate levels , suggesting that esmolol improves the tissue oxygen metabolism of the body. Combined with the changes in hemodynamic indicators, the difference between Pcc and Pmsf was significantly increased, and it seems that the improvement in oxygen metabolism was associated with the restoration of vascular waterfalls and improved microcirculatory perfusion in more tissues and organs.We also monitored the oxygen supply and demand balance indicators before and after esmolol administration in 56 patients admitted to the hospital, and the results are shown in Table P = 0.012). However, there was no significant correlation found directly between the Pcc-Pmsf and lactate levels, before or after treatment  and mean systemic circulation filling pressure (Pmsf) to evaluate the response to esmolol in septic shock patients, in relation to the vascular waterfall phenomenon and body oxygen supply and demand. It was found that patients with septic shock whose heart rate is greater than 95 beats/min, benefited from addition of esmolol after hemodynamic optimization, demonstrating a significant decrease in CI and a HR. The difference between Pcc and Pmsf before and after treatment was statistically significant, indicating a marked increase in the body circulation vascular resistance indices and successful restoration of the “Vascular Waterfall”.According to the classic Poiseuille law, arterial blood pressure is determined by the cardiac output and systemic vascular resistance, that is, the flow is proportional to the pressure gradient of the pipeline. However, an increasing number of studies have reported the presence of vascular waterfalls in vascular beds –7. When Based on understanding of waterfall phenomenon, monitoring of Pcc and Pmsf, which can be performed at the bedside in the ICU, gives the opportunity for hemodynamic management to shift from macrocirculation to microcirculation. Draw VO curve and VR curve, respectively, through cardiopulmonary interaction, end-inspiratory breath-holding and continuous increase of end-inspiratory airway platform pressure, and linear fitting can be used to obtain the corresponding Pcc and Pmsf when CO is zero , 17. ThiSo far, many evidence-based medical sources, including Chinese guidelines for patients with septic shock, recommend esmolol to control the increased heart rate of septic shock patients after hemodynamic optimization, which can improve the hemodynamic status, microcirculation perfusion, renal function and prognosis of patients , 14. HowIn this study, we found that after treatment with esmolol, as heart rate was effectively controlled, patients showed a significant decrease in CI and no statistical changes in MAP. However, due to the existence of the vascular waterfall, the patient's arterial and venous resistance did not change. This finding seems to explain the problem of previous studies that the systemic vascular resistance increased significantly after the use of esmolol , 14. TheIt is interesting to note, that the waterfall (Pcc-Pmsf) could be negative in some cases, as demonstrated in Fig. Unfortunately, we did not observe any association between Pcc-Pmsf and Lac before and after esmolol treatment. The reason may be the restoration of vascular waterfall phenomenon, as with the difference of Pcc-Pmsf from negative to positive, tissue perfusion also changed, and microcirculation perfusion improved. However, with the increase of Pcc, the difference of vascular waterfall Pcc-Pmsf further increased (Pmsf did not change significantly in this study), and the tissue perfusion pressure (MAP-PCC) decreased significantly (no significant change occurred before and after MAP). In this study, CI also decreased significantly after esmolol treatment, so tissue perfusion level decreased instead. Therefore, no link to the changes in Lac was found during the given timeframe.This study still has certain limitations: First, this was a nonrandomized controlled study; because clinical guidelines for sepsis in China and evidence-based data is currently available to recommend esmolol for patients with septic shock whose heart rate remains greater than 95 bpm after hemodynamic optimization , 21, 22,Patients with septic shock whose heart rate remained greater than 95 bpm after hemodynamic optimization were treated with esmolol, which effectively controlled the heart rate and reduced the CI. At the same time, it can increase the Pcc, increase the difference between Pcc and Pmsf  without affect on MAP, CVP, Pmsf as well as arteriovenous vascular resistance and it can improve the body's oxygen supply–demand balance status.


The diagnostic efficiency of the proposed model has been evaluated at the second stage. It appeared to have a high specificity of 83.3%, a sensitivity of 95.8%, and a diagnostic accuracy of 93.3%. Conclusion. The developed model for predicting CHF progression within 48 weeks after STEMI has a high diagnostic efficiency and can be used in early stages of myocardial infarction to stratify the risk of patients.A multivariate model for predicting the risk of decompensated chronic heart failure (CHF) within 48 weeks after ST-segment elevation myocardial infarction (STEMI) has been developed and tested. Methods. The study included 173 patients with acute STEMI aged 51.4 : 42–61) years. Two-dimensional (2D) speckle-tracking echocardiography (STE) has been performed on the 7th–9th days, and at the 12th, 24th, and 48th weeks after the index event with the analysis of volumetric parameters and values for global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS). A 24-h ECG monitoring (24 h ECG) of the electrocardiogram (ECG) to assess heart rate turbulence (HRT) has been performed on the 7th–9th days of STEMI. The study involved two stages of implementation. At the first stage, a multivariate model to assess the risk of CHF progression within 48 weeks after STEMI has been built on the basis of examination and follow-up data for 113 patients (group M). At the second stage, the performance of the model has been assessed based on a 48-week follow-up of 60 patients (group T). Results. A multivariate regression model for CHF progression in STEMI patients has been created based on the results of the first stage. It included the following parameters: HRT, left ventricular (LV) end-systolic dimension (ESD), and GLS. The contribution of each factor for the relative risk (RR) of decompensated CHF has been found: 3.92 (95% CI: 1.66–9.25) ( Chronic heart failure (CHF) has become a major public health problem of the 21st century, significantly reducing the life potential of the population worldwide. Major causes of CHF are arterial hypertension and coronary heart disease .Annual costs of treating CHF patients grow progressively due to an increase in the life expectancy of patients ,5. AccorNowadays, patients with acute ST-segment elevation myocardial infarction (STEMI) receive high-quality treatment due to the achievements of interventional cardiology and drugs that are able to restore and “revive” hibernating cardiomyocytes in the infarct zone. Thus, the prognosis of patients after myocardial infarction has significantly improved in the era of pharmacoinvasive therapy ,8. AccorDue to the increase in the survival rate of patients with myocardial infarction, the prediction and prevention of CHF decompensation are the key tasks for the cardiological community .Currently, there are some urgent problems, dealing with the introduction of the possibilities of laboratory and instrumental diagnostic methods to predict the risk of developing CHF decompensation, and how to reduce the risk of re-hospitalization of patients. To predict a high risk of CHF in early stages of STEMI is essential for personalized anti-remodeling therapy, reliable recommendations for therapeutic rehabilitation, and timely cardiac surgery.The aim of this study was to create a model for reliable risk prediction of CHF progression after acute STEMI during a 48-week follow-up using a combination of echocardiography (EchoCG) and 24 h ECG monitoring.A total of 1256 STEMI patients were examined in the Emergency Cardiology Department of the Regional Clinical Hospital n. a. N.N. Burdenko . According to evaluated inclusion/exclusion criteria, a total of 173 STEMI patients were enrolled in the study. The study protocol and informed consent were approved by the Local Ethics Committee at Penza State University.The study included patients having met the following criteria: aged 35–65 years; acute STEMI of any localization, confirmed by laboratory and instrumental methods , EchoCG). The main exclusion criteria were as follows: repeated and recurrent myocardial infarction; stenosis of more than 30% of the left coronary artery; stenosis of more than 50% of other coronary arteries, except for an infarct-related one; NYHA class II-IV of CHF; non-sinus rhythm; severe concomitant diseases.The average age of the patients was 51.4 (95% CI: 42–61) years, men prevailed—152 patients (87.8%). Two-dimensional EchoCG has been performed on the 7th–9th days, and at the 12th, 24th, and 48th weeks after STEMI using a MyLab90 ultrasound scanner  with analysis of generally accepted volumetric parameters. The ejection fraction (EF) has been calculated using a modified Simpson method. The end-diastolic volume index (EDVI) and the end-systolic volume index (ESVI) have been determined by indexing to body surface area (BSA). Speckle-tracking EchoCG has been performed using Esaote XStrain™ software. The values for global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS) have been estimated .A 12-lead 24-h ECG monitoring has been carried out using Holter Analysis-Astrocard complex devices  on the 7th–9th days of STEMI. Episodes of ischemia, arrhythmias have been assessed: ventricular and supraventricular extrasystoles, running of stable and unstable tachycardias, paroxysms of atrial fibrillation and flutter, ventricular fibrillation, conduction disturbances—sinoatrial and atrioventricular blockades. An analysis of heart rate turbulence (HRT) has been performed on the basis of the 24-h ECG. The deviation of at least one of two parameters has been taken as pathological HRT: turbulence onset (TO) <0%), and turbulence slope (TS) >2.5 ms/RR). Heart rate variability (HRV) has been assessed by temporal , and spectral characteristics  .The level of brain natriuretic peptide (BNP) has been determined on the 7th–9th days after STEMI. A six-minute walk test has been performed to determine NYHA class of CHF starting from the 12th week of the postinfarction period.The progression of CHF in the postinfarction period has been considered to be the endpoint, determined by the development of one of the following events ,13: hospThe STEMI patients have been receiving treatment in accordance with the ESC Clinical Practice Guidelines . PercutaThe study involved two stages of implementation. At the first stage, a multivariate model for assessing the risk of CHF progression within 48 weeks after STEMI has been built on the basis of examination and follow-up data for 113 patients (group “M”). At the second stage, the sensitivity and specificity of the multivariate model for the risk of CHF decompensation has been tested based on a 48-week follow-up of 60 patients (group “T”).2 test has been used for independent samples. To determine the influence of the parameters on the endpoint development, and to estimate the relative risk (RR) and 95% CI, the method of univariate analysis by applying logistic regression has been used. The value of p < 0.05 was taken as a threshold of statistical significance. To include the indicators in a multivariate model using the Cox multiple linear regression, the absence of a correlation between thereof should be a prerequisite. To assess the information content and adequacy of the logistic model, the coefficients of sensitivity and specificity have been determined. Sensitivity (Se) is the ability of a diagnostic method to give a reliable result, and specificity (Sp) is the ability of a diagnostic method not to provide false positive results in the absence of a disease [Statistical data processing has been performed using the licensed version of STATISTICA 13.0 program . All values of quantitative traits are given with the 95% confidence interval (CI). The McNemar criterion has been used when comparing qualitative characteristics for paired samples, and χ disease .According to the results of the first stage of the study , the endThe following factors for CHF progression have been established according to the univariate regression analysis of data from 113 STEMI patients: pathological values of TO and HRT, BNP level, ESD, GLS, GCS, and GRS values obtained on the 7th–9th days of STEMI . The EF X1 is equal to 1.0 with pathological HRT on the 7th–9th days of STEMI, and it is equal to 0 with normal HRT; X2—ESD, mm; X3—GLS, %; h0(t)—baseline risk of 0.018611 at the 6th week, 0.100065 at the 12th week, 0.108673 at the 16th week, 0.181305 at the 24th week, and 0.212152 at the 48th week. The risk of predicting CHF has been calculated at the 6th, 12th, 16th, 24th, and 48th weeks of the postinfarction period. We have concluded that if the value of h was higher than 1.0, CHF progression was predicted; if the value of h was less than 1.0, there was a stable course of the postinfarction period.Considering correlations between given parameters and using a stepwise variable selection method, a multivariate regression model for CHF progression in STEMI patients has been created. It includes HRT, ESD, and GLS values, and has the form of the formula:p = 0.00016).The analysis of variance (ANOVA) has shown that the present model of differentiation of patients by the nature of the postinfarction period has a high information content: the Wilk’s Lambda = 0.83243, F (3109) = 7.3139 . CHF progression was recorded in 12 (20%) patients of group “T” over the 48-week follow-up. One (8.3%) patient was hospitalized due to CHF decompensation; NYHA class III of CHF was estimated in 2 (16.7%) patients according to the six-minute walk test; a decrease in EF was determined in 9 (75%) patients: with the transition from HFpEF to HFmrEF—in 3 (25%), and from HFmrEF to HFrEF—in 6 (50%) patients.Sensitivity, specificity, and diagnostic accuracy of the method have been determined to assess the adequacy of the presented logistic regression individual risk model for predicting CHF.n = 60) within 48 weeks after STEMI.The diagnostic model is characterized by low sensitivity with a high level of specificity and diagnostic accuracy at the 12th week. However, sensitivity of the model has increased to 83.3% by the 48th week at the later stages of the postinfarction period. Thus, the individual risk model for predicting CHF after STEMI has acceptable sensitivity, high specificity, and diagnostic accuracy and can be used in early stages of STEMI (on the 7th–9th days) to identify patients with a high risk of CHF decompensation.Late and/or unsuccessful pharmacoinvasive revascularization, large-size myocardial infarction, life-threatening arrhythmias, old and senile age, lack of previous drug therapy of cardiovascular diseases, type 2 diabetes, and comorbidity are known as factors to be associated with a high risk of CHF progression ,5,12,17.BNP is one of the most common CHF indicators ,18. AccoInvestigation of cardiac biomechanics is essential in assessing the function of the entire cardiovascular system in patients with myocardial infarction, since this group of patients has a high risk of CHF progression due to left ventricular (LV) pathological remodeling. As LV EF is the most studied, the expediency of its monitoring in CHF is beyond doubt, since reduced ejection fraction is associated with an unsatisfactory prognosis, poor quality of life of patients, increased mortality and hospitalization rates ,5,12,20.Many researchers have found that HRV is a valid factor for a high risk of mortality and CHF progression ,21. Low HRT is an appropriate technique for stratification of CHF risk in postinfarction patients . A groupAnother urgent problem is the risk stratification of life-threatening rhythm disturbances in CHF patients who have had myocardial infarction. Due to the lack of an accurate system for determining the risk of sudden death in such patients, implantation of a cardioverter defibrillator is not always properly performed ,24,25. SAn integrated approach is essential to apply for assessing the risk of CHF progression. Determination of individual parameters does not reflect a complex clinical and functional picture and cannot be used in patients after STEMI. The best way to assess the risk of developing decompensated CHF is a combination of several parameters reflecting the condition of the cardiovascular system as a whole.According to the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) research, a risk score for prediction of mortality in CHF has been constructed from 13 patient characteristics: age, EF, NYHA class, serum creatinine, diabetes, systolic blood pressure, body mass index, heart failure duration, current smoker, chronic obstructive pulmonary disease, gender, not prescribed a beta-blocker, and not prescribed an ACE inhibitor or ARBs. The difference between the model-predicted and the observed 3-year mortality in the six risk groups varied between 5% and −12% . An addiOther researchers  have proAs there are no available publications describing the calculation of the risk of CHF progression based on a combined assessment of volumetric and strain characteristics of the LV myocardium together with determination of autonomic rhythm regulation, the approach to risk stratification of STEMI patients is to improve the diagnostic accuracy of prediction. A multivariate diagnostic model for predicting CHF progression within 48 weeks after STEMI has been created and successfully tested. Its high specificity, diagnostic accuracy and sensitivity have been proved in the current study.The proposed multivariate model for predicting CHF decompensation within 48 weeks after myocardial infarction, which includes such parameters as heart rate turbulence, left ventricular end-systolic dimension, and global longitudinal strain, has an adequate specificity of 83.3%, a high sensitivity of 95.8%, and a diagnostic accuracy of 93.3%. This technique can be used in the early stages of myocardial infarction to identify patients with a high risk of heart failure progression within the next 48-weeks of postinfarction period.The present study included young and middle-aged patients predominantly (35–65 years old) with primary STEMI with hemodynamically significant stenosis of exclusively infarct-related coronary artery, without a history of CHF. These strict inclusion criteria have been driven by the attempt to exclude the influence of other factors that could lead to myocardial remodeling before the index event (STEMI) and affect the baseline values of the volumetric and deformation characteristics of the myocardium. For this reason, the number of the study participants was relatively small. The authors consider the present study a preliminary one in the process of searching and refining the combination of predictors of the development and progression of CHF after STEMI.