Identification of a urinary metabolite biomarker with diagnostic or prognostic significance for early immunoglobulin A nephropathy (IgAN) is needed. We performed nuclear magnetic resonance‐based metabolomic profiling and identified 26 metabolites in urine samples. We collected urine samples from 201, 77, 47, 36 and 136 patients with IgAN, patients with membranous nephropathy, patients with minimal change disease, patients with lupus nephritis and healthy controls, respectively. We determined whether a metabolite level is associated with the prognosis of IgAN through Cox regression and continuous net reclassification improvement (cNRI). Finally, in vitro experiments with human kidney tubular epithelial cells (hTECs) were performed for experimental validation. As the results, the urinary glycine level was higher in the IgAN group than the control groups. A higher urinary glycine level was associated with lower risk of eGFR 30% decline in IgAN patients. The addition of glycine to a predictive model including clinicopathologic information significantly improved the predictive power for the prognosis of IgAN [cNRI 0.72 (0.28‐0.82)]. In hTECs, the addition of glycine ameliorated inflammatory signals induced by tumour necrosis factor‐α. Our study demonstrates that urinary glycine may have diagnostic and prognostic value for IgAN and indicates that urinary glycine is a protective biomarker for IgAN. We first hypothesized that a differentially expressed urinary metabolite biomarker in individuals with early IgAN compared to controls could be identified. Further, we asked whether this biomarker has prognostic value and performed experimental validation to determine the pathophysiologic role of the identified metabolite.22.1This study was conducted according to the Declaration of Helsinki. The institutional review board of Seoul National University Hospital, Seoul, Korea (H‐1601‐076‐732) approved the study. All clinical characteristics and biospecimens were prospectively collected with the approval of the study patients with informed consents.2.22 as we intended to study patients without substantial impairment in their kidney function. In addition, a few prominent outliers regarding urine metabolomic profiles, when identified by visualized principal component analysis plots based on the first and second principal components, were excluded to prevent technical bias. As a clinical outcome, an 30% reduction in eGFR from baseline was used, as most patients had relatively preserved kidney function, and the follow‐up duration was relatively short (median 1.6 years).The kidney biopsies and urine sample collection at the timing of diagnosis were performed between October 2009 and March 2016. Patients with pathologically confirmed IgAN from kidney biopsies were included as the study group. We included patients diagnosed with membranous nephropathy (MN), minimal change disease (MCD) or lupus nephritis (LN) as the disease‐control group. We also constructed a healthy control group, with no evidence of kidney dysfunction, including abnormal urinalysis or reduced estimated glomerular filtration rate (eGFR), and assessed donated urine and blood samples from health screening examinees. The baseline clinical characteristics and biospecimens, including morning random urine samples, were collected at the time of kidney biopsy for initial diagnosis and for health screening examinees at their time of visit. eGFR was calculated with the chronic kidney disease epidemiology collaboration equation.2.3The nuclear magnetic resonance (NMR)‐based urine metabolomic profiling method has been previously published, and details are explained in the Supplemental Methods, Figures 2.4During statistical analysis, a biostatistician was blinded to all names of the metabolites, and the names were revealed at the time of planning further experimental validation to limit confirmation bias.The principal component analysis and partial least squares discriminants analysis were performed by ‘mixOmics’ package in R.U test. The correlations between the clinical characteristics and the urinary metabolite levels were investigated with Spearman's test.We compared the urinary metabolite levels between the IgAN group and another disease or healthy control group with the Mann‐Whitney The predictability for IgAN was assessed by area under curve analysed by receiver operating characteristics (ROC) curve, and we compared the area under curve by DeLong's method with ‘pROC’ package in R.The association between the metabolite values and the risk of poor kidney prognosis, a 30% reduction in eGFR, was determined with panelized spline regression. For those metabolites that had a potential linear association with adverse kidney outcome risks, we performed Cox regression analysis to confirm the prognostic significance. Multivariable models were adjusted for age, sex, baseline eGFR, random urine protein/creatinine ratio, mean arterial pressure and pathologic parameters including the Oxford classification scores, history of angiotensin‐converting enzyme inhibitor or angiotensin II receptor blocker use, and history of immunosuppressive agent use at the time of kidney biopsy to include the variables for the current risk prediction tool for IgAN. We also included sex and crescent scores, which were not included in the suggested prediction tool but might have clinical importance, in the full model.We tested whether the addition of metabolite levels to a prediction model including clinical information improved the predictability analysed by continuous net reclassification improvement (cNRI) with thousands of bootstrapping cycles.P value (0.05/number of comparison) was implemented when identifying differences in urine metabolite levels among the study groups or identifying correlation between the metabolite levels and clinical characteristics. In the prognostic analysis or when comparing model predictive power, conventional two‐sided P value < .05 indicated statistical significance. All statistical analyses were performed with R .In the cNRI analysis, when 95% confidence intervals crossed zero, the difference between the prognostic predictability of the models was interpreted to be non‐significant. A Bonferroni‐adjusted 2.5For immunohistochemistry, we included pathologic slides from kidney biopsies of 12 IgAN cases, 6 controls and 3 MCD and MN cases. The primary antibodies used for staining were for the glycine cleavage system, including T protein, P protein, L protein, and H protein and SHMT 1 and 2 (Abcam). For staining, we cut unstained, paraffin‐embedded tissue sections that were stored at the time of kidney biopsy into 4 μm sections. The sections were deparaffinized in xylene and rehydrated with a descending concentration series of ethanol. Sliced specimens were heated three times in a microwave oven for 5 minutes with 10% citrate buffer solution (pH 6.0) to retrieve the antigen. We blocked the endogenous streptavidin activity with 3% hydrogen peroxide in methanol for 10 minutes at room temperature. Blocking reagent  was used to block non‐specific binding. Images were captured using a light microscope system . Quantification of the immunohistochemical staining was performed with ImageJ . We measured the proportion of the stained area with the same cut‐off thresholds for at least 5 high‐power fields in each sample, and the average value was used to represent the degree of staining of the sample.2.6g for 5 minutes). The recovered hTECs were collected from the pallet and incubated in DMEM/F12  for 4 hours. Floating tubules in the media were retrieved and cultured on collagen‐coated petri dishes  until the establishment of colonies of hTECs in REGM medium  supplemented with 10% foetal bovine serum, 12 mg/mL bovine brain extract, 1 mg/mL hydrocortisone, 10 ng/mL epidermal growth factor, 50 mg/mL gentamycin and 50 ng/mL amphotericin B. hTECs at 2‐3 passages were used in the current study.The unaffected kidney cortices of renal cell carcinoma patients were mechanically dissected. In the dissected cortex, the specimens were minced and digested with Hank's 201 balanced salt solution (HBSS) containing 3 mg/mL collagenase  and incubated at 37°C for 1 hour. The digested cells were washed through a series of sieves  with phosphate‐buffered saline, followed by centrifugation (500 We first tested the expression of target glycine cleavage system molecules identified by the above immunohistochemistry after different dosages of tumour necrosis factor‐α (TNF‐α). The use of TNF‐α to trigger the inflammatory response in hTECs was based on a previous study regarding the tubule pathophysiology of IgAN. After 1 hour of treatment, hTECs were incrementally treated with 2.5, 5.0, 10.0 and 20.0 ng/mL TNF‐α. The dosage resulting in the expression of the target glycine cleavage system molecule (10 ng/mL for 1 hour) was implemented to stimulate hTECs in the following experiments.Second, we treated hTECs with 10 ng/mL TNF‐α for 1 hour, with cotreatment of glycine  in cell culture media with incremental dosages of 2.5, 5.0, 10.0 and 20.0 mmol/L. We investigated the relative expression of inflammation‐related molecules, including intercellular adhesion molecule 1 (ICAM1), p38, phosphor‐p38, p65 and phosphor‐p65, to β‐actin. We also measured glutathione concentrations using a glutathione assay kit , along with the inflammation‐related molecules.Third, we inhibited the target glycine cleavage system molecule (protein H) by siRNA and tested the expression of inflammatory molecules under conditions of TNF‐α induction in hTECs. We transfected the hTECs with siRNA for protein H  according to the manufacturer's protocol. As controls, hTECs treated with scrambled siRNA and hTECs in conditions without TNF‐α induction were tested. Levels of glycine in cell lysates were measured in each condition by the glycine assay kit (Abcam) with mean fluorescence intensity units.For immunoblotting of the inflammatory molecules and glycine cleavage system, 80 μg of proteins was separated by electrophoresis on 10% sodium dodecyl sulphate‐polyacrylamide gels and transferred onto Immobilon‐FL 0.4 μmol/L polyvinylidene difluoride membranes . Proteins were probed with primary antibodies targeting ICAM1 (Thermo Fisher Scientific), p38 (Abcam), phosphor‐p38, p65, phosphor‐p65 , protein H and protein T (Abcam) followed by anti‐rabbit IgG  secondary antibodies. The labelled proteins were detected by an enhanced chemiluminescence system . Quantification of Western blot bands was performed with ImageJ.33.11H NMR‐based metabolomic profiling to identify and quantify urinary metabolites in 203 IgAN patients with eGFR ≥ 60 mL/min/1.73 m2. With the same criteria applied, MN patients (n = 81), MCD (n = 49), LN (n = 38) patients and healthy controls (n = 146) were profiled for their urine metabolomics. After we excluded the outliers, 201, 77, 47, 36 and 136 patients remained in the IgAN, MN, MCD, LN and healthy control groups, respectively. The baseline clinical characteristics among the study population are shown in Table 2, and the MN and MCD groups had higher urinary random protein/creatinine ratios than the other groups. Within the IgAN groups, 170 (85.4%) patients were on angiotensin‐converting enzyme inhibitors or angiotensin II receptor blockers, and 54 (27.1%) patients were on immunosuppressive drugs.We applied 3.2Unsupervised principal component analysis indicated the composite of metabolites did not clearly separate the study groups in total Figure . When weP < .001), MN (P = .001) and LN (P = .001) patients. The glycine level was higher in the MN cases than in the controls, but the significance did not reach the Bonferroni‐adjusted significance level (P = .017), and the MCD (P = .584) or LN group (P = .798) showed similar levels as the healthy control group.When individual metabolite level was considered Figure , fifteenWhen area under curve of ROC curve by logistic regression model predicting IgAN was calculated, the model including urine glycine level along with clinical variables showed significantly higher area under curve than the base clinical model including age, sex, urine protein‐to‐creatinine ratio, eGFR and mean arterial pressure Table . When th3.3When we tested the correlations between the urinary metabolite levels and the clinical characteristics of the IgAN patients, several positive associations were revealed between the urine protein‐to‐creatinine ratio and several metabolites Figure . Urine gNext, we asked whether certain urinary metabolites were linearly associated with the risk of adverse renal outcomes with panelized spline curves. Several metabolites showed a negative association with the risk of a 30% reduction in eGFR Figure . The assWhen we tested the additive prognostic value of the identified metabolites, the addition of glycine or other metabolites to a clinical model improved the prognostic predictability Table .4 In a3.4Among the metabolites associated with the prognosis of IgAN, glycine was selected as our target urine metabolite for further experimental validation because only glycine was significantly increased in the urine from the IgAN group compared to the disease‐control group. Additionally, this metabolite has been suggested to be associated with a lower risk of incident chronic kidney disease.3.5As glycine is primarily metabolized via the glycine cleavage system, which consists of the T, P, L and H proteins, and via serine hydroxymethyltransferase (SHMT) 1 and 2, we performed immunohistochemistry for these enzymes. The enzymes were mainly detected in kidney tubules Figure . Regardi3.6We found that the expression of protein H of the glycine cleavage system was significantly reduced in the hTECs treated with TNF‐α at 10.0 ng/mL or 20 ng/mL for 1 hour Figure . HoweverThe protein expression of ICAM‐1, pp38 and pp65 was significantly increased in the hTECs treated with 10.0 ng/mL TNF‐α Figure . MoreoveWe next inhibited protein H via the transduction of hTECs with protein H siRNA to explore whether alteration of glycine metabolism through inhibiting the target molecules may replicate the protective effect of high glycine on inflammation in hTECs. Inhibition of protein H by siRNA significantly decreased the endogenous expression of protein H Figure , which a4In this study, we found that glycine levels were increased in the urine of IgAN patients without reduced eGFR compared to those of healthy individuals or patients with MN, MCD, or LN. When assessing the predictive power, measuring urine glycine level showed certain diagnostic value for IgAN. Moreover, higher urinary glycine levels, along with several other metabolites, were significantly associated with the prognosis of early IgAN patients, and the inclusion of urinary glycine levels significantly improved the power of a prognostic prediction model. In the glycine cleavage system, protein H expression was decreased in the tubules of the IgAN patients. Furthermore, we showed that glycine may have a protective role against inflammatory signals by in vitro experiments using hTECs. Inhibition of protein H resulted in an increase in cellular glycine levels along with amelioration of inflammatory signals. Our results suggested that urinary glycine may be a prognostic biomarker for IgAN in those without established kidney function impairment, and glycine metabolism may be a targetable pathway that can improve inflammatory insult in kidney tubules.Although IgAN is defined as a single type of primary glomerulonephritis, the diagnosis mostly depends on morphological changes in kidney pathology, and thus, patients have heterogeneous characteristics and prognosis. Thus, efforts have been made to predict the prognosis of IgAN, and a combination of pathologic grading and clinical characteristics has been used to develop a predictive model with a certain degree of power.in vivo and in vitro experiments.Glycine is a simple amino acid that is present at approximately 170‐330 µmol/L in human or animal blood,in vitro experiment also resulted in amelioration of inflammatory signals in hTECs, glycine may be a targetable metabolite that is associated with prognosis of IgAN.In the current study, we first reported the possibility of a protective role of glycine in the prognosis of early IgAN, which is the most common primary glomerulonephritis worldwide.Our study have several limitations and unanswered questions. First, there were other metabolites, mostly the levels that showed a strong correlation with the levels of glycine, that were associated with the prognosis of IgAN. A future study is warranted to reveal whether they are consequences of altered glycine metabolism or have an independent role in IgAN pathophysiology. Second, although glycine was higher in the IgAN group than in both the healthy control group and the MN/MCD/LN groups, this finding does not mean that the role of glycine is IgAN specific. Given previous reports suggesting various benefits of glycine in ischaemic‐reperfusion injury or inflammatory conditions, the protective role of glycine in the kidney may be due to general mechanisms. This study suggests that glycine can be a prioritized metabolite in early IgAN as the metabolism of glycine was significantly altered in IgAN without prominently reduced eGFR. Third, additional external validation of the results in an independent cohort or a repetitive measurement of urine metabolites during the follow‐up period is necessary to confirm the possible diagnostic or prognostic value of urinary glycine. Despite the relatively large number of IgAN patients, a selection bias remains in this study. Fourth, additional studies are warranted to investigate the possible benefits of interventions targeting glycine in human IgAN. As glycine is an amino acid normally ingested in foods and generally tolerated in humans, additional supplementation with glycine may be considered. However, this study only suggests the possibility but cannot confirm whether increasing the external intake of glycine or targeting the glycine metabolic system can replicate the possible benefits of glycine in human IgAN that was shown in hTECs. Last, our findings may not be applicable to patients with reduced eGFR, as all the study patients had preserved eGFR.In conclusion, urinary glycine levels were increased in IgAN patients without reduced eGFR compared to healthy, MN, MCD, and LN controls. Higher levels of urinary glycine were associated with better prognosis of early IgAN, and the addition of the urine metabolite to the prognostic prediction model of IgAN resulted in improved predictive power. As glycine and related metabolic pathways may have protective roles against inflammatory injury in hTECs, a future study may target glycine when considering interventions to improve the prognosis of IgAN.The authors declare no conflicts of interest.Sehoon Park: Conceptualization ; Data curation ; Formal analysis ; Funding acquisition ; Methodology ; Project administration ; Resources ; Software ; Writing‐original draft (lead); Writing‐review & editing . Jueun Lee: Conceptualization ; Data curation (lead); Formal analysis ; Investigation ; Methodology (lead); Project administration ; Resources ; Software ; Visualization ; Writing‐original draft (lead); Writing‐review & editing . Seung Hee Yang: Data curation ; Formal analysis ; Funding acquisition ; Investigation (lead); Methodology (lead); Resources ; Software ; Supervision ; Validation ; Visualization (lead); Writing‐original draft (lead); Writing‐review & editing . Hajeong Lee: Data curation ; Formal analysis ; Investigation ; Resources ; Software ; Supervision ; Writing‐original draft . Joo Young Kim: Data curation ; Formal analysis ; Investigation ; Methodology ; Resources ; Writing‐original draft . Minkyoung Park: Data curation ; Formal analysis ; Investigation ; Methodology ; Project administration ; Visualization ; Writing‐original draft . Kyu Hong Kim: Data curation ; Formal analysis ; Methodology ; Supervision ; Validation ; Writing‐original draft . Jong Joo Moon: Conceptualization ; Data curation ; Investigation ; Methodology ; Visualization ; Writing‐original draft . Semin Cho: Investigation ; Methodology ; Validation ; Visualization ; Writing‐original draft . Soojin Lee: Data curation ; Formal analysis ; Methodology ; Project administration ; Visualization ; Writing‐original draft . Yaerim Kim: Data curation ; Investigation ; Methodology ; Visualization ; Writing‐review & editing . Hajeong Lee: Data curation ; Funding acquisition ; Investigation ; Project administration ; Supervision ; Validation ; Writing‐review & editing . Jung Pyo Lee: Data curation ; Formal analysis ; Methodology ; Resources ; Software ; Writing‐review & editing . Chang Wook Jeong: Data curation ; Formal analysis ; Investigation ; Methodology ; Supervision ; Writing‐review & editing . Cheol Kwak: Data curation ; Formal analysis ; Methodology ; Supervision ; Writing‐review & editing . Kwon Wook Joo: Conceptualization ; Data curation ; Investigation ; Methodology ; Writing‐review & editing . Chun Soo Lim: Formal analysis ; Investigation ; Methodology ; Software ; Supervision ; Writing‐review & editing . Yon Su Kim: Data curation ; Formal analysis ; Investigation ; Methodology ; Resources ; Supervision ; Validation ; Visualization ; Writing‐review & editing . Geum‐Sook Hwang: Data curation ; Formal analysis ; Funding acquisition ; Investigation ; Methodology ; Software ; Supervision ; Validation ; Visualization ; Writing‐original draft ; Writing‐review & editing (lead). Dong Ki Kim: Conceptualization ; Data curation ; Formal analysis ; Funding acquisition (lead); Investigation ; Methodology (lead); Project administration ; Resources ; Software ; Supervision ; Validation ; Visualization ; Writing‐original draft (lead); Writing‐review & editing (lead).Supplementary MaterialClick here for additional data file.


This study aimed to investigate the relationship between the new-onset hyperintense lesions on diffusion-weighted images (DWI) and the changes of cerebral blood flow (CBF) before and after carotid artery stenting (CAS) in patients with symptomatic unilateral carotid artery stenosis. Twenty-four patients with symptomatic unilateral carotid stenosis (50–99%) were enrolled. Routine head magnetic resonance imaging and three-dimensional pseudo-continuous arterial spin labeling were taken 7 days before the surgery and for four consecutive days post CAS. While the incidence of new DWI lesions were high  and 176 lesions were observed among the 17 cases, there was only one subject showing the symptoms. The majority of the lesions were located at the cortex/subcortex of the ipsilateral frontal and parietal lobes (60.8%) with 92.6% of the lesions size being less than 3 mm. The CBFs in this area were significantly higher than that of the temporal lobe on the first 3 days post stenting (p < 0.05). No periprocedural CBF differences were observed between the two groups, however, the micro-embolism group presented decreased relative CBF in frontal and parietal lobes prior to stenting compared with the non-embolism group. The systolic blood pressure in the micro-embolism group at discharge was significantly lower than that at admission. The high incidence rate of micro-embolism in patients receiving CAS may not be the result of direct changes of hemodynamics in the brain but rather the loss of CBF regulation due to long-term hypoperfusion prior to the stenting. There are approximately 2.7 million new-onset stroke patients each year which counted for one case every 12 s3. According to the mortality rate, one in every five deaths results from stroke, translating to one death from stroke every 21 s2. Approximately 70–80% of the stroke cases are ischemic stroke and a quarter of which are related to carotid artery stenosis, making carotid artery stenosis the primary cause of ischemic cerebrovascular disease4.Cerebrovascular disease is the number one cause of casualty in China6. But some studies showed that microembolization is associated with cognitive impairment8. Gensicke et al. reported that the new DWI lesions after CAS increased future cerebrovascular risk9. In this study, we investigated the relation between new-onset DWI hyperintensity and CBF changes in patients receiving CAS, intending to provide references for customized treatment to carotid artery stenosis.Atherosclerosis causes more than 90% of the carotid artery stenosis and carotid endarterectomy (CEA) had been the main treatment. However, carotid artery stenting (CAS) has become an alternative option to CEA given its broad application and the rapid progress in medical devices and intervention materials and techniques. It was reported that patients received CAS were prone to develop new lesions on DWI without symptomsA total of 24 symptomatic unilateral carotid artery stenosis patients, 20 males and four females with average age of 62.7 ± 5.2 years old, were enrolled into People's Liberation Army General Hospital and Dongfang Hospital of Beijing University of Chinese Medicine between November 2015 and December 2019. All study protocols were approved by the Institutional Review Board of our two hospitals, and written informed consents were obtained from all patients. All methods were performed in accordance with the relevant guidelines and regulations.10 were confirmed by Digital Subtraction Angiography (DSA) and carotid duplex ultrasound. The inclusion criteria were as follows: (1) patients with symptomatic carotid artery stenosis; (2) DSA confirmed unilateral carotid artery narrowing > 50%, contralateral and posterior circulation arteries narrowing < 50%, and cerebral arteries narrowing < 50%; (3) the carotid stenosis was caused by atherosclerosis. Subjects with one of the following conditions were excluded: (1) unilateral carotid artery occlusion or bilateral carotid artery narrowing > 50%; (2) history of stroke or new-onset stroke in the past 2 weeks; (3) patients with symptomatic coronary artery disease; (4) patients with resistant hypertension and diabetes or poor blood pressure and glucose control; (5) patients received CEA due to personal preference or other underlying health conditions making CAS unfavorable; (6) patients who had poor imaging results, did not complete the study, or sign the consent.Patients with moderate to severe carotid artery stenosis All subjects received magnetic resonance imaging (MRI) within seven days before the surgery (after DSA examination) and for 4 consecutive days post CAS, including T1-and T2-weighted imaging, diffusion-weighted imaging (DWI), three-dimensional fast-spoiled gradient-recalled echo sequence (3D-FSPGR), and three-dimensional pseudo-continuous arterial spin labeling (3D-pCASL). The post-labeling delay (PLD) was 2.0 s.MRI was performed with a GE Discovery MR750 3.0 T system  using a 32-channel head coil. The 3D-pCASL was acquired using 3D spiral fast spin echo sequence with the following parameters: 36 slices, thickness = 4.0 mm, field of view (FOV) = 24 × 24 cm, repetition time (TR) = 4844 ms, echo time (TE) = 10.5 ms, spatial resolution = 3.64 mm, number of excitation (NEX) = 3, and the background suppression pulse was on. The parameters for 3D FSPGR were: 156bslices, thickness = 1 mm, FOV = 24 × 24 cm, TR = 8.2 ms, TE = 3.2 ms, bandwidth = 31.2 kHz, inversion time (TI) = 450 ms, matrix = 256 × 256, and NEX = 1.www.fil.ion.ucl.ac.uk/spm/software/Spm8) in Matlab . The MR images were then coregistered to the normalized 3D FSPGR followed by a 6 mm Gaussian smoothing filter. The three-dimentional CBF measures in frontal, parietal, and temporal lobes were then abstracted with DPABI software 13.The 3D-pCASL CBF images were processed by using Function Tool in Advantage Workstation 4.5 software  and transferred for frontal, parietal, and temporal lobes CBF quantification. The 3D FSPGR were first normalized to the Montreal Neurological Institute templates using the SPM8 software collection  up to standard. All procedures were performed under local anesthesia with a EV3 embolic protection device (Spider FX) except one subject received general anesthesia due to intolerance to the operation. Patients were monitored with electrocardiogram post stenting for 24 h or more depending on the circulation stability of the patients. Blood pressure was monitored and the systolic pressure was controlled within 100–130 mmHg to reduce the incidence of hyperperfusion syndrome and the impact of blood pressure fluctuation on CBF. Isoprenaline and dopamine were given if the heart rate was < 50 per minute and the systolic blood pressure (SBP) was < 90 mmHg or the mean arterial pressure (MAP) was < 50 mmHg.15. Continuous hypotension was defined as either SBP < 90 mmHg, MAP < 50 mmHg, or requirement of more than 6 h administration of vasoactive drugs16. MRI were read and analyzed by two experienced physicians and a senior physician participated to the interpretation of the images to help reach consensus in case of disagreement. New-onset DWI hyperintensity was determined as the occurrence of hyperintensity on DWI sequence postoperatively in the area where there was no hyperintensity before operation. Patients were then divided into micro-embolism and non-embolism groups based on the existence of new DWI hyperintensity and CBF and relative CBF  were compared between groups.The heart rate, blood pressure, dynamic changes of CBF, hyperperfusion condition and syndrome, and new-onset hyperintensity on DWI were monitored and recorded. Neurological functions were accessed in clinic or through phone follow-up by using a modified Rankin Scale (mRS) 30 days post stenting. The heart rates and blood pressures were taken four times a day for daily average. Hyperperfusion condition was defined as > 100% CBF increase post surgery and hyperperfusion syndrome was defined as clinical manifestations of migraine, ophthalmalgia, facial neuralgia, epilepsy, and focal neurological dysfunction caused by cerebral edema or hemorrhage excluding any ischemic lesionsStatistical analyses were performed by using SPSS 20.0 software. Measurement data was represented as mean ± SD. Independent sample t-test and paired-sample t-test were used to perform inter- and intra- group comparison respectively when the data were normal distributed. Rank sum test was used for non-gaussian distributed data. Categorical data was represented as percentage and comparison was performed with chi-square test. Bonferroni correction was performed when multiple statistical analyses was used. P < 0.05 was considered statistically significant.The study design was approved by the appropriate ethics review board of Chinese PLA General Hospital and Dongfang Hospital of Beijing University of Chinese Medicine.We declare that all study participants provided informed consent.All patients successfully underwent the surgery without new-onset neurological dysfunctions. Among the two patients (8.3%) with hyperperfusion, one (4.2%) developed hyperperfusion syndrome. Six patients (25%) encountered hypotension and bradycardia. Of the 17 patients (70.8%) with new DWI lesions, one presented nausea, vomiting, vertigo, and nystagmus which were resolved in 2 days, while the rest patients exhibited no clinical symptoms  appeared in the first day post CAS with 96.6% ipsilateral lesions and 92.6% lesion size of less than 3 mm. The lesions located mainly in the cerebral cortex and subcortex with 60.8% occurrences at frontal and parietal lobes and 5.7% and 13.6% at temporal lobe and occipital lobe respectively. We also observed new DWI lesions at centrum semiovale (5.7%), lateral ventricle white matter (6.8%), basal ganglia (1.1%), insula (0.6%), ipsilateral cerebellum (2.3%), and cortical watershed (33.0%) , the non-embolism group presented lower diastolic blood pressure at discharge admission than that on admission .Cerebral blood flows in the frontoparietal and temporal lobes were measured to further investigate the relation between CBF dynamics and the formation of embolism after stenting. All patients exhibited comparable pre-surgery CBFs in these two locations and experienced significant higher CBFs in both ipsilateral and contralateral frontoparietal lobes on day 1–3 post stenting compared with that of temporal lobe. The differences disappeared on day 4. We also observed increased ipsilateral CBFs from baselines in these two locations for 4 consecutive days after the surgery with most patients’ CBF peaked at day 3 before it decreased Table .Table 3TWhen patients were grouped according to the presence of new DWI lesions, we did not see CBF differences in the frontoparietal and temporal lobes between the two groups despite the patients exhibited significant increased ipsilateral CBFs post intervention Tables .Table 4TThe relative CBF (rCBF) in the frontoparietal and temporal lobes were further compared between groups and we observed a significant reduced rCBF of the frontoparietal lobes in the micro-embolism group , whereas the rCBF of temporal lobe showed no differences between the two groups .20. The differences of perioperative stroke are the results of excessive mild non-disabling infarctions. Currently recognized possible mechanisms of ischemic stroke involve hemodynamics mechanism, artery-to-artery embolism, and combination of the two. To investigate the pathogenetic mechanism of perioperative microembolism, we analyzed the size and distribution of the DWI lesions and changes of hemodynamics in patients receiving CAS.Several large-scale randomized clinical trials have reported that patients receiving CAS have greater risk of stroke than CEA patients within 30 days post surgery6. Other studies also indicated that it can be a result of continuous emboli dislodging after the surgery, although the cause and mechanism are still not clear21.In this study, we showed 17 (70.8%) patients with new DWI lesions and most of them were free from symptoms, except one patient experienced vertigo and nystagmus. The new lesions on DWI images are generally considered as embolism resulting from plaque rupture or dislodged during the stenting procedure22, contralateral micro-emboli after intervention may be caused by catheter destruction of the aortic arch plaques22. Our study showing contralateral embolism observable 1 day after surgery is in keeping with the mechanism of catheter induced thrombosis. Although 85.8% of the emboli were observed on day 1 post stenting, the discovery of new lesions on day 2–4 indicated a continuous spontaneous release of unstable emboli.While the majority of perioperative micro-embolism occurred as ipsilateral hemispheric events with a few were located in areas unrelated to the carotid artery therapies24. The less micro-embolic incidences in this area might be the result of relative low blood flows compared with the cortex25. Our study showed that the majority (60.8%) of micro-embolism occurred at the cortex/subcortex of the frontal and parietal lobes, and only 5.7% and 6.8% were observed in centrum semiovale and paraventricular white matter, respectively. In addition, the fact that these micro-embolism did not mainly occur in the cortical watershed territory, suggested the hypoperfusion might not be the causal mechanism of micro-embolism. This view is further strengthened by our observation of reduced cortical CBF and incidences of embolism in temporal lobe post stenting compared with that of the frontal and parietal lobes. The less increase of CBF in temporal lobe can be partially explained by the disproportionate increment of blood flow after stenting as a portion of the temporal lobe, particularly the basal temporal region, is supplied by the posterior cerebral artery.The cerebral cortical arteries, also known as pial collaterals, are small arterial networks joining the terminal branches of anterior, middle, and posterior cerebral arteries along the surface of the brain. The vessel branches penetrate through the cortex, white matter, and the axon fibers with the deepest ones forming the perforating medullary branches supplying the blood to centrum semiovale. The medullary branches locate at the distal end of the internal carotid artery with a relatively low perfusion pressure. As the medullary branches rarely anastomose with the deep perforating branches, hypoperfusion is more prone to occur in centrum semiovale in the presence of severe stenosis of internal carotid artery. It has been shown that large particles may be restricted from entering these blood vessels, however, particles less than 150 μm show equal opportunity of entryWe further grouped the patients into non-embolism and micro-embolism groups based on the presence of new DWI lesions after intervention. Interestingly, we observed a significantly reduced rCBF in the frontal and parietal lobes prior to the surgery in the micro-embolism group, but the basal and post stenting CBFs of the 2 groups were comparable. The relative CBF is associated with impaired regulation of pre-operative CBF, indicating a possible relationship between micro-embolism and impaired CBF regulation caused by long-term hypoperfusion in patients receiving CAS. This phenomenon was not observed in the temporal lobe, probably because it is fed by anterior and posterior circulations whereas the frontal and parietal lobes are fed by anterior circulation only.26. While most of the emboli penetrated through the vessel wall27, a few arrived at the corresponding arteries on the surface of the brain. The blood vessels may be capable of regulating the vasodilation for maintaining the blood supply in the local brain tissue until the emboli are dissolved or expelled. However, ischemia is inevitable when the arteries are in its critical condition and lose the ability of regulating blood supply due to long-term hypoperfusion27. Because of the higher CBF in the frontal and parietal lobes, the microemboli mainly flow to and lodge in these areas. Further research is needed to support our speculation.When the catheter passed the unstable plaque, thousands of the emboli were released and circulated along the edge of the blood vessel wall8. Zhou et al. reported a correlation between the volume of subclinical embolic infarct and long-term cognitive changes after carotid revascularization28. Other animal studies also demonstrated neural and cognitive damages in association with the size of microemboli30. Thus, it is of important to further compare the changes of long-term cognitive function between patients receiving CAS and CEA.Although most micro-embolism do not cause apparent neurological dysfunction, some studies have shown otherwiseIn this study, we could see increased CBF in contralateral hemisphere after stenting of ipsilateral side. For carotid artery stenosis may lead to ipsilateral cerebral hemisphere ischemia, contralateral CBF may supply this area due to the existence of circle of Willis. Similarly, the ipsilateral CBF can flow to the contralateral cerebral hemisphere after stenting through the circle of Willis, which increases the contralateral CBF.We observed that there was no difference in systolic and diastolic blood pressure between the two groups at admission and discharge. But in the microembolism group, the systolic blood pressure at discharge was significantly lower than that at admission. We speculate that patients with impaired CBF regulation are more likely to develop microembolism if their systolic blood pressure drops too much after operation. This result needs to be confirmed by further research.We recognize the limitations of this study as follows: (1) the relative small sample size; (2) we did not analyze the risk factors of the micro-embolism; (3) we did not measure the patients’ cognition; (4) some patients did not show up for the follow-up MRI examination 30 days after the surgery; (5) we performed a relatively short-term follow-up as most subjects came from other provinces.The CAS-induced micro-embolism might not be the result of direct changes of hemodynamics in the brain but rather the loss of CBF regulation due to long-term hypoperfusion prior to the stenting. It might also be related to the excessive decrease of systolic blood pressure post stenting.Supplementary Information.


Hypertension is characterised by a high prevalence, low awareness and poor control among rheumatoid arthritis (RA) patients. Correct blood pressure (BP) measurement is highly important in these subjects. The “unattended” BP measurement aims to reduce the “white-coat effect,” a phenomenon associated with cardiovascular risk. Data on “unattended” BP measurement in RA and its impact on hypertensive organ damage are very limited.BP was measured in the same patient both traditionally (“attended” BP) and by the “unattended” protocol  by a randomised cross-over design. Patients underwent clinical examination, 12-lead electrocardiography and trans-thoracic echocardiography to evaluate cardiac damage.p < .0001). Among the two techniques, only “unattended” systolic BP showed a significant association with left ventricular mass .Sixty-two RA patients  were enrolled. Hypertension was diagnosed in 79% and 66% of patients according to ACC/AHA and ESC/ESH criteria, respectively. Concordance correlation coefficients between the two techniques were 0.55  for systolic BP and 0.73  for diastolic BP. “Unattended” (121.7/68.6 mmHg) was lower than “attended” BP (130.5/72.8 mmHg) for systolic and diastolic BP  BP and more closely associated with LV mass. In these patients, the “unattended” automated BP measurement is a promising tool which requires further evaluation. Several studies suggest that the risk of major cardiovascular (CV) events, such as stroke, myocardial infarction and congestive heart failure, is increased in patients with rheumatoid arthritis (RA) when compared with the general population . Among tSystolic Blood Pressure Intervention Trial (SPRINT), in which 9361 hypertensive patients were randomised to 2 different BP targets (<140 mmHg versus <120 mmHg) [Since BP is a highly variable biological trait ,7, the d20 mmHg) . The tri20 mmHg) . Some da20 mmHg) . The “whThus, the present study was designed to specifically compare the “unattended” with the traditional (“attended”) BP measurement technique and to investigate its association with cardiac organ damage in a cohort of RA patients.From February 2019 to June 2020, consecutive Caucasian RA outpatients attending the Rheumatology Unit and meeting the American College of Rheumatology (ACR) or the 2010 ACR/European League Against Rheumatism classification criteria were included in the study ,16. PatiThe Disease Activity Score in 28-joint (DAS28)-ESR and the Clinical Disease Activity Index (CDAI) scores were assessed as measures of disease activity . PatientFinally, self-reported and medical chart-derived data about current use of lipid-lowering medications, anti-hypertensive drugs, insulin, insulin analogs, non-insulin oral hypoglycaemic drugs, non-steroidal anti-inflammatory drugs (NSAIDs), ongoing corticosteroids and/or conventional synthetic/biological disease modifying anti-rheumatic drugs for RA were collected.The study was conducted in collaboration with the Cardiologic staff of the same hospital. The protocol, conforming to the ethical guidelines of the Declaration of Helsinki, was approved by the local Regional Ethical Committee  and all patients provided written informed consent.All BP measurements were scheduled in the morning of the same day and the unattended and attended measurement techniques were performed in random order according to a cross-over design. BP was measured in the same patient both traditionally (“attended” BP) and by the “unattended” protocol. We used the same device, an Omron HEM 907  for attended and unattended BP measurements. The device model was the same as that used in the SPRINT trial . For unaHypertension was defined by a traditional (“attended”) BP ≥140/90 mmHg as suggested by the European Society of Cardiology/European Society of Hypertension (ESC/ESH) Guidelines , or ≥1303) (10) according to the following formula: Cornell-Body Mass Index (BMI) product (mV·kg/m2) = ((R wave amplitude in lead aVL + S wave depth in lead V3) × BMI) (20).We recorded standard 12-lead ECG in all subjects during a brief end-expiratory apnoea. We defined electrographic left ventricular hypertrophy according to a validated method developed to correct for obesity . The met2.7) [The M-mode echocardiographic study of the LV was performed under 2 D control. Only frames with optimal visualisation of interfaces and showing simultaneous visualisation of septum, LV internal diameter and posterior wall have been used for reading. We reported elsewhere the details about reading procedures and reproducibility of echocardiographic measures in our laboratory . We calc2.7) . In our 2.7) . LV mech2.7) . A depre2.7) ,27 and a2.7) .http://www.R-project.org) were used. Data are presented as mean ± standard deviation (SD) for continuous variables and proportions for categorical variables.STATA 15  and R software version 3  are reported in As reported in Prevalence of HT was 66% according to the ESC/ESH Guidelines, and 79% according to the ACC/AHA Guidelines. Of note, among patients with history of HTN, none had BP values < 130/80 mmHg. Furthermore, 12 patients (48%) without prior diagnosis of HTN exhibited BP values ≥ 130/80 mmHg.p > .05).Using definition of HT by ACC/AHA Guidelines, all patients classified as normotensive (or with controlled BP) by “attended” BP were also normotensive (or with controlled BP) by “unattended” BP. Conversely, among the 48 patients classified as HT (or with uncontrolled hypertension) by “attended” BP, 33 (69%) were normotensive (or with controlled BP) by “unattended” BP (white-coat effect). Main characteristics  showed similar distributions between patients with or without white-coat effect  and to the ACC/AHA guidelines (attended BP <130/80 mmHg), respectively.p < .0001). p = .887) and diastolic (p = .215) BP. Furthermore, we tested the influence of the following covariates: age, sex, disease duration, and use of BP lowering drugs and corticosteroids. The association between “attended” and “unattended” BP (for both systolic and diastolic components) were unaffected by these variables .On average, BP was lower with the ‘unattended’ than the ‘attended’ protocol  and unattended  systolic BP. There was a generally weak association between LV mass and BP measured with the two protocols. However, the degree of association was stronger with unattended compared with attended BP . Among other characteristics of study population, only age showed a significant association with LV mass .r = 0.03/r = 0.02 and r = 0.16/0.10 respectively), LV mass (r = 0.14) endocardial shortening fraction (r = 0.17) or mid-wall shortening fraction (r = 0.04). Similarly, DAS28 was not associated with unattended or attended systolic/diastolic BP (r = 0.03/r = 0.06 and r = 0.22/0.06 respectively), LV mass (r = 0.09) endocardial shortening fraction (r = 0.21) or mid-wall shortening fraction (r = 0.03). When disease remission was defined by CDAI ≤ 2.3 plus DAS28 < 2.6, 30% of patients were classified as in remission and the remaining 70% not in remission. There were no statistically significant differences between the two groups in terms of unattended (118/65 mmHg vs 117/65 mmHg) and attended (120/67 mmHg vs 127/71 mmHg) BP, LV mass (31 vs 35 g/height(m)2.7), endocardial shortening fraction (31% vs 40%) and mid-wall shortening fraction (15% vs 17%).CDAI did not show any statistically significant association with unattended or attended systolic/diastolic BP  BP and more closely associated with LV mass, an established index of target organ damage and independent CV prognostic marker ,34,35. TThe strong epidemiological link between RA and CV disease may be related to multiple factors which include inflammatory background, immune-mediated mechanisms, concomitant therapies and the increased prevalence of traditional CV risk factors ,36. In tIn this context, it is important to investigate which type of BP measurement is more closely associated with target organ damage and, hopefully, prognosis. In addition to 24-h BP monitoring  and selfet al as compared to the present study may account for such inconsistency and reflect possible different effects of inflammatory cytokines on myocardial structure. Moreover, the cross-sectional nature of the study and the punctual evaluation of disease activity preclude from quantifying the burden of inflammation patients were exposed over time and its long term effect on myocardial structure. Finally, other limitations include the small sample size of our cohort and the evidence that majority of our patients were in remission to low disease activity at inclusion. In this setting, a recent study evaluating cardiac resonance imaging indices of structure, function and fibrosis in a cohort of RA patients with low to moderate disease activity did not found evidence of increased diffuse myocardial fibrosis or inflammation [In our study, we did not detect any association between disease activity and “attended” or “unattended” BP values. Disease activity, moreover, was not associated with echocardiographic measures of organ damage, at first glance contrasting previous reports in RA patients . Left veammation , reinforammation . Notablyammation . Moreoveammation . SimilarIn conclusion, the present study highlights the importance of a correct measurement of BP in patients with RA and provides the first demonstration that, by reducing or eliminating the “white-coat effect” phenomenon, the “unattended” BP measurement may be a reliable method for evaluation of BP values in these patients as it strictly correlates with measures of HT-induced target organ damage. Given the relevance of HT as CV risk factor in RA patients and its detrimental role on CV outcome, we suggest that this method may be employed in future studies aimed to assess prevalence of HT in RA patients. Larger prospective studies are needed to evaluate accuracy and reproducibility of the novel “unattended” BP measurement in comparison with the traditional measurement in patients with systemic rheumatic diseases.


Data on the long-term effects of neonatal acute kidney injury (AKI) are limited.th percentile) according to gestational age, weight, and postnatal age. Clinical and laboratory features in the neonatal AKI period were recorded for 72 cases; at long-term evaluation (2–12 years), kidney function tests with glomerular filtration rate (eGFR) by the Schwartz formula, microalbuminuria, office and 24-h ambulatory blood pressure monitoring (ABPM), and kidney ultrasonography were performed.We invited 302 children who had neonatal AKI and survived to hospital discharge; out of 95 patients who agreed to participate in the study, 23 cases were excluded due to primary kidney, cardiac, or metabolic diseases. KDIGO definition was used to define AKI. When a newborn had no previous serum creatinine, AKI was defined as serum creatinine above the mean plus two standard deviations (SD) (or above 97.52. Office hypertension (systolic and/or diastolic BP ≥ 95th percentile), microalbuminuria (> 30 mg/g creatinine), and hyperfiltration (> 187 ml/min/1.73 m2) were present in 13.0%, 12.7%, and 9.7% of patients, respectively. ABPM was performed on 27 patients, 18.5% had hypertension, and 40.7% were non-dippers; 48.1% had abnormal findings. Female sex was associated with microalbuminuria; low birth weight  and low gestational age (< 32 weeks) were associated with hypertension by ABPM. Twenty-three patients (33.8%) had at least one sign of microalbuminuria, office hypertension, or hyperfiltration. Among 27 patients who had ABPM, 16 (59.3%) had at least one sign of microalbuminuria, abnormal ABPM (hypertension and/or non-dipping), or hyperfiltration.Forty-two patients (58%) had stage I AKI during the neonatal period. Mean age at long-term evaluation was 6.8 ± 2.9 years (range: 2.3–12.0); mean eGFR was 152.3 ± 26.5 ml/min/1.73 mEven children who experienced stage 1 and 2 neonatal AKI are at risk for subclinical kidney dysfunction. Non-dipping is seen in four out of 10 children. Long-term follow-up of these patients is necessary. The incidence of acute kidney injury (AKI) in newborns is high compared to other age groups of childhood. Its incidence is 20–40% in neonatal intensive care units (NICUs) –3; low bThere is limited knowledge about the long-term effects of neonatal AKI, such as hypertension, decreased kidney function, and tubular malfunction. Kidney dysplasia, obstructive uropathy, cortical necrosis, and cystic kidney diseases are risk factors for progression to CKD in the future . In addiWe aimed to assess the prevalence of long-term (2–12 years) kidney dysfunction , based on clinical indicators including ambulatory blood pressure monitoring (ABPM), and to determine associated factors in a case series of children who had suffered from AKI in the neonatal period .th percentile) according to birth characteristics  and postnatal age [Medical records of patients hospitalized in newborn wards of Hacettepe University Ihsan Dogramaci Children’s Hospital from January 2000 to December 2009 were retrospectively reviewed to identify the patients who suffered from AKI. AKI was defined as an increase in serum creatinine level of 0.3 mg/dl or more within 48 h or 50% or more from the previous lowest value within 7 days, based on the Kidney Disease: Improving Global Outcomes (KDIGO) workgroup’s definition of AKI modified for neonates, as used in previous neonatal studies . We exclatal age –25.Of the patients who had developed neonatal AKI according to the defined criteria, 347 patients survived and were discharged. Of those, 27 patients (7.8%) had died following discharge. Of 302 parents or caregivers who were sent invitation letters, 109 responded by telephone, and 95 agreed to participate in the study. Twenty-three patients with primary kidney, cardiac or metabolic diseases that may affect long-term evaluation were excluded. In total, 72 patients were analyzed, including 46 males (63.9%) and 26 females (36.1%) , AKI features . AKI severity was classified according to KDIGO methods.Patients were asked about their current medical condition, chronic diseases, and medications. Physical examination, weight, height, body mass index (BMI) measurement; laboratory studies including complete blood count, kidney function test, venous blood gas, urinalysis, urinary microalbumin, creatinine, phosphate; kidney ultrasonography (US), kidney Doppler US, auscultatory office blood pressure (BP) measurement, and 24-h ABPM were performed.Estimated glomerular filtration rate (eGFR) was calculated based on the Schwartz formula [Serum creatinine was measured with Jaffe method .  formula .Hyperfiltration: Mean GFR between 2 to 12 years of age is 133 ± 27 ml/min/1.73 m2 [2 (> mean + 2 SD) [/1.73 m2 , 29. GFR + 2 SD) , 27.Microalbuminuria was defined as a urinary microalbumin (mg)/creatinine (g) ratio (ACR) above 30 in a spot urine sample.Tubular phosphorus reabsorption (TPR) was calculated; TmP/GFR was defined as maximum serum phosphorus level adjusted to GFR and measured as TmP/GFR = TPR x serum phosphorus level. The normal range is 4–6 mg/dl.Tubular function disorder was defined as TPR level below 85% and/or venous blood HCO3 level below 20 mmol/L.th percentile was defined as hypertension.Standard procedures were applied for office BP measurement using the auscultatory method; BP was measured three times with an interval of 3 min between measurements and the average of the last two was used. The patient’s BP percentile was determined according to age, gender and height percentile according to 2016 European Society of Hypertension guidelines . The preth percentile by sex and age) were calculated for the 24-h period, daytime (from 08.00 am to 08.00 pm), and nighttime (from midnight to 06.00 am) periods. SD scores (SDS) for SBP, DBP and MAP were determined according to the standard values adjusted by age and gender [th percentile, with normal ABPM profile. Masked hypertension was defined as office BP < 95th percentile and ABPM hypertension [24-h ABPM was performed in patients with height ≥ 120 cm and ≥ 6 years of age; patients with poor cooperation or who were not able to carry the equipment for 24 h were excluded. Patients were not hospitalized during ABPMs and they performed normal daily activities. Spacelabs ABPM devices (Model no: 90207–30) were used. Measurements were performed every 15–20 min during waking hours (day) and every 30 min during sleep periods (night). A valid ABPM profile was defined as follows: 24-h recording with at least 70% of expected measurements, at least 40 to 50 readings for a 24-h period; and at least two valid daytime and one valid nighttime measurement per hour , 30. Thed gender . The prertension .Patients underwent kidney US and kidney Doppler US in the supine position. All evaluations were performed by a single pediatric radiologist (BO). Kidney size, parenchymal thickness, parenchymal echogenicity, and the kidney Doppler indices  were evaluated by US. Kidney vertical lengths were evaluated according to age, sex, weight, and height, and percentiles were determined .2). Three kidney dysfunction sets (KDS) were defined for the evaluation. KDS-1 was defined as the presence of microalbuminuria and/or hypertension by office BP and/or hyperfiltration (eGFR > 187 ml/min/1.73 m2); KDS-2 was defined as the presence of microalbuminuria and/or hypertension with ABPM and/or hyperfiltration. KDS-3 was defined as the presence of microalbuminuria and/or abnormal ABPM (hypertension and/or non-dipping) and/or hyperfiltration. Univariate analysis was used to evaluate the following as independents factors for the presence of proteinuria, hypertension, hyperfiltration, KDS-1, KDS-2, and KDS-3: age, gender, birth weight, gestational age, weight according to gestational age, systemic diseases in the neonatal period, mechanical ventilation, surgical procedure before AKI, age at AKI diagnosis, total fluid intake before AKI, aminoglycoside use, indomethacin use, radiocontrast use, vasopressor drug use, oliguria, AKI stage, and KRT. Since the significance of hyperfiltration for long-term kidney dysfunction is still unclear; we additionally, repeated our analyses excluding hyperfiltration from the composite outcome.Long-term kidney dysfunction was defined as the presence of at least one sign of microalbuminuria (ACR > 30), hypertension (office or ABPM), or hyperfiltration , and the categorical variables were calculated as the number of cases and percentage. The categorical variables were evaluated by Pearson’s chi-square or Fisher’s exact test. Student’s t-test and Mann–Whitney U test were used to determine the significance of the difference between the groups. A p-value of ≤ 0.05 was considered to be statistically significant.Baseline clinical features of the patients are summarized in Table p = 0.247). Clinical and laboratory characteristics of patients at long-term evaluation are summarized in Table 2 (range: 99–229 ml/min/1.73 m2). Mean eGFR levels were 154.0 ± 29.3 ml/min/1.73 m2 in males and 151.2 ± 21.3 ml/min/1.73 m2 in girls (p = 0.785), and they were 161.3 ± 30.8 ml/min/1.73 m2 between the ages of 2 to 6 and 145.9 ± 21.2 ml/min/1.73 m2 between the ages of > 6 to 12 years (p = 0.014).The mean age of the participants at the time of assessment was 6.8 ± 2.9 years (range: 2.3–12.0 years). The mean ages of boys (6.5 ± 2.8 years) and girls (7.4 ± 3.0 years) were comparable (n = 8) or only systolic (n = 1) BP ≥ 95th percentile.Office auscultatory BP measurements were available for 69 patients; BP was not measured in three patients due to poor cooperation. Nine patients (13.0%) had either systolic and diastolic (n = 23), who were not able to stay overnight (n = 17), who gave insufficient cooperation (n = 4), and who did not accept (n = 1).24-h ABPM measurements were available for 27 patients (6.6–12.0 years). ABPM was not performed in patients who were shorter than 120 cm  or elevated BP load  during 24-h or daytime or nighttime. Eleven patients (40.7%) had systolic  or diastolic  non-dipper; only 14 patients (51.9%) had a normal ABPM pattern . When combined with office BP measurement, 19 patients (70.4%) had normal BP, three patients (11.1%) had white coat hypertension, four patients (14.8%) had masked hypertension, and one patient (3.7%) had elevated BP with both office BP and ABPM.Detailed results of the 24-h ABPM are presented in Table nd percentile, IQR 51st percentile for the right kidney; 57th percentile, IQR 48th percentile for left kidney), and the mean parenchymal thickness  had minor abnormal kidney US findings, including unilateral ectopic kidney  and minimal dilatation of the collecting system . Doppler US results were normal in all cases.Kidney and Doppler US were performed in 71 patients. The median kidney longitudinal length  had at least one sign of KDS-1; among 27 patients who had ABPM, 11 (40.7%) and 16 (59.3%) had at least one sign of KDS-2 and KDS-3, respectively , 12.7% (9 of 71), and 9.7% (7 of 72) of patients, respectively. None of the patients had an eGFR < 90 ml/min/1.73 mThe distribution of kidney dysfunction parameters according to AKI stage groups are shown in Fig. p = 0.010). A higher percentage of girls also met KDS-1 criteria compared to boys . The rate of hyperfiltration (GFR > 187 ml/min/1.73 m2) in the large for gestational age (LGA) group was higher with a borderline significance compared to small for gestational age (SGA) and appropriate for gestational age (AGA) . However, analysis using the Bonferroni method indicated that the comparisons between each paired group were not significantly different. ABPM hypertension was more frequent in patients with a birth weight less than 1,500 g , and in patients with a gestational age less than 32 weeks . No significant association was found with other factors.Girls had a higher rate of microalbuminuria than boys , proteinuria (12.7%), and hyperfiltration (9.7%). To our knowledge, this is the first study that analyzed ABPM in a cohort with neonatal AKI, and it was found to be abnormal in approximately 50% of cases.The distribution of gestational age and birth weight were representative. Systemic diseases among the pre-renal causes and risk factors for AKI, such as sepsis, PDA, RDS, and dehydration rates, were found to be high, and these rates were similar to those found in other studies , 34. It n = 20) who weighed < 1,000 g [n = 25) and the non-AKI group (n = 49), the mean GFR was lower in children with very low birth  independent of AKI [Routine serum biochemistry values for kidney function were normal at the re-evaluation period. Abitbol et al. showed high serum creatinine and low GFR values in 9 (45%) patients in a long-term follow-up study of newborns with AKI . There is evidence that hyperfiltration is a marker for kidney dysfunction, and these patients may be considered as stage 1 CKD [2 (> mean + 2SD). In the study performed by Askenazi et al., hyperfiltration (defined as > 150 ml/min/1.73 m2) was present in 31% (9 out of 29 patients) of patients with AKI (age of diagnosis 6.4 ± 5.8 years) after 3–5 years follow-up [Seven patients (9.7%) had hyperfiltration . The prevalence of hypertension in our population was shown to be 6.1% in a population based study covering 3622 children aged 5–18 years (42). One patient had isolated systolic hypertension, and eight patients had both systolic and diastolic hypertension. In other studies, examining the long-term effects of patients with AKI, the frequency of hypertension varied between 3 and 20% %. The pr, 43. Anip = 0.047), and in patients with a gestational age < 32 weeks . As suggested in the Brenner hypothesis, low nephron numbers or nephron deficiency, such as low birth weight, SGA, preterm birth, may increase the risk of hypertension and kidney disease in the long-term into adulthood [p = 0.5); while diastolic (27% vs. 17% p < 0.01) and systolic  BP loads were higher in the very low birth weight group [p < 0.05) [ABPM was performed in 27 patients (37.5%). Five patients (18.5%) had hypertension by ABPM. ABPM hypertension was more frequent in patients with a birth weight < 1,500 g  . We hypoThe non-dipping phenomenon detected by ABPM is known to be associated with metabolic syndrome, diabetes mellitus, obesity, hypertensive end-organ damage, and cardiovascular diseases . In our Although we did not detect any significant anomalies in our study, kidney volume loss was identified as a long-term effect of AKI in the neonatal period , 35, 38.One- to two-thirds of the patients had at least one long-term kidney dysfunction. Notably, the correlation between microalbuminuria, hyperfiltration, and hypertension was not remarkable. Longitudinal studies are needed to understand the evolution of these abnormalities, their interaction, and the significance of the non-dipping pattern.We are aware of the limitations of our study. The cross-sectional design was the first limitation; as a result, we were not able to examine changes over time. Second, eGFR was based on serum creatinine. Third, we were not able to evaluate markers for renal tubular injury other than TPR and metabolic acidosis. Fourth, lack of a non-AKI comparison group is a limitation of the study. Although the follow-up duration in our cohort is comparable to other studies, a longer follow-up could be associated with higher prevalence of the outcomes. However, compared to previous studies, this study was strengthened by a relatively larger patient group, long-term follow , exclusion of diseases that may interfere with long-term outcome, and performance of ABPM.In conclusion, in a cohort of patients mainly with stage 1 and 2 AKI during the neonatal period and excluding those with primary diseases that may affect the kidney outcome, we found an increased rate of office hypertension, glomerular hyperfiltration, and microalbuminuria approximately 7 years after the AKI episode. Moreover, we showed that majority of patients had abnormal ABPM pattern with a very high rate of non-dipping. Long-term and longitudinal follow-up of these patients is necessary to shed light on the significance of these parameters and the value of any intervention.


The aim of this review was to explore existing evidence from studies conducted on humans and summarize the mechanisms of action of dietary polyphenols on vascular health, blood pressure and hypertension. There is evidence that some polyphenol-rich foods, including berry fruits rich in anthocyanins, cocoa and green tea rich in flavan-3-ols, almonds and pistachios rich in hydroxycinnamic acids, and soy products rich in isoflavones, are able to improve blood pressure levels. A variety of mechanisms can elucidate the observed effects. Some limitations of the evidence, including variability of polyphenol content in plant-derived foods and human absorption, difficulty disentangling the effects of polyphenols from other dietary compounds, and discrepancy of doses between animal and human studies should be taken into account. While no single food counteracts hypertension, adopting a plant-based dietary pattern including a variety of polyphenol-rich foods is an advisable practice to improve blood pressure. Dietary risk factors represent a heavy burden for global chronic, non-communicable diseases . There iPolyphenols are a large group of plant secondary metabolites that exert a number of biological activities involved in plant defense, including antioxidant and antibacterial actions . While aPolyphenols are found in different quantities and proportions in most edible and wild plants, fruits, and plant-derived beverages, but their consumption in humans is widely affected by the variety of the diet and, specifically, of plant-derived foods. In fact, consuming a high proportion of fruits and vegetables generally leads to a high dietary content of flavonoids ; populatIn the most recent meta-analysis on the relation between dietary flavonoid consumption and cardiovascular outcomes  conducteWe recently performed a systematic review and meta-analysis of observational studies on dietary polyphenol consumption and risk of hypertension including 15 cross-sectional investigations and 7 prospective cohorts . The metConcerning polyphenol-rich foods, a comprehensive summary of evidence from umbrella meta-reviews showed a decreased risk of hypertension associated with higher consumption of plant-based foods, including fruit, whole grains, nuts, and legumes/pulses ,20,21,22A summary of the main results from meta-analyses of randomized controlled trials (RCTs) is presented in p = 0.02; I2: 96%) [p = 0.0001) and diastolic blood pressure  [p < 0.001) [Some studies investigating polyphenol supplementation consistently revealed null effects on blood pressure, suggesting that the lack of significant results may be due to the limited number of included studies and their quality; among the existing meta-analyses, supplementation with hesperidin (a major flavanone contained in citrus fruits) , genisteI2: 96%)  and loweI2: 96%) . A meta- = 0.01) , despite = 0.01) . A meta- = 0.01) . Finally< 0.001) . Howeverp = 0.005) and diastolic blood pressure , while no effects were found on VCAM  and ICAM  [p < 0.001; diastolic, −0.20, p < 0.001) [p = 0.02) and diastolic blood pressure by −1.78 mmHg  and elevated sVCAM-1 levels by 14.57 ng/mL  [p < 0.001) and diastolic blood pressure  after pomegranate juice (rich in anthocyanin) consumption [Dietary intervention trials aiming to investigate the role of dietary polyphenols on blood pressure are typically characterized by supplementation with a polyphenol-rich food (or food group) in comparison to a control group. Regarding the potential effect of fruits on blood pressure, a recent meta-analysis on flavonoid-rich fruits  including 15 RCTs and 572 participants showed no effect of flavonoids on systolic or diastolic blood pressure when compared to the placebo; however, pooled results from two crossover RCTs evidenced a reduction in systolic blood pressure . Among so 0.275) . Similar< 0.001) . These r = 0.02)  and chok = 0.02) . Concern = 0.02) . Among ssumption . Anotherp = 0.04; I2 = 45%) and diastolic blood pressure  [p = 0.007) was found, whereas changes in flow-mediated dilation and diastolic blood pressure were not significant [Although no significant association between total vegetable intake and risk of hypertension has been found in observational studies, a meta-analysis of RCTs on garlic (rich in hydroxycinnamic acid derivatives) revealed lowering effects on systolic  and diastolic blood pressure  . Supplem2 = 43%) . A meta-2 = 43%) ,50. Howe2 = 43%) . In contnificant . Similarnificant .p = 0.009, and −1.76 mmHg, 95% CI: −2.57 to −0.94, p < 0.001, respectively) [p = 0.03; I2 = 89%) and diastolic blood pressure by 1.47 mmHg  [Concerning cocoa products (rich in flavan-3-ols), a meta-analysis of 35 trials (40 treatment comparisons) involving 1804 mainly healthy participants showed a significant blood pressure-reducing effect of flavanol-rich cocoa products compared with the control in trials  . A meta-2 = 45%) .p = 0.04, and −1.17 mmHg, 95% CI: −2.18 to −0.16, p = 0.02, respectively) and diastolic blood pressure , although with some evidence of heterogeneity between studies [p = 0.004) and diastolic blood pressure  [While no intervention trials are available for regular coffee consumption and blood pressure, a meta-analysis of nine RCTs on green coffee extract supplementation showed a significant reduction in systolic  and diastolic blood pressure  with low heterogeneity among the studies . In cont studies ,59. An a= 0.029) .p = 0.011; I2 = 89%) and diastolic blood pressure , although the overall level of evidence is relatively weak due to the high heterogeneity between studies and the small number of participants [p = 0.38; I2 = 79% for systolic blood pressure; −2.70 mmHg, 95% CI: −5.71 to 0.31, p = 0.08; I2 = 78% for diastolic blood pressure) [Among other foods rich in polyphenols, ginger is rich in gingerols and it has been studied for its potential effects on blood pressure; a meta-analysis including six RCTs and 345 participants showed that ginger supplementation would reduce both systolic  .A summary of the potential mechanisms of action through which polyphenols may affect endothelial health and reduce the risk of hypertension is shown in 2+ channels) or indirectly , eventually limiting construction and leading to vasorelaxation [Vascular functions, including vascular tone maintenance, redox balance, and inhibition of platelet aggregation and coagulation, are key factors for endothelial health and the prevention of hypertension, atherosclerosis, and CVD . Endothelaxation . Howeverlaxation .Oxidative stress following free radical and reactive oxygen species (ROS) production is a cornerstone process in aging and disease, including atherosclerosis and CVD . RegardiInflammation plays a central role in numerous non-communicable diseases, including cardiovascular disorders . ConcernProinflammatory stimuli lead to changes in the endothelial phenotype, leading to damage of barrier function and upregulation of adhesion molecules expression, including vascular cell adhesion molecule-1 (VCAM-1) and intercellular adhesion molecule (ICAM-1) . Such chFirmicutes and Proteobacteria from carnitine and choline-rich foods , has been demonstrated to induce vascular inflammation through mitogen-activated protein kinase (MAPK) and NF-κB signaling [Dietary polyphenols have been described to be of great relevance for the composition of the colonic bacterial flora . Althougignaling . Polypheignaling , with siignaling . Additioignaling . Other iignaling . In vivoignaling , anthocyignaling , and flaignaling , have beExisting evidence from meta-analyses is generally limited by common general limitations, such as a small number of studies or participants, involvement of manufacturers, and scarce clinical relevance of some significant results (not enough variation in blood pressure). Moreover, while there is a certain agreement between studies conducted on humans and mechanistic studies from the laboratory setting, some limitations of the retrieved evidence may stem from the following: (i) large variability of polyphenol content in plant-derived foods  as well as in absorption of polyphenols among humans; (ii) dietary sources of polyphenols are typically rich in other compounds that may exert cardioprotective effects, including fiber or monounsaturated fatty acids; thus, disentangling the unique effects of polyphenols is rather difficult when studying food groups; (iii) mechanistic studies conducted on cells and animals often do not take into account the cooking processes, which may lead to a loss in total polyphenol or transformation of specific molecules into others with different biological activities; and (iv) discrepancy between in vitro and in vivo doses .In conclusion, evidence from human studies suggests that some polyphenol-rich foods exert positive effects on blood pressure levels. However, given the small clinical effects reported, the real-world implications for their consumption rely on their inclusion in a healthy diet rather than consumption of an individual food. There is no singular mechanism nor individual polyphenol compound that may explain the pathway to improve endothelial health and prevent hypertension and CVD. On the contrary, it is likely that the health benefits of plant-based diets rich in polyphenols may depend both on the quantity and the variety of compounds acting through several pathways, leading to synergistic actions toward health. Furthermore, a recommendation for the adherence to a healthy diet rich in plant-based foods, providing not only substrates to the gut microbiome  and important co-factors playing a role in polyphenol bioavailability but also influencing gut microbiota profile, could strengthen the beneficial effects of polyphenols toward cardiovascular health. Although recommendations on the consumption of single foods are inappropriate, it can be concluded that a diet rich in multiple polyphenol-rich foods is likely to improve vascular health and reduce the risk of hypertension.


Atrial Fibrillation (AF) is a common cardiac arrhythmia and has been identified as a major risk factor for acute ischemic stroke (AIS). Gender differences in the disease process, causative mechanisms and outcomes of AF have been investigated. In the current study, we determined whether there is a gender-based disparity in AIS patients with baseline AF, and whether such a discrepancy is associated with specific risk factors and comorbidities.Baseline factors including comorbidities, risk and demographic factors associated with a gender difference were examined using retrospective data collected from a registry from January 2010 to June 2016 in a regional stroke center. Univariate analysis was used to differentiate between genders in terms of clinical risk factors and demographics. Variables in the univariate analysis were further analyzed using logistic regression. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for each factor were used to predict the increasing odds of an association of a specific comorbidity and risk factor with the male or female AIS with AF.P = 0.016), sleep apnea , and higher serum creatinine  levels were found to be significantly associated with the male gender. Higher levels of HDL-cholesterol , LDL-cholesterol , and the inability to ambulate on admission to hospital  were associated with females.In the population of AIS patients with AF, a history of drug and alcohol use (OR = 0.250, 95% CI, 0.497–1.006, Our findings reveal that in the AIS patients with atrial fibrillation, migraines, HDL, LDL and poor ambulation were associated with females, while drugs and alcohol, sleep apnea, and serum creatinine level were associated with male AIS patients with AF. Further studies are necessary to determine whether gender differences in risk factor profiles and commodities require consideration in clinical practice when it comes to AF as a risk factor management in AIS patients. Atrial Fibrillation (AF) is a significant public health concern due to its growing prevalence and association with increased risk of cardiovascular events and death . It is aAlthough AF is less prevalent in females than in males, females with AF have an overall greater risk of stroke than males with AF , 7. StudThis is a population based cross sectional study for the retrospective analysis of patients’ data collected from PRISMA Health ischemic stroke population. This study was approved by the PRISMA Health Ethics Committee. PRISMA Health is a primary stroke center serving patients from an 8-county region located in upper South Carolina. Data for all patients treated between January 2010 and December 2016 in the Stroke Unit of PRISMA Health were used in this study. Stroke was defined according to the World Health Organization (WHO) criteria, as “a rapidly developing clinical symptoms of focal or global disturbance of cerebral function, lasting more than 24 h, with no apparent cause other than that of vascular origin” . In thisFor each AIS patient, demographic information, risk factors, comorbidities or past medical history, and standard laboratory values were collected and analyzed. The registry has been described in previous retrospective studies –17. For 2 tests to identify demographic, comorbidities, risk factors, and laboratory values associated with males or females. For ordinal and dichotomous variables (such as ambulatory status or gender), a Pearson x2 test was used while a Student’s t-test was performed for all interval variables (such as age or BMI). A second univariate analysis was performed to differentiate between patients with and without a history of atrial fibrillation. Thereafter, three binary logistic multivariate analyses were performed; the first identified factors associated with gender in the whole AIS patients with and without AF. The dependent variable includes male or female patients. The second analysis focused on factors associated with males or females in the AIS population without AF, while the final analysis identified factors associated with males or females in the AIS population with baseline AF. These analyses were post-hoc adjusted logistic regression with a backward selection method. We used the backward approach because it has the advantage of considering the effects of all parameters simultaneously in fitting our regression models. This allows us to address the potential problem of multicollinearity by reducing the number of predictors and resolving the problem of overfitting. In the logistic regression, the association between the independent variables  and male or female (dependent variables) was determined for the atrial fibrillation and no atrial fibrillation group. The primary outcome is the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for each factor associated with each gender group, fully adjusting for all confounding factors identified in our univariate analyses. The resulting ORs were used to predict the increasing odds of an association of a specific factor with the male or female AIS with or without AF. A probability value of < 0.05 was considered statistically significant in the analyses. The Hosmer-Lemeshow test was used to validate our model, and the overall correct classification percentage including the area under the Receiver Operating Curve (ROC) for score prediction was determined to test the sensitivity, specificity and accuracy of our logistic model.We conducted descriptive analyses to determine the distribution of the demographic data and risk factors in the AIS population using SPSS 24.0 . All data have been previously normalized using the Shapiro–Wilk and Levene test to assess the data for homogeneity. Categorical variables were presented as proportions or expressed as frequencies (percentage) and quantitative variables as mean ± standard deviation. Variables were compared between male and female patients using Pearson xA total of 5469 AIS patients were identified. Of this, 2662 were males and 2807 were females. Table Table For AIS patients with a past medical history of AF, females were older (80.09 ± 10.48 vs 74.01 ± 11.01), use antidepressants (15.7% vs 11.0%), HDL-cholesterol (45.39 ± 13.34 vs 38.33 ± 12.40), and presents with higher HRT (2.6% vs 0.0%), migraines (1.8% vs 0.3%), LDL-cholesterol (95.52 ± 35.11 vs 86.78 ± 33.64), and heart rate (84.72 ± 20.64 vs 81.79 ± 19.79). Male AIS patients with AF were more likely to present with higher BMI (27.58 ± 5.62 vs 26.67 ± 7.26), a past medical history of coronary artery disease (53.3% vs 37.8%), carotid artery stenosis (10.2% vs 4.2%), diabetes (40.2% vs 30.8%), substance use (4.7% vs 1.1%), obesity (43.6% vs 31.5%), sleep apnea (6.3% vs 2.6%), tobacco use (12.9% vs 6.6%), cholesterol reducers (62.5% vs 46.0%), and diabetic medication (31.5% vs 21.4%); and higher laboratory values including serum creatinine (1.50 ± 1.33 vs 1.17 ± 0.70) and INR (1.48 ± 1.05 vs 1.34 ± 0.85).P < 0.001), history of smoking , increasing serum creatinine , increasing diastolic blood pressure , changes or improvement in ambulation  were associated with males, while atrial fibrillation , heart failure , anti-HTN medication , increasing total cholesterol l, increasing HDL-cholesterol , and increasing NIHSS  were associated with females. As shown in Fig. P < 0.001) demonstrates a strong sensitivity and specificity of our regression model.In the adjusted analysis for the whole AIS population with and without AF Fig. , coronarP = 0.032), BMI , depression , HRT , migraine , increasing HDL-cholesterol , increasing heart rate , and antihypertensive  were associated with females without AF, while CAD , drugs and alcohol , higher serum creatinine level , INR, and increasing diastolic blood pressure , were associated with males  demonstrates a strong sensitivity and specificity of the model , increasing HDL , increasing LDL-cholesterol , and the inability to ambulate on admission  were associated with females, while history of drug and alcohol abuse , sleep apnea , and increasing serum creatinine level  were associated with males. The ROC curve .In the AIS patients with atrial fibrillation Fig. , migrainThree major findings arise from this study. First, we found that in the whole AIS population with and without AF, coronary artery disease, history of smoking, increasing serum creatinine, increasing diastolic blood pressure, changes or improvement in ambulation, were associated with males, while atrial fibrillation, heart failure, anti-HTN medication, increasing total cholesterol, increasing HDL-cholesterol and increasing NIHSS, were associated with females. Second, in AIS patients without AF, increasing age, BMI, depression, HRT, migraine, increasing HDL-cholesterol, increasing heart rate, and antihypertensive were associated with females without AF, while CAD, drugs and alcohol, higher serum creatinine level, INR, and increasing diastolic blood pressure were associated with males. Finally, in the AIS patients with AF, migraines, increasing HDL, LDL-cholesterol, and the inability to ambulate on admission were associated with females, while history of drug and alcohol abuse, sleep apnea, and increasing serum creatinine level were associated with males.The effect of HDL-cholesterol which was significant in the whole AIS with and without AF was sustained in the adjusted analysis for the female AIS patients without AF. Although age, BMI, depression, HRT, migraine, heart rate, and antihypertensive medications were not associated with female patients in the whole AIS population, these factors were significant and associated with females in the adjusted analysis for the AIS patients without AF. The effect of coronary artery disease, smoking and higher rates of improved ambulation which were more likely to be associated with male patients in the whole AIS with and without AF were attenuated in male patients for the adjusted analysis of AIS patients without AF. In addition, higher serum creatinine levels and diastolic blood pressure were significant among males in the whole AIS with and without AF, and such an effect was sustained and associated with male AIS patients without AF in the adjusted analysis. While CAD, drugs and alcohol were not significant in the whole AIS population, they were significantly associated with males in the adjusted analysis for the AIS without AF.Our finding that in the AIS population without AF, older AIS patients that present with depression, HRT, migraine, elevated HDL-cholesterol, elevated heart rate, and take antihypertensive medications were associated with females, while CAD, history of drugs and alcohol abuse, high serum creatinine level, elevated INR and increased diastolic blood pressure were associated with males are consistent with other studies for both females –21 and fWe observed that in AIS patients with atrial fibrillation, migraines, elevated HDL-cholesterol and LDL-cholesterol with the inability to ambulate on admission were associated with females, while history of drug and alcohol abuse, sleep apnea, and higher serum creatinine level were associated with male AIS patients with AF. Our finding of the association of poor ambulatory outcome with female AIS with AF is consistent with existing evidence on stroke patients . This fiTherefore, our findings that in the AIS patients with AF, migraines, elevated HDL-cholesterol, elevated LDL-cholesterol, and poor ambulation were associated with females, while history of drug and alcohol abuse, sleep apnea, and increased serum creatinine level were associated with male AIS patients with AF supports our hypothesis that a gender based disparity in comorbidities and risk factors occurs in AIS population with baseline AF. While the frequencies of vascular disease vary between the males and females AIS patients, and the rates of hypertension (60% versus 56%) are higher in females than in males , we showThe prevalence of stroke in the female gender is predicted to rise rapidly due to the continuous increase in the global elderly female population . Our curThere some limitations in the interpretation of the results of this study. This study was conducted at a single institution; therefore, the findings cannot be generalized to other institutions. Retrospective studies are known to have biases for selection because the data is not randomized. We predetermined all our subgroup analyses and repeated our analysis several times to eliminate the possibility of type 1 statistical errors. Our female subgroup analyses conducted reveal more significant variables associating more risk factors and comorbidities in females more than that of male AIS with AF. While this is a single study, the demonstration of consistent gender disparities in the AIS with and without AF increases the generalizability of our findings. Since mRS as a validated index of function for outcome was not included in the registry data based, therefore functional outcome could not be determined.Our findings reveal that migraines, elevated HDL, and elevated LDL were associated with female AIS patients with a baseline AF, while drugs and alcohol abuse history, sleep apnea, and higher serum creatinine level were associated with male AIS with baseline AF. Improved management strategies for baseline risk factors for AIS patients with a history of AF will be beneficial for both males and females AIS patients with AF.