Visual stimulation increased posterior cerebral artery conductance, but the magnitude of the response was blunted in patients with AF  and hypertension (17 [8] %), in comparison with healthy controls (26 [9] %) (P < 0.05). In contrast, transmission of MAP to MCA Vm was greater in AF patients compared to hypertension and healthy controls, indicating diminished cerebral autoregulation. We have shown for the first time that AF patients have impaired neurovascular coupling responses to visual stimulation and diminished cerebral autoregulation. Such deficits in cerebrovascular regulation may contribute to the increased risk of cerebral dysfunction in people with AF.The risk of cognitive decline and stroke is increased by atrial fibrillation (AF). We sought to determine whether neurovascular coupling and cerebral autoregulation are blunted in people with AF in comparison with age-matched, patients with hypertension and healthy controls. Neurovascular coupling was assessed using five cycles of visual stimulation for 30 s followed by 30 s with both eyes-closed. Cerebral autoregulation was examined using a sit–stand test, and a repeated squat-to-stand (0.1 Hz) manoeuvre with transfer function analysis of mean arterial pressure  and middle cerebral artery mean blood flow velocity (MCA V Poor cerebral blood flow in AF may lead to vasodilatation of cerebral arterioles thus reducing cerebral vasodilatory reserve.11 Indeed, a 13% reduction in hemispheric cerebral blood flow has been documented in individuals with AF aged between 51 and 65 years, in the absence of signs of heart failure or cerebral vascular disease.12 Moreover, systemic endothelial dysfunction has also been reported in AF and may impair cerebrovascular regulation. Plasma von Willebrand factor, a biomarker of endothelial damage/dysfunction, is raised in AF and has been related to adverse outcomes.13 In addition, stable patients with chronic AF have an impaired conduit  artery flow-mediated dilatation response in comparison to sinus rhythm controls,14 indicative of attenuated endothelial nitric oxide (NO) bioavailability.16 This is important since endothelium-derived NO is an important local regulator of cerebral blood flow17 and some evidence indicates that it is involved in cerebral autoregulation19 and neurovascular coupling,21 although this is controversial23 and remains an active area of exploration.17The brain has a high metabolic demand and possesses regulatory mechanisms to ensure a close matching of local blood flow to neuronal activation and metabolism (neurovascular coupling) and an adequate cerebral oxygen delivery over a wide range of perfusion pressures to prevent over/under perfusion and consequent risk of haemorrhage or ischemia .24 and herein sought to extend those observations by determining whether neurovascular coupling and cerebral autoregulation are impaired in AF. These key cerebrovascular regulatory processes were assessed in patients with AF, hypertension and healthy volunteers. Patients with hypertension were also recruited to serve as a ‘disease control’ group with the aim of controlling for the effect of medications and comorbidities.25 We hypothesized that neurovascular coupling and cerebral autoregulation would be poorer in patients with AF when compared to age-matched healthy controls and patients with hypertension.We have identified a blunted cerebrovascular carbon dioxide reactivity as an important control mechanism of cerebral blood flow in AF patientsThis study was approved by the National Research Ethics Service Committee West Midlands (13/WM/0210 and 15/WM/0447) and adhered to the principles of the Declaration of Helsinki (2008). Prospective participants were provided with an information sheet and all procedures were verbally explained in detail. All volunteers provided written informed consent after having the opportunity to ask questions and receive appropriate clarification.n = 30), primary hypertensive patients in sinus rhythm (n = 29), and healthy control participants (n = 24). AF and hypertension patients were recruited from dedicated clinics at City Hospital, Birmingham, United Kingdom, while healthy controls were recruited from the surrounding communities by recruitment advertisements and word of mouth. In addition, GP practices within the National Institute of Health Research Clinical Research Network were also employed to recruit participants to all groups. Individuals with a fast ventricular rate ( > 90 b/min), left ventricular dysfunction, valvular heart disease, previous myocardial infarction, angina, ischemic and haemorrhagic stroke / transient ischemic attack, malignancy, uncontrolled thyroid disorders, insulin-dependent diabetes, secondary hypertension and respiratory, hepatic, renal, connective tissue, inflammatory or neurological diseases were excluded from participation. Also excluded were those using oral nitrates, hormone replacement therapy, smokers and those with a weekly alcohol consumption of > 28 units. Participant characteristics and prescribed medication use are provided in Eighty-three people were recruited to participate in this cross sectional, case control study, across three groups: AF patients  or persistent AF (i.e. each untreated episode lasts longer than seven days), while patients with hypertension were also previously clinically diagnosed . Four healthy participants were found to have raised blood pressure and were referred to a GP but upon follow-up all were confirmed as being normotensive.m) was continuously recorded in all participants, while posterior cerebral artery mean blood velocity (PCA Vm) was obtained in a sub-set of participants, using a 2 MHz transcranial Doppler probe  fixed at the temporal window with an adjustable headband and ultrasound gel. MCA insonation was attempted on both sides with recordings made from optimal side; the contralateral PCA was then insonated and again data only from optimally insonated vessels were recorded. Vessels were confirmed in accordance with published guidelines.26 Minute ventilation was measured using an oronasal mask connected to a heated pneumotach . Continuous breath-by-breath partial pressure of end-tidal carbon dioxide (PETCO2) was obtained by a capnograph connected to the mask by a sample line .Baseline brachial arterial pressure was determined non-invasively using an automated oscillometer . Continuous beat-by-beat blood pressure was obtained using finger photoplethysmography  and heart rate (HR) was monitored by a lead II ECG . Middle cerebral artery mean blood velocity (MCA VParticipants refrained from taking medications (excluding anticoagulants) on the morning before the study. Height and weight were measured. After instrumentation, a 10-min baseline was acquired while participants lay supine breathing room air. At least three brachial artery blood pressure readings were obtained during this period.21Following a 2-min baseline period with both eyes closed, five cycles of 30 s with eyes open  followed by 30 s eyes closed were performed. Reading material consisted of general tourist information relating to Birmingham, UK. The neurovascular coupling protocol was undertaken in accordance with published guidelines.Cerebral autoregulation was assessed by performing a single sit-to-stand. Participants sat comfortably with the legs uncrossed on a chair for 2 min followed by single movement to a standing position, which was maintained for a further 2 min.28Following 2-min of standing, participants performed a repeated squat-to-stand manoeuvre for 5-min (0.1 Hz). Squats consisted of bending the knees at ∼90° for 5 s followed by standing straight for a further 5 s. This manoeuvre produces large amplitude oscillations in blood pressure and cerebral blood flow velocity, thus increasing the coherence between these signals and optimizing the transfer function analysis method and its reproducibility.Study design restricted blinding during data collection. However, researchers were blinded during data and statistical analysis. Body mass index (BMI) was expressed as the ratio between participant's weight and the square of their height. Cardiorespiratory and transcranial Doppler signals were digitized at 1 kHz  and recorded using multi-channel data acquisition software . Mean blood pressure of each cardiac cycle was calculated as the mean arterial pressure (MAP), while an index of the cerebrovascular conductance (CVCi) was calculated using the following formulam, MCACVCi, PCA Vm, PCACVCi, MAP and PETCO2 were calculated for the eyes open and eyes closed phases. Additionally, peak responses to eyes open were computed and expressed as percentage change from eyes closed. The magnitude of the neurovascular coupling response was principally taken as the peak percentage change in PCACVCi. A secondary analysis was undertaken in an attempt to better understand the “task-specific selectivity” of the response, in which the “non-selective” cerebrovascular responses to the neurovascular coupling test were excluded by calculating the difference between the PCACVCi and MCACVCi responses.Baseline values for cardiorespiratory and cerebrovascular data were averaged over 10 min. For neurovascular coupling analysis, beat-to-beat (cardiovascular and cerebrovascular) and breath-by-breath (respiratory) data underwent cubic spline interpolation at 5 Hz using a custom built Matlab code . The average values of MCA Vm) signals for the supine baseline (5 min) and the repeated squat-to-stand manoeuvre (5 min). For sit–stand data, baseline values of MCA Vm, MCACVCi, MAP and PETCO2 were calculated as the average of 20 s data before stand (i.e. while seated). The magnitude of the change  to nadir was calculated along with the time to nadir. For the repeated squat-to-stand, extracted data underwent cubic polynomial interpolation and resampling at 10 Hz for transfer function analysis using the fast Fourier transform in accordance with the recommendations of the International Cerebral Autoregulation Research Network .29 The relationship between input (MAP) and output (MCA Vm) was quantified with respects to power, absolute gain (cm/s/mmHg), normalised gain (%/mmHg), phase and coherence, averaged at 0.1 Hz (i.e. coincident with frequency of repeated squat to stand).27 In addition, averages were computed over the very low frequency (0.02–0.07 Hz), low frequency (0.07–0.2 Hz), and high frequency (0.2–0.5 Hz) ranges.30Cerebral autoregulation was determined from cardiovascular and cerebrovascular responses to the sit–stand manoeuvre, along with the transfer function analysis of cardiovascular (MAP) and cerebrovascular . Significance was set at P < 0.05. Normally distributed data are presented as mean (SD), while non-normally distributed data are presented as median [interquartile range]. Assuming a 6% SD for NVC as Nowak-Fluck et al.,31 the minimal detectable difference between the groups would be 7% with a sample size of 12 patients in each group, at 80% power and 5% alpha. Assuming a 0.35%/mmHg SD for normalized gain at 0.1 Hz during the repeated squat-to-stand manoeuvre as Smirl et al.,32 the minimal detectable difference between the groups would be 0.28%/mmHg with a sample size of 25 patients in each group, at 80% power and 5% alpha.Participant numbers included for each analysis are shown in the figure and table legends. Normality was assessed by the Shapiro–Wilk test. Normally distributed data were analyzed using one-way analysis of variance (ANOVA) or Students m and PETCO2 were lower in AF, while PCA Vm was not different between groups.Groups were closely matched for age and waist/hip ratio, while BMI was higher in AF and hypertension patients . During CVCi in all groups (P < 0.05). AF patients exhibited the greatest increase in MCACVCi  and when this “non-selective” effect of the neurovascular coupling test was subtracted, a significantly diminished peak PCACVCi response was observed in AF patients compared to both other groups. When the peak MCA Vm was similarly accounted for, the peak PCA Vm was also observed to be diminished in AF patients . The neurovascular coupling test slightly elevated PETCO2, but to a similar extent in each group. MAP was also slightly elevated in the AF and hypertension patient groups .Visual stimulation evoked an increase in PCAl groups , but them or MCACVCi. Similarly, no between group differences were noted for the time taken to reach a nadir. P < 0.05). Coherence and absolute gain were not different between the groups during the repeated squat-stand manoeuvre at 0.1 Hz; however, phase was lower in patients with hypertension when compared to normotensive controls in sinus rhythm (P < 0.05). As anticipated, the coherence was appreciably increased by performance of the squat-stand manoeuvre in all groups.Cardiovascular and cerebrovascular responses to the sit-stand manoeuvre are provided in m, PETCO2, whereas HR, BMI , DBP  and MAP  were higher, and MCA Vm was lower in those AF patients that were fibrillating when tested (Supplementary Table 2). Neither neurovascular coupling (Supplementary Table 3), nor the cardiovascular and cerebrovascular responses to the sit-stand manoeuvre were different in these sub-groups of AF patients (Supplementary Table 4). Supplementary Table 5 provides transfer function analysis derived coherence, phase and gain at 0.1 Hz, both at baseline and during a repeated squat-stand manoeuvre. Interestingly, during the squat-stand manoeuvre, absolute gain was lower (0.64 [0.22] vs. 0.92 [0.37] cm/s/mmHg) and phase was higher (0.63 [0.25] vs. 0.35 [0.17] radians) in AF patients that were fibrillating when studied (P < 0.05).Approximately 50% of AF patients were in AF when studied, and so a subgroup analysis was undertaken between these patients compared to those not in AF when tested. Groups were not different in terms of age, hip-to-waist ratio, SBP, PCA Vm) than those AF patients not in AF when tested, but cerebral autoregulatory performance was not less effective.The aim of this study was to determine whether neurovascular coupling and cerebral autoregulation are impaired in AF. Our major novel findings are that: (1) individuals with AF have a blunted neurovascular coupling response to visual stimulation when compared to age-matched healthy controls; (2) cerebral autoregulation is diminished in AF patients as indicated from the elevated normalised gain derived from transfer function analysis, and (3) AF patients that were fibrillating when studied had a lower cerebral perfusion ,21 and while an association between impaired neurovascular coupling and diminished cognitive function has been reported,33 human studies of causality are awaited. In the present study, we observed that increases in visual stimulation evoked a blunted PCACVCi response in patients with AF compared to healthy control participants, indicative of diminished neurovascular coupling. This may be attributable to visual stimulation causing a blunted neuronal activation in AF as sub-clinical neurodegeneration can occur in some cases,34 or alternatively a disruption in the coupling between neuronal activation and increases in local blood flow.A complex array of signalling cascades normally couples neuronal activation and metabolism to cerebral blood flow with a high spatial and temporal fidelity.35 Endothelial damage/dysfunction has been reported in AF, and may in part be due to blood flow abnormalities associated with an irregular heart rate, with resultant turbulent flow both in the left atrium and systemically.36 Loss of shear stress, which occurs in conditions of turbulent flow, decreases endothelial NO synthase expression as compared with laminar or pulsatile flow conditions.38 Diminished NO signalling may contribute to the diminished neurovascular coupling we report.35 However, in contrast to the abundance of studies employing isolated preparations and non-human models, the mechanistic basis of neurovascular coupling has been more sparsely studied in humans.21 Further studies are needed to better understand the physiological mechanisms for the observed deficit in the cerebral perfusion response of the occipital lobe to visual stimulation in AF patients.A multitude of substances are believed to link neuronal and astrocytic activation to local vasodilatation, including vasoactive ions , metabolites , neurotransmitters  and factors derived from the endothelium (e.g. NO).CVCi response to visual stimulation in comparison with healthy control participants. This is in general agreement with a previous report of a blunted cerebral blood flow response in the parietal cortex during a memory task in untreated hypertension patients compared to normotensive controls.33 Interestingly, a poorer cerebral blood flow response was associated with a worse cognitive performance.33 In mice, the systemic administration of angiotensin II raises blood pressure and diminishes the cerebral blood flow response to whisker stimulation (i.e. a blunted neurovascular coupling response).39 Given that phenylephrine administration to induce a similar pressor response to angiotensin II did not blunt the hyperaemic response to whisker stimulation, hypertension per se does not appear to explain the blunted neurovascular coupling and perhaps points to an effect of angiotensin II on a vascular regulation .40 In the present study, PCACVCi responses to visual stimulation were similar in patients with AF and hypertension. This occurred despite the known right-shift in the cerebral autoregulation curve documented in hypertension, which is reported to have a complex influence on the neurovascular coupling response,42 and may relate to the diminished vasoactive signalling mechanisms described above. Of note, AF patients exhibited a larger MCACVCi and MCA Vm response than patients with hypertension. The MCA does not supply the visual cortex and this “non-selective” response may reflect the engagement of cognitive pathways that are independent of visual cortex stimulation.43 Interestingly, when the “non-selective” MCACVCi and MCA Vm responses to the neurovascular coupling test were subtracted from the PCACVCi and PCA Vm responses in a secondary analysis, AF patients displayed the poorest neurovascular coupling of all the groups studied (i.e. the lowest percentage increase in PCACVCi and PCA Vm). Diminished neurovascular coupling, may over time, disrupts the neuronal microenvironment and causes functional deficits in the brain.Patients with hypertension were observed to have a lower PCA44 Alzheimer's disease,45 type 2 diabetes mellitus46 and following mild ischaemic stroke.47 In accordance with previous studies, we observed that MCA Vm  was reduced in AF patients in the supine position, and this has previously been postulated to be both a cause12 and a consequence11 of an impaired cerebral autoregulation. A number of complex mechanisms are involved in the autoregulatory process and include stretch-activated cation channels,48 autonomic influences49 metabolic influences (e.g. CO2),50 and NO,19 although the latter is still debated.17 As described above, endothelial damage/ dysfunction and diminished endothelial NO bioavailability have been identified in AF,14 along with autonomic imbalance.51 Our study is the first to determine whether cerebral autoregulation is impaired in AF and this was assessed using two approaches. First, the examination of the temporal pattern of the MCA Vm and MAP responses to a simple sit–stand manoeuvre, and second, the transfer function analysis of these same signals during a repeated squat-to-stand manoeuvre. Importantly, these manoeuvres have high ecological validity as they commonly occur in normal everyday life (e.g. rising from a chair or standing up after retrieving something from the floor) and can be accompanied by symptoms indicative of cerebral hypoperfusion (e.g. light-headedness). Both manoeuvres evoke pronounced changes in blood pressure, and in the case of the repeated squat-to-stand manoeuvre, the large oscillations in blood pressure evoked are transmitted to cerebral perfusion  versus those not in AF  when tested identified that the former group had a reduced transfer function absolute gain and increased phase. Phase is representative of the delay between the input (MAP) and output (MCA Vm), and a lower phase shift may indicate a more passive following of MCA Vm to MAP, thus a reduced cerebral autoregulatory performance.53 The lower absolute gain and increased phase observed suggest a more effective cerebral autoregulation in the AF patients that were fibrillating when studied. This puzzling observation may be directly attributable to the fibrillation per se, but the contribution of a secondary related factor, such as the higher MAP (tendency) and lower MCA Vm, cannot be excluded. Indeed, normalised gain, which negates group differences in MCA Vm, was not different between AF sub-groups. Additional studies are required to better understand the mechanisms, whereby cerebral autoregulation may be altered in this population. Interestingly, there were no between-group differences in the cerebral perfusion response to the single sit–stand manoeuvre, suggesting that the more haemodynamically strenuous manoeuvre (i.e. repeated squat-to-stand) was required to reveal the AF-related alterations in cerebral autoregulation.In line with our hypothesis, cerebral autoregulation was diminished in AF patients compared to either healthy controls or patients with hypertension . A higher gain is usually indicative of poorer buffering of changes in MAP by the cerebral vasculature, but it can also suggest a decreased cerebral vascular resistance.m and PCA Vm derived using transcranial Doppler ultrasound are only proportional to cerebral blood flow if the cross-sectional area of the insonated artery remains unchanged. Of note, the transcranial Doppler technique is the only practical way we could have quantified the cerebral perfusion responses to posturally induced changes in blood pressure and thus derive cerebral autoregulatory data. An increase in AF burden from paroxysmal to persistent, and the duration of AF and hypertension since diagnosis, might be expected to further worsen cerebrovascular function. However, this information for individual patients was not obtained thus limiting further within group analysis. Investigations of sub-clinical indices of end-organ damage and cerebral scans for covert infarcts were beyond the scope of the protocol and as such were not performed.The reported changes in MCA VNeurovascular coupling and cerebral autoregulation are diminished in AF patients compared to age-matched, healthy controls and patients with hypertension. Future studies should explore the molecular basis for these observations, along with their clinical implications as they may be significant in terms of AF-related cognitive decline and brain dysfunction.Click here for additional data file.Supplemental Material for Neurovascular coupling and cerebral autoregulation in atrial fibrillation by Rehan T Junejo, Igor D Braz, Samuel JE Lucas, Johannes J van Lieshout MD Aaron A Phillips, Gregory YH Lip and James P Fisher in Journal of Cerebral Blood Flow & Metabolism


Zoological institutions often use immersive, naturalistic exhibits to create an inclusive atmosphere that is inviting for visitors while providing for the welfare of animals in their collections. In this study, we investigated physiological changes in salivary cortisol and blood pressure, as well as psychological changes among visitors before and after a walk through the River’s Edge, an immersive, naturalistic exhibit at the Saint Louis Zoo. Study participants had a significant reduction in salivary cortisol and blood pressure after walking through the exhibit. Psychological assessments of mood found that most visitors felt happier, more energized, and less tense after the visit. Additionally, participants who spent more time in River’s Edge, had visited River’s Edge prior to the study, and had seen more exhibits at the Zoo prior to entering River’s Edge experienced greater psychological and/or physiological benefits. We conclude that immersive, naturalistic exhibits in zoos can elicit positive changes in physiological and psychological measures of health and well-being and argue for a greater scientific focus on the role of zoos and other green spaces in human health. Stress and illness have a complicated relationship, yet there is strong evidence that acute and chronic stress may lead to long-term negative outcomes on an individual’s overall health and quality of life , 2, 3, 4One predictor of general health and level of stress is access to green spaces , 10, 11.in situ with animals throughout the world [One Health is an initiative based on the understanding that the health of all life is inextricably linked and involves multi-disciplinary collaboration to optimize the health of people, animals, and the environment , 20, 22.he world , 25, 26.he world , 28.Only a handful of studies have explored how zoos and aquariums provide direct benefits to human health. A study conducted at a Japanese zoo found that visitors experienced a decrease in blood pressure, walked over 6,000 steps, and reported an increased self-perceived quality of life during their visit . AnotherIn this study, we examined changes in health parameters among visitors associated with a walk-through of an immersive, naturalistic exhibit at a zoo by using physiological and psychological assessments. We predicted that there are health benefits that zoos provide to their visitors and that our study will help to identify ways in which zoos improve the health of their visitors. We measured blood pressure and salivary cortisol to assess changes in physiological stress and used a psychological tool to assess mood. Blood pressure measurement is a standard indicator of stress . ChangesWe used the University of Wales Institute of Science and Technology Mood Adjective Checklist (UMACL) to assess psychological parameters of zoo visitors’ mood , 41. ThiTremarctos ornatus), bush dogs (Speothos venaticus), capybaras (Hydrochoerus hydrochaeris), black rhinoceros (Diceros bicornis), painted dogs (Lycaon pictus), red river hogs (Potamochoerus porcus), bat-eared fox , hippopotamus (Hippopotamus amphibious), spotted hyenas (Crocuta crocuta), cheetahs (Acinonyx jubatus), dwarf mongoose , Asian elephants (Elephas maximas), Malayan sun bear , and a variety of North American fish species.We conducted the study from April to June 2018 in the River’s Edge exhibit at the Saint Louis Zoo . River’s Edge is a 1.21 km trail on which visitors walk from entrance to exit along a heavily planted, winding trail featuring naturalistic habitats. Animals housed along the trail include: Andean bear, , age, parking experience rating , number of exhibits seen prior to River’s Edge, and time of arrival at the Zoo. Each participant then answered the pre-UMACL, which included 24 mood adjectives, with eight corresponding adjectives to each of the three dimensions .After completing all forms, we then collected physiological data. Prior to saliva collection, each participant rinsed their mouth with water (supplied by the researcher) and placed a SalivaBio Oral Swab  under their tongue for two minutes (as specified by the manufacturer), while sitting quietly. After two minutes, the swab was inserted into a Saliva Storage Tube , either directly by the participant or by the researcher without direct contact. After collection, saliva samples were placed in a cooler on ice packs for no longer than two hours, and then brought to the lab for processing.Next, a trained researcher took the participant’s blood pressure using an OMRON M6 AC (HEM-7322-E) upper arm blood pressure monitor in accordance with the IRB-approved protocol . The AmeFinally, we asked participants to wear a colorful lanyard to identify themselves to the researchers at the end of the exhibit trail. Participants were also instructed not to consume any food or drinks (other than the boxed water provided) and refrain from chewing gum during their walk through the exhibit. We invited participants to enjoy their time in River’s Edge at their normal pace without any time restrictions.Once the participant finished walking through River’s Edge, they performed a similar suite of tests, including measurement of blood pressure and collection of saliva samples, and a post-visit questionnaire. This had the following questions: gender (as identified by the participant), party size, number of kids in party under 14 years old, incidence of having a staff interaction, animal that they found most engaging (if any), whether they had a close up encounter with that animal, and looked into the animal’s eyes. Each participant then answered the post-UMACL. A researcher timed and recorded each step in the data collection process. The total number of minutes spent in River’s Edge was calculated, total number of minutes spent in the Zoo prior to entering River’s Edge and outside air temperature during River’s Edge was recorded for each participant. Daily Zoo attendance was included as an additional variable.Upon completion of the UMACL form, post-questionnaire survey, saliva collection, and blood pressure reading, participants received a $10 Zoo gift certificate.This study was approved by Heartland Institutional Review Board (IRB) and all principal investigators completed the Collaborative Institutional Training Initiative (CITI) IRB training. The study was deemed expedited with written consent.Saliva swabs within the storage tubes were spun in a centrifuge at 1500 g for 15 minutes to extract saliva from the swabs. Saliva samples were then pipetted into cryovials and stored at -20°C until assay. Salivary cortisol concentrations were measured using a commercially available enzyme immunoassay designed for human saliva . The assay has been validated previously, with a mean recovery percentage of 104.9 ± 2.0% (n = 8), and a mean dilution recovery percentage of 105.3 ± 1.4% (n = 4) (data provided by the manufacturer). The lower detection limit was 0.012 μg/dL and the upper detection limit was 3.0 μg/dL. Samples were assayed neat; any sample that was above the detection limits was diluted 1:10 with assay buffer and reanalyzed. All samples were assayed in duplicate. Mean intra-assay variation of duplicate samples was 8.0%; mean inter-assay coefficient of variation for two quality control pools was 6.1%.t-test was used to calculate differences in means from pre to post for the six experimental measures, including systolic and diastolic blood pressure, cortisol, EA, HT, and TA. A Pearson’s chi-squared test was run on systolic and diastolic blood pressure categories  to test for differences in proportions from pre to post.Descriptive statistical analyses were completed using IBM SPSS software v23 . Descriptive statistics were used to determine if there was adequate variability in each variable for inclusion in the model described below. A paired sample Regarding the UMACL, participants marked how each adjective reflected his or her current mood using a four-point scale . Within each set of eight adjectives, four represented the positive end of each dimension and four the negative end . ResponsInferential statistical analyses were performed in SAS® Studio 3.7 . Prior to analysis, study participants were assigned to two blocks based on the time of day they entered River’s Edge (prior to 12:30 PM vs. after 12:30 PM), controlling for effect of time of day on the response variables measured. The effects of possibly associated factors on systolic and diastolic blood pressure, salivary cortisol concentrations, TA, EA, and HT were all evaluated using a generalized linear mixed model within the MIXED procedure. Fixed categorical factors included time (pre or post River’s Edge experience), gender , first visit to River’s Edge (yes or no), found the elephants the most engaging (yes or no), had a staff interaction (yes or no), had a close up encounter with the animal found to be most engaging (yes or no), and looked into this animal’s eyes (yes or no). Quantitative variables included air temperature, age, daily Zoo attendance, party size, number of kids in party under 14 years old, parking experience score, total number of exhibits seen prior to River’s Edge, total number of minutes spent at the Zoo prior to River’s Edge, and total number of minutes spent in River’s Edge. These variables were selected based on sufficient variation in subject responses and previous data that support their impacts on visitor experiences. For example, at the Saint Louis Zoo, visitors report parking as the most experienced inconvenience during a Zoo visit . Additiop values when simple effect means were compared. Differences were declared significantly different using an alpha = 0.05. The block effect was not significant in any of the analyses and therefore not explored further within this study. All data met the assumptions for parametric tests based on visual examination of the residuals.Individual ID and block (described above) were included as random factors, as well as the interaction terms between time, and the fixed and quantitative factors. Non-significant interaction terms between time and quantitative factors were removed to generate a single slope term for the final models. All other variables, regardless of statistical significance, were included in the final models. Though the design of the study is repeated measures in nature, there were only two measurements made within each subject, therefore a simple variance component (VC) covariance structure was used. The Tukey method for multiple mean comparisons was used to adjust Over the eight week period of data collection, 1,656 Zoo visitors were approached and invited to complete the study. Of these, 1,052 chose not to participate and 402 agreed to participate, but did not meet all of the qualifications and were not included. There were 202 participants who completed the study for an overall response rate of 12%. We excluded data from 16 individuals, leaving 186 participants for the final analysis. Reasons for exclusion included not finishing the post-study questionnaire, drinking something other than water during their River’s Edge visit, too little saliva collected either during between pre or post swab, or not fully completing the mood adjective checklist in either the pre or post study survey. Demographic and zoo experience-related descriptive statistics are provided in t185 = 3.61, p = 0.0004, t185 = 3.07, p = 0.0024, 1,179 = 4.51, p = 0.035) and marginally significant for diastolic blood pressure . Males had significantly higher systolic blood pressure and marginally higher diastolic blood pressure compared to females . Age was significantly associated with both systolic and diastolic blood pressure: higher blood pressure was associated with increasing age . Diastolic blood pressure was also affected by air temperature and party size. Lower diastolic values were associated with higher air temperatures  and larger party sizes .On average, both systolic and diastolic blood pressure significantly decreased from pre- to post- (over time) River’s Edge experience . Additionally, 15% of participants shifted from a higher diastolic blood pressure category to the normal diastolic blood pressure category . We defined categories based on the guidelines of the American Heart Association, Inc. [During their River’s Edge visit, 23% of the 186 participants shifted from a higher systolic blood pressure category to a lower systolic blood pressure category with 17% of the total participants shifting down to the normal category . Participants who had visited more exhibits prior to River’s Edge had lower salivary cortisol upon arrival to the River’s Edge . This association was no longer significant upon completion of the River’s Edge experience . Although only marginally significant, the greater the amount of time a person spent walking through River’s Edge, the greater the observed decrease in cortisol .On average, salivary cortisol significantly decreased from pre- to post-River’s Edge experience . Overall, HT was higher in people who had visited River’s Edge at least once before in the past , and there was a trend in which HT tended to increased more over time only in individuals who were visiting River’s Edge for the first time . Similar to HT, EA was higher in people who had visited the River’s Edge at least once before  which was the only significant predictor of EA.On average, EA significantly increased from pre- to post-River’s Edge experience . The magnitude of the decrease in TA from the time the participants entered River’s Edge to the time they exited River’s Edge was dependent on gender. Women had a greater decline in TA over time (pre to post) compared to men . TA decreased in women over time but did not change significantly over time in men. Other observed effects that were independent of time included a significant positive association between the daily Zoo attendance and the level of TA in participants; the higher the attendance the higher the TA . Similarly, people with a more negative parking rating also had higher TA . The number of exhibits seen prior to arriving at River’s Edge was negatively associated with TA , therefore, the more exhibits visited, the lower the TA.On average, TA significantly decreased from pre- to post-River’s Edge experience . People with higher TA more often reported looking into an animal’s eyes, but the experience itself did not affect the degree of change in TA between the pre to post experience. In contrast, people who reported having a close-up encounter with an animal they had “the most engaging experience with” during the River’s Edge experience had a significant decrease in TA over time. People without a close-up experience did not have a change in TA  and/or undergoing treatment for high-blood pressure (six participants).Despite the statistical significance, the biological significance of the physiological and psychological changes observed in this study are unclear. For example, the changes in diastolic and systolic blood pressure measures were approximately two mmHg. While two mmHg appears to be a small decrease, a sizeable percentage of participants shifted from a higher systolic and diastolic blood pressure category to the normal systolic and diastolic blood pressure category. A larger sample size may have revealed a more significant effect. Although these categorical changes are remarkable and suggest biological significance, it is not clear whether this is the case.Dan Ashe, President and CEO of AZA, argues “AZA-accredited zoos and aquariums are places where people of all ages, gender, races, religions, ethnicities, abilities and cultures create bonds with animals they will likely never have opportunity to see in the wild. In a world where people are increasingly urbanizing and disconnected from nature, aquarium and zoo experiences are providing connections to the natural world…” . In addiWe recommend that additional studies be conducted to look at the overall effects of zoos on human health. These will allow us to determine the role zoos may play in regards to human health, and specifically how zoos may better serve the physical and psychological health needs of people from diverse backgrounds, including marginalized populations who already experience significant health disparities.


The association between blood pressure change and kidney damage in patients with abnormal blood glucose remains unclear. The current study aimed to identify systolic blood pressure (SBP) trajectories among the prediabetic population and to determine their association with kidney damage after a long-term follow-up.The incidence, development, and prognosis of diabetic kidney disease (INDEED) study is nested in the Kailuan cohort study with a focus on population with diabetes and prediabetes. We screened out people with prediabetes in 2006 and with more than three SBP records from 2006 to 2014 biennially. We used the latent mixture modeling to fit five groups of trajectories of SBP. In 2016, estimated glomerular filtration rate (eGFR), urinary albumin creatinine ratio (uACR), and urinary α1-microglobulin (α1MG), transferrin and α1-acid glycoprotein were measured, and the association between SBP trajectories and these markers was analyzed by linear regression and logistic regression models.Totally, 1451 participants with prediabetes and without kidney damage were identified in 2006. Five heterogeneous SBP trajectories were detected based on the longitudinal data from 2006 to 2014, as low-stable group (n = 323), moderate-stable group (n = 726), moderate-increasing group (n = 176), moderate-decreasing group (n = 181), and high-stable group (n = 45). Linear regression analysis showed that the moderate and high SBP groups had lower eGFR, higher uACR, higher urinary α1MG, higher transferrin, and higher α1-acid glycoprotein than the low-stable group. Multivariable analysis attenuated the association but did not change the statistical significance.Prediabetic patients with persistent high-level SBP trajectory or gradually increased SBP trajectory had severer kidney damage during follow-up. China is one of the countries with the highest prevalence of diabetes and prediabetes, which exert a heavy burden on social economy and health care. It was reported that the prevalence of prediabetes was 38.0% and 37.5% among adults in the United States and China, respectively , 2. PredThe optimal blood pressure (BP) target for patients with diabetes or prediabetes is not well defined , 15, and2 or urinary protein > ± with proteinuria dipstick. The above people with more than three times of systolic blood pressure records were retained. Forty-two participants who had missing value on total cholesterol (TCHO), triglyceride, high-density lipoprotein (HDL), low-density lipoprotein (LDL), uACR or eGFR were excluded. Finally, 1451 participants were eligible and analyzed  study is based on the participants with diabetes and prediabetes in the Kailuan study, as described previously . The KaiQuestionnaire information included demographic and socioeconomic data. Variables including age, gender, smoking status, alcohol consumption, physical activity, education level, history of antihypertensive medicine, lipid-lowering drugs, and antidiabetic medicine, were used in this current study. Smoking status and alcohol consumption were all classified as ‘never’, ‘former/quit’, ‘often’. Physical activity was divided as ‘never’, ‘occasionally’ and ‘often’. Education was classified as ‘illteracy/primary school’, ‘middle school’, and ‘college/university’. Diagnosis and treatment of diabetes, diabetic kidney disease (DKD), and cognitive function were also administrated.Anthropometric indices included height and weight. Height measurement was accurate to 0.1 cm with a tape rule and weight measurement was accurate to 0.1 kilograms with calibrated platform scales. Body mass index (BMI) was calculated as weight (kilograms) divided by height (meters) squared.Whole blood samples were drawn from all participants, generally after an overnight fast and analyzed in the Central Laboratory of Kailuan General Hospital on the same day. Plasma samples were used to measure biochemical variables. Triglyceride, TCHO, hemoglobin, HDL, LDL were measured using a Hitachi 7600 auto-analyzer . Fasting blood glucose (FBG) was tested with the Hexokinase method . High sensitivity C reactive protein (hsCRP) was measured using a high-sensitivity particle-enhanced immunonephelometry assay . Laboratory urine tests including urinary creatinine, urinary albumin, and urinary α1MG, transferrin and α1-acid glycoprotein that regarded as the indices of early DKD  were meaDuring the biennial follow-up, BP was measured according to the JNC7 recommendation . After r2 test/Fisher exact test.Continuous variables were presented as the mean with standard deviation or median with interquartile range. Categorical variables were presented as counts with percentages. Intergroup differences were assessed using one-way ANOVA for normally distributed data. Differences of parameters that were not normally distributed were tested with the Kruskal–Wallis test. Differences of qualitative parameters were compared using the χThe SBP trajectories from 2006 to 2014 biennially were identified by latent mixture modeling (PROC TRAJ) measures which was used to identify subgroups of people sharing similar SBP patterns and the model fit was assessed using the Bayesian information criterion (BIC) , 27. We 2; eGFR < 60 ml/min/1.73 m2) ). During the 10-year follow-up, five SBP trajectories were distinctly separated among the 1451 participants with three or more SBP measurements. The patterns of the trajectories were shown in Fig. P values < 0.01). Meanwhile, compared with the low-stable group, the proportions of never alcohol intake and taking antihypertensive medicine were higher, and the education levels were lower in the other four groups . Proportions of use of lipid-lowering drugs were not significantly different among the five groups  and transferrin > 3.83 mg/L, respectively, compared with the low-stable group   and decreased beta-cell function have already presented in the stage of prediabetes . IR is aDKD is a common complication of diabetes, which manifested as albuminuria and/or decline of eGFR. eGFR indicates the kidney function, and hyperfiltration of glomeruli is responsible for the excretion of urinary albumin. Thus, although albuminuria is considered as a marker for glomerular damage and is an independent risk factor for the progression of CKD, some individuals could only present decreased eGFR and have a normal level of uACR , 34. In The current study has some strengths and limitations. Strengths included the large sample size and long-term follow-up. Also, we used longitudinal SBP trajectories and included a spectrum of markers for kidney injury. However, some limitations should be mentioned. First, our study was based on a population with a majority of men and that may limit the generalizability of the study findings to women. Besides, for women, we don’t have records of menopause, so we cannot evaluate the effects of estrogen on blood glucose. Second, patients with isolated impaired glucose tolerance are more than those with isolated abnormal fasting glucose , and ourIn summary, patients with persistent high-level SBP or gradually increased SBP could lead to lower level of eGFR and higher levels of markers of kidney damage than those with persistent low SBP. Performing long-term dynamic monitoring for trajectories of blood pressure may be a reliable approach to identify the prediabetic population with a higher risk of DKD.Additional file 1: Table S1. Linear regression analysis between SBP trajectory groups and indicators of kidney disease in 2016 among participants with two or more records of SBP. Table S2. Logistic regression analysis between SBP trajectory groups and abnormality for indicators of kidney disease in 2016 among participants with two or more records of SBP. Table S3. Concomitant therapies between SBP trajectory groups from 2006 to 2012.Additional file 2: Figure S1. Systolic blood pressure was classified into five groups according to the latent mixture modeling from 2006 to 2014 among participants with two or more records of SBP.


Growth differentiation factor 15(GDF15) is a distant member of the superfamily of the transforming growth factor beta (TGF-β). It has been established that increased GDF15 levels are associated with an increased risk of cardiovascular disease. However, the detail effect of GDF15 on cardiovascular system in patients with chronic kidney disease (CKD) needs detail analysis.Patients with CKD who did not need dialysis were enrolled in the study. Blood pressure (BP), endothelial function, pulse wave velocity (PWV) and heart rate variability (HRV) were taken in all subjects. Plasma GDF15 concentration was measured by an enzyme-linked immunosorbent assay.2. The average plasma GDF15 level was 1394.7 (±610.1) pg/mL. Higher GDF15 concentrations were significantly associated with decreased eGFR and increased urine protein-to-creatinine ratio (uPCR). In multivariable models, after adjusting for potential confounders, plasma GDF15 has negative concerning with HRV parameters including the standard deviation of the normal-to-normal (NN) interval (SDNN), the square root of the mean of the sum of the squares of differences between adjacent NN intervals (RMSSD) and Triangular Index.Among the 355 participants, the mean age was 57.4 (±14.2) years old and the mean estimated glomerular filtration rate (eGFR) was 50.1 (±33.2) mL/min/1.73mWe observed there was a link between increased plasma of GDF15 and decreased HRV. The mechanisms and prediction of GDF15 in the cardiovascular disease with CKD needs further discussion and study. It is well known that patients with chronic kidney disease (CKD) are at a high risk of cardiovascular disease and death . A majorGrowth differentiation factor 15 (GDF15) is a protein of the transforming growth factor beta (TGFβ) superfamily. It was first separated from a U937 subtraction cDNA library and originally named macrophage inhibitory factor 1 (MIC-1)  and is aCurrently, many reports have focused on the effects of GDF15 on cardiac function. There is a paucity of data regarding the association between GDF15 levels and cardiovascular alterations in patients with CKD, which we sought to explore in this study. We hypothesized that plasma GDF15 levels would be higher in patients with CKD, which could have probable effects on arterial stiffness, endothelial function, and heart rate variability (HRV).A total of 355 patients were recruited for this study. We included all adult patients (over 18 years old), who had a CKD diagnosis according to the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Guidelines . ExclusiThe pulse wave velocity (PWV) and peripheral arterial tonometry (PAT) measurements were obtained as described previously . CarotidGeneral demographic and medical information were obtained through an inquiry of history and review of medical records. We defined previous history of CVD as any of following: acute myocardial infarction, ischemic or hemorrhagic stroke, atrial fibrillation, coronary heart disease other than myocardial infarction, chronic heart failure and other types confirmed by the research staff. A sample of fasting blood or first voided morning urine was sent to the local laboratory department for examination. Blood routine biochemical tests included hemoglobin, C-reactive protein (CRP), total cholesterol, triglyceride, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), calcium, and phosphorus. The protein-to-creatinine ratio (PCR) in urine was examined. Estimated glomerular filtration rate (eGFR) was calculated using the CKD-EPI formula.Fasting blood samples were collected into ethylenediaminetetraacetic acid (EDTA)-treated tubes and frozen at −80 °C until measurement. Plasma GDF15 was measured by an enzyme-linked immunosorbent assay (ELISA)  according to manufacturer’s protocol. The assay range is 7.81–500 pg/mL and all plasma samples were measured at a dilution of 1:10.p values less than .05 were considered statistically significant.Continuous variables were expressed as the mean ± standard deviation or median (interquartile range) and categorical variables were expressed as counts (%). Numerical variables with a skewed distribution were logarithmically transformed for further analysis if needed. The relationship between GDF15 and renal function or proteinuria was determined using Pearson’s correlation analysis. A multiple linear regression model was constructed to confirm the relationship between GDF15 and cardiovascular risk factors. Variables such as uPCR, SDNN, RMSSD, Triangular Index and LF/HF were logarithmically transformed in regression analysis due to their skewed distribution. All statistical analyses were performed using SPSS 19.0 , and 2 and median urine protein-to-creatinine ratio (uPCR) was 150 mg/g.A total of 355 participants were included in the study. p < .05).The average plasma GDF15 level was 1394.7 (±610.1) pg/mL. We first evaluate GDF15 concentration within several subgroups, including diabetes mellitus (no vs. yes), previous history of cardiovascular disease (no vs. yes), different CKD stages (CKD stage 1 + 2 group vs. 3 vs. 4 + 5) and uPCRs (uPCR <30mg/g vs. 30–300mg/g vs. >300mg/g). As shown in p < .001) and a significant positive correlation for uPCR .As shown in r = 0.303, p < .001) and cfPWV . GDF15 was negatively correlated with SDNN , LF/HF , and Triangular Index .Further analysis revealed the correlation between GDF15 and cardiovascular evaluation results in patients with CKD . Based op > .05). Plasma GDF15 levels were significantly and negatively associated with SDNN , RMSSD , Triangular Index , and LF/HF . All ß values were calculated for each standard deviation increment of GDF15  [The production of GDF15 could be more potent under the stressful conditions of impaired kidney function. The mRNA expression of GDF15 was negatively associated with eGFR in the patients of CKD . Other s< .0001) . TherefoN = 1823, mean age 61 years), circulating GDF15 was positively associated with CfPWV and inversely associated with FMD after multivariable adjustment [We also analyzed the correlation between GDF15 and arterial stiffness and endothelial function in the current study. In the age-, sex-, and BMI-adjusted analysis, higher GDF15 was associated with increased arterial stiffness. The association disappeared after adjusting for potential confounders. We also measured RHI and found that it was not related to GDF15. This seems to differ from the findings in the general population. In a study of participants from the Framingham Offspring Study Cohort .


Vascular calcification (VC) is an independent predictor of cardiovascular disease (CVD) present in 30–70% of patients with chronic kidney disease (CKD). Copeptin is a sensitive surrogate marker of arginine vasopressin (AVP), which is involved in many pathophysiologic processes in CKD. The aim of the present study was to explore the association of copeptin with VC in CKD stage 5.n = 43) or hemodialysis (HD) (n = 53). We analyzed the association of copeptin with presence and extent of VC ascertained both histologically in biopsies from the inferior epigastric artery (n = 137) and by coronary artery calcification (CAC) score measured by computed tomography.Copeptin was investigated in conjunction with living donor kidney transplantation in 149 clinically stable CKD stage 5 patients (CKD5), including 53 non-dialyzed (CKD5-ND) and 96 dialysis patients treated by peritoneal dialysis (PD) (p = 0.003) and presence of medial VC . Multivariate logistic regression analysis showed that 1-SD higher age, male gender, diabetes and 1-SD higher copeptin were significantly associated with the presence of moderate-extensive VC.Patients with higher copeptin were older, had higher systolic blood pressure, higher prevalence of CVD and their preceding time on chronic dialysis was longer. In Spearman’s rank correlations (Rho), copeptin concentrations were significantly associated with CAC score (Rho = 0.27; High circulating levels of copeptin in CKD5 patients are independently associated with the degree of medial calcification ascertained by histology of arterial biopsies. Thus, plasma copeptin may serve as a marker of the uremic calcification process. Chronic kidney disease (CKD) is associated with markedly increased morbidity and mortality which is mainly a result of premature cardiovascular disease (CVD) –3. The c3, osteoprotegerin (OPG) and sclerostin, play important roles in pathological pathways of CKD-BMD . Tumor necrosis factor (TNF), interleukin-6 (IL-6) were analyzed by immunometric assays on an Immulite 1000 Analyzer  using commercial kits. Plasma osmolality was measured using VAPRO Vapor Pressure Osmometer 5520 .Blood samples for copeptin measurement were taken in patients following overnight fasting, in hemodialyzed patients samples were taken the day after HD session. Copeptin concentration was measured with a commercial enzyme immunoassay  according to the manufacturer’s protocol. Briefly, samples were incubated at 37 °C with respective reagents. Optical density was read at 450 nm immediately. The minimum detectable dose of copeptin is typically <6.1 pg/mL. The intra-assay coefficient variation (CV) was <10% and the inter-assay CV was <12%.Body mass index (BMI) was calculated as weight in kilograms divided by the square of height in meters. Lean body mass (LBM) and fat body mass (FBM) were calculated by anthropometry based on measurements of the thickness of biceps, triceps, subscapular and supra-iliac skinfold as described previously , using eCardiac CT scans were performed using a 64-channel detector scanner  Healthcare, Milwaukee, WI). CAC scores were expressed in Agatston units, the protocol and measurements as described previously in detail . Total CInferior epigastric arteries were collected from patients within 20 min from the start of kidney transplantation procedure. After preparation, the sections were then stained with hematoxylin and eosin and von Kossa staining before evaluation by one experienced pathologist. The degree of medial calcification was quantified semiautomatically according to method described previously  and gradP value was set at p < 0.05. For comparisons between three groups non-parametric Kruskal-Wallis ANOVA-test was used for continuous variables and Chi-square test was used for nominal variables. Associations between variables were determined using non-parametric Spearman rank correlation analysis. Multivariate linear regression analyses of copeptin were used and results were shown as standardized β regression coefficients. We performed multinomial logistic regression analysis to examine factors associated for determinants of vascular calcification 0 and 1 score versus 2 and 3. Statistical analyses were performed using statistical software SAS version 9.4  and Stata 16 .Continuous data are expressed as median (10th to 90th percentile) and nominal data as percentage. p = 1.0), while plasma copeptin was significantly lower in CKD5-ND patients compared to PD and HD patients . Plasma osmolality and copeptin correlated in CKD5-ND patients , whereas in the two groups of dialyzed patients this association was not observed. In Spearman’s rank correlations (Rho), copeptin concentrations were significantly associated with age , presence of CVD , systolic blood pressure , triglycerides , serum creatinine , TNF , sclerostin , troponin T , CAC score  and histological scoring of medial calcification . Copeptin did not have significant association with gender and diabetes mellitus.Demographics and clinical characteristics of the examined patients according to copeptin tertiles are shown in Table p = 0.76) but there was statistically significant difference between the group of CAC = 0 and CAC ≥ 1000 .When CAC scores were categorized as CAC = 0, CAC ≥ 100 and CAC ≥ 1000, we found no statistically significant differences in copeptin concentration between the group of CAC = 0 and CAC ≥ 100 . Receiver operating characteristic (ROC) curves for prediction of VC showed that the area under the curve (AUC) was for copeptin – AUC 0.64 (p = 0.02) and for hsCRP - AUC 0.54 (p = 0.02). Multivariate logistic regression analysis showed that 1-SD increase of age, male gender, presence of diabetes and 1-SD increase of copeptin were significantly associated with the presence of moderate-extensive VC  via the activation of phospholipase (PL) C and D leading to augmentation of phosphate transport during proliferation of VSMC [To the best of our knowledge, this is the first study to show a link between plasma copeptin level and the degree of VC in CKD. Emerging research suggest that vasopressin plays important role in the progression of CKD and hypertension via stimulation of the renin angiotensin aldosterone system (RAAS) leading to vasoconstriction and higher systemic and glomerular blood pressure . Direct  of VSMC , 28. Amo of VSMC , 30. Thi of VSMC . A schemOur study showed positive correlation between plasma osmolality and copeptin in the group of non-dialyzed CKD5 patients, whereas such relationship was not observed in PD and HD groups, and non-dialyzed patients had also lower plasma copeptin levels than the other two groups. This accords with Ettema et al.  who examA noteworthy finding of the study is the strong correlation of plasma copeptin with the use of β-blockers. To the best of our knowledge, such relationship has not been described before. Since the mechanism (s) of this correlation remain unclear, further studies are needed to clarify if this is merely a reflection of confounding by indication or if β-blockers do affect copeptin.peter.The results of the present study should be considered given some important limitations. First, we examined CKD5 patients with different types of treatment; i.e. conservative, HD and PD. Moreover, since the group in which vascular biopsies were available was selected for LD-Rtx and thus represent a selected group of “healthier” CKD5 patients. Thus, since diabetic nephropathy was underrepresented compared to the typical CKD5 population the association between VC and copeptin may have been underestimated. Third, as in any observational study, cause-effect relations cannot be determined. Finally, although the circulating concentration of copeptin directly reflects that of AVP and copeptin shows the same response to osmotic changes as AVP in CKD, copeptin is reported to increase more than vasopressin suggesting that the clearance rate of copeptin is more markedly reduced than for vasopressin when GFR decreases. Thus, while copeptin reflects vasopressin levels, in CKD stages 4 and 5, a correction for renal function might be required , 32.High circulating levels of copeptin in CKD5 were found to associate with total CAC score (by cardiac CT), and with the degree of medial vascular calcification  even after adjusting for confounders. Further studies are needed to resolve if copeptin is simply a marker or a player in the complex uremic vascular calcification process.Additional file 1: Table S1. Characteristics of CKD 5 patients stratified according to dialysis-dependence.


The typical clinical presentations of patients with primary aldosteronism (PA) include generalized weakness, fatigue, high blood pressure, and potassium deficiency. However, normotensive PA is rare. Therefore, an atypical presentation of normal blood pressure is a challenge for the diagnosis and treatment of PA.2) with generalized weakness for 1 day presented to our emergency department, where hypokalemia was a significant finding. The initial diagnosis was anorexia nervosa with the evidence of renal potassium wasting with low urinary sodium and chloride levels, metabolic alkalosis, normal blood pressure, and low body mass index. However, neither vomiting features nor other specific induced vomiting features were noted.A 43-year-old, thin, and tall woman (body mass index, 18.6 kg/mThe laboratory examination revealed high plasma aldosterone level, low plasma renin activity, and extremely high aldosterone-to-renin ratio indicating the diagnosis of PA, confirmed via adrenal computed tomography.Surgical adrenalectomy was performed. Pathological diagnosis was a benign cortical adenoma.Patient's serum potassium level and hormonal status became normalized after surgical removal of adrenal adenoma. She fully recovered without any further sequelae.It is too early to rule out PA based on the presence of normal blood pressure in a patient with metabolic alkalosis and renal wasting hypokalemia. Moreover, PA should be considered in a normotensive patient with an unknown hypokalemic etiology to avoid delayed diagnosis and treatment. Although some patients with PA may not have hypokalemia, the vast majority of PA patients suffer from hypertension. Normotensive PA is rare.–4 To date, only a total of 30 such cases reported in China and other countries. Unusual cases of normotensive PA are identified by hypokalemia or by an incidentally discovered adrenal mass. The mechanisms underlying normal blood pressure in such cases are unknown.The most common cause of secondary hypertension is primary aldosteronism (PA), caused by increased aldosterone secreted in the zona glomerulosa of the adrenal cortex.We highlight a case with an atypical presentation of PA with hypokalemia and normal blood pressure, initially expressing the clinical features of anorexia nervosa (AN). The early recognition of PA is crucial to provide appropriate treatment and avoid complications due to PA. Moreover, appropriate and timely management decrease morbidity, mortality, and healthcare expenditure.2A 43 years old Chinese woman presented to our emergency department with progressively general weakness for 1 day. She had experienced 1 episode of sudden onset of flaccid paralysis of lower extremities for a couple of minutes, but it spontaneously resolved by itself 5 days before admission. Neither she nor her family members had previously experienced any such attack. She denied any history of vomiting, diarrhea, and abdominal pain. Moreover, there was no history of recent strenuous exercise or the use of diuretics.2) . No flaccid paralysis of the limbs or areflexia of the joints at the time of admission was observed. Other physical examination findings were unremarkable.On physical examination, her blood pressure was normal (122/71 mm Hg), body temperature was 37°C, respiration rate was 18 breaths per minute and heart rate was 78 beats per minute. She looked very thin with 54 kg body weight and 170 cm body height, indicating low body mass index (18.6 kg/m–: 36.8 mmol/L) and renal potassium wasting (transtubular potassium excretion gradient: 9). Moreover, the relatively low urine sodium and chloride levels were also noted. Serum magnesium level, thyroid function test, and cortisol level were within normal limit. Treatment for hypokalemia was initiated by oral and intravenous supplementation of potassium (2.2 mmol/L). Serum potassium level remained low (3.1 mmol/L) after oral potassium supplementation and intravenous infusion of potassium chloride .The results of biochemical studies on admission were shown in Table Initially, AN with remote vomiting was highly suspected as the etiology of hypokalemia because laboratory data were compatible with remote vomiting or diarrhea and in accordance with the hypokalemia differential diagnosis flow chart Fig. . She strThus, the other etiologies apart from AN were investigated. High aldosterone level (290.3 pg/mL) and low renin level (2.74 pg/mL) with extremely high aldosterone-to-renin ratio (105.8) biochemically indicated the diagnosis of PA. Contrast enhanced computed tomography scan of abdomen revealed a well-circumscribed homogenous mass, 2.2 cm in diameter, in the inner arm of the right adrenal gland, confirming the diagnosis of PA (Fig. 3 PA results in sodium and fluid retention, leading to extracellular volume expansion. Further, hypervolemia results in hypertension and suppressed renin secretion. Other effects of aldosterone may contribute to increased blood pressure levels in PA. In fact, aldosterone promotes the vascular action of angiotensin II, impairs endothelial function, alters vascular compliance and activates sympathetic ways in central nervous system mechanisms.The main clinical manifestation of PA is the combination of hypertension and hypokalemia. Although recent studies have found that the incidence of hypokalemia is only approximately 50% in patients with PA, the vast majority of patients suffer from hypertension. first reported a normotensive patient with PA. To date, only a total of 30 such cases were reported in China and other countries. Rossi et al analyzed the 26 normotensive patients with PA in the literature, showing that 85% of cases were from Europe and Asia, especially and mainly from Japan. Most of the patients were middle-aged and females. Blood pressure level is the product of cardiac output and vascular resistance. Vascular resistance is the resultant of 2 opposite systems: the vasoconstrictor system which tend to increase blood pressure and the vasodilator system which tend to lower it. Patients with normotensive PA may have lower level of vasoconstrictor system or higher level of vasodilator system. Lower level of vasoconstrictor system may result from lower secretion of, or decreased responses to vasoconstrictor factors, such as angiotensin II and catecholamines. High level of vasodilator system may result from higher secretion of vasoconstrictor factors, such as Prostaglandin E, Kallikreins and nitric oxide, or increased responses to these factors. Excessive urinary kallikrein excretion was found in a patient with normotensive PA.There have been a few reports of normotensive PA in China and abroad. In 1972, Brooks et al  Patients with AN usually present with extracellular volume depletion and associated with metabolic alkalosis, hypokalemia, hypophosphatemia, and hyperreninemic hyperaldosteronism. Among these presenting symptoms, hypokalemia is the most commonly encountered and may be due to potassium deficiency from restricting diet, repeating vomiting, and excessive renal loss. In patients with AN, estimated prevalence of hypokalemia was 19% to 20% in studies.AN, a type of eating disorder characterized by self-enforced starvation and vomiting for the maintenance of body weight, is a psychiatric disease with increased prevalence.–21 (Fig. Our patient's clinical features presented as AN such as low body mass index and hypokalemia. According to hypokalemia differential diagnosis flow chartIn summary, PA rarely presents with normal blood pressure and hypokalemia, mimicking AN at a young age. We concluded from our case that, for adrenal incidentaloma with hypokalemia, renal potassium wasting, normotension, and metabolic alkalosis, it is necessary to conduct screening tests for the possibility of PA, after the exclusion of other etiologies.Conceptualization: Yu-Wei Fang, Mei-Lan Tu.Supervision: Ming-Hsien Tsai, Yu-Wei Fang, Mei-Lan Tu.Validation: Ming-Hsien Tsai, Yu-Wei Fang, Mei-Lan Tu.Writing – original draft: Yen-Chu Huang, Mei-Lan Tu.Writing – review & editing: Yen-Chu Huang, Mei-Lan Tu.


Background: Despite the benefits of physical activity on cardiovascular risk in kidney transplant recipients (KTRs), the long-term effects of exercise have been poorly investigated. This is a three-year observational study comparing graft function and cardiovascular risk factors in active KTRs (AKTRs) vs. sedentary KTRs (SKTRs). Methods: KTRs with stable renal function were assigned to active or sedentary group in relation to the level of daily physical activity based on World Health Organization (WHO) recommendations . Complete blood count, renal function indices, lipid profile, blood pressure and anthropometric measures were collected yearly for an observation period of three years. The comparisons between the two groups were performed by repeated measures analyses of covariance (ANCOVAs), with age as a covariate. Results: Fifty-four subjects were included in the study. Thirty of them were identified as AKTRs  and 24 as SKTRs . Baseline characteristics were similar between the groups except body mass index (BMI) that was significantly higher in SKTRs (p = 0.043). Furthermore, over the three-year observation period, BMI decreased in AKTRs and increased in SKTRs (p = 0.006). Graft function was stable in AKTRs, while it showed a decline over time in SKTRs, as indicated by the rise in serum creatinine levels (p = 0.006) and lower eGFR (p = 0.050). Proteinuria, glucose and uric acid levels displayed a decrease in AKTRs and an increase in SKTRs during the three-year period . Finally, concerning lipid profiles, AKTRs had a significant reduction over time of triglycerides levels, which conversely showed a clinically relevant increase in SKTRs (p = 0.014). Conclusions: Our findings indicate that regular weekly exercise training may counteract the increased cardiovascular risks and also prevent graft function decline in KTRs. Kidney transplantation is the gold standard treatment for end stage renal disease. Patients receiving kidney transplant have a cardiovascular mortality rate dramatically increased compared to the general population, although lower than patients on maintenance dialysis ,2.Cardiovascular disease (CVD) remains the main cause of death with functioning graft worldwide ,4. ThereThe decrease of graft function between the first and the third year after transplant is also significantly predictive of patient survival, and a decline in estimated glomerular filtration rate (eGFR) above 30% results in a more than doubled cardiovascular mortality rate in KTRs ,9.Systolic (SBP) and diastolic blood pressure (DBP) are associated with heart failure and CVD in KTRs. It is worth noting that hypertension and reduced renal function are independent predictors of cardiovascular risk and end-organ damage . ProspecEmerging research also demonstrates that sedentary lifestyle in KTRs is predictive of CVD and premature mortality . On the A recent review by Takahashi et al. analysed the potential benefits of physical activity on renal function and cardiovascular risk factors in KTRs up to a time frame of 12 months . HoweverThe present study is a three-year observation of the changes in renal function indices and cardiovascular risk factors over time in active KTRs compared to sedentary KTRs. In particular, we aimed to assess whether regular physical activity may have beneficial effects on cardiovascular burden in KTRs during a three-year period.This is an observational cohort study on clinically and functionally stable active and sedentary kidney transplant recipients . Demographic features, complete blood count, renal function indices, lipid profile, transplant-related parameters, blood pressure and anthropometric measures (weight and height) from 30 AKTRs and 24 SKTRs were collected during an observation period of three years with a 12 ± 1-month interval between each data entry. Participants were enrolled from two clinically distinct populations. Between January 2013 and November 2016, AKTRs were recruited from the Italian National Association of Dialysis and Kidney Transplanted Sportsmen , which organises the national transplant games every year in partnership with the World Transplant Games Federation (WTGF). SKTRs were recruited from the Nephrology, Dialysis and Renal Transplant Unit of the S. Orsola-Malpighi University Hospital of Bologna during routine follow up visits. Patients in both groups were selected according to the eligibility criteria consisting in age range of 45–51 years, time after transplantation between 6 and 8 years, 20–30 months of dialysis vintage prior to transplantation, non-smokers and no recent episode (at least 3 months) of rejection with the related treatment. Exclusion criteria were clinical instability, orthopaedic limitations, psychiatric or neurological disorders and proteinuria within the nephrotic range. Moreover, patients with ascertained diabetic nephropathy were not included.Global recommendations on physical activity for health published by the American College of Sport Medicine and the World Health Organization to promote and maintain health for adults ,25 were Written informed consent was obtained from the patients before inclusion, in accordance with the procedures approved by the Ethics Committee. This trial was registered in the ISRCTN registry  and was conducted in compliance with the ICH Guidelines for Good Clinical Practice, the Helsinki Declaration and national rules regarding clinical trial management.Blood and urine samples were collected in both groups under clinically stable conditions , and in AKTRs at least 24 h after exercise. Blood samples were taken from patients in a seated position and fasting state (at least 10–12 h fasting) and assayed using the automatic haematology analyser ADVIA 212, Haematology System .The following laboratory parameters were recorded for all the study participants yearly: serum creatinine (mg/dL) measured using the Jaffè method ,27; estiibrated) ; protein2 units) every year during the three-year observation period in both groups.Body weight was recorded and height was measured using a calibrated stadiometer. Body mass index (BMI) was derived as the ratio between body weight and the square of the height . For accurate blood pressure recording, standard procedures were used in line with the AHA guidelines [SBP and DBP were repeatedly collected during the study in both groups using a manual sphygmomanometer  and the amount of physical activity expressed in number of sessions per week and the total time per session (training volume).t-test or Chi-squared test. Repeated measures analyses of covariance (ANCOVAs) with one within subject factor (time) and one between subject factors (group) and age as a covariate were used. This analysis allows for testing of the main effects of group and main effect of time, as well as the interaction of group and time. This interaction indicates whether the change over time is determined by group (active vs. sedentary). Bonferroni corrected post-hoc tests were used to assess significant interaction effects. Furthermore, to evaluate the effects of individual physical activity volume (expressed in minutes/week) on cardiovascular risk factors (BMI and blood pressure parameters), linear mixed regressions were performed with training volume as independent variable. These mixed model regressions were used with random intercepts for individual subjects to account for the within-subject variability due to repeated measurements. For all analyses, statistical significance was set at p < 0.05. The statistical analysis was performed using SPSS, Version 20 .All descriptive data are presented as the mean ± standard deviation. Baseline comparisons between active and sedentary groups were performed using Student’s The baseline characteristics and non-modifiable risk factors  of the two groups are presented in p = 0.043). None of the participants in either group had diabetes, dyslipidaemia, respiratory disease or peripheral vascular disease. No major cardiovascular events occurred before and after transplantation. All KTRs were on regular immunosuppressive therapy. Immunosuppressive drug treatment consisted of corticosteroids in all KTRs, cyclosporine and antimetabolic agent (azathioprine and mycophenolate mofetil) in 30 subjects  and tacrolimus and mycophenolate mofetil in 24 KTRs .At baseline, a higher BMI was observed in SKTRs compared to AKTRs (p = 0.006), with decreasing values over time in AKTRs and increasing in SKTRs. A significant time ×group interaction was also observed for creatinine (p = 0.006). Specifically, AKTRs had stable renal function, while SKTRs experienced a decline in renal function, as indicated by the increase in serum creatinine levels over time. Accordingly, a similar interaction was observed for eGFR (p = 0.050), that showed an increase in AKTRs and a progressive reduction in SKTRs. Furthermore, a significant interaction was noticed for proteinuria (p = 0.015) and uric acid (p = 0.013), both decreasing over the three-years period in AKTRs and rising in SKTRs.A significant time × group interaction was found for BMI (p = 0.004), with AKTRs decreasing and SKTRs increasing fasting blood glucose. Finally, a significant group × time interaction was found for triglycerides (p = 0.014), with decreasing levels in AKTRs and a clinically relevant increase in SKTRs over time that exceeded the normal reference values. No significant between-group differences or interactions were detected for total cholesterol, HDL, LDL, SBP, DBP, MAP and pulse pressure.Another significant time × group interaction was observed for glucose levels (p = 0.0017), an about 0.4 mmHg lower DBP (p = 0.0358), an about 0.7 mmHg lower MAP (p = 0.0059) and an about 0.8 mmHg lower pulse pressure (p = 0.0063). Increased BMI showed an association with higher physical activity level , although not statistically significant (p = 0.135). The mixed model regressions showed a significant relationship of individual physical activity volume on all blood pressure variables: a 60 min/week higher physical activity level corresponded to an about 1.0 mmHg lower SBP , indicating that even vigorous-intensity activities may be protective for patients with chronic kidney disease (CKD) and after transplantation [In a prospective study of 4011 adults by Cohen et al., both energy expenditure in leisure-time physical activity and exercise intensity were found to be inversely associated with rapid kidney function decline  effects of regular physical activity on renal function, lipid profile and blood pressure in KTRs. Our findings support the concept that regular weekly training may counteract cardiovascular risks typically experienced by this patient population, may promote health and may support maintenance of renal function in KTRs.An important point to address in the future is the positive economic impact of practicing regular physical activity and the potential cost savings of exercise in solid organ transplanted patients. Further investigations should also be aimed to understand if AKTRs experience less long-term CVD and fewer hospital readmissions compared to their sedentary counterparts.


Capsicum annuum L., Garcinia cambogia, Centella asiatica L., artichoke, and Aesculus hippocastanum L. which are virtually devoid from side effects, but rich in antioxidant and antiradical properties, could represent a valid therapeutic adjunct in the clinical management of nephropathic patients. Moreover, quantitative analysis performed in vitro on such compounds showed that they expressed good total antioxidant  and antiradical activity (above 80%). In this study, 23 male nephropathic patients and 10 age and body composition parameter matched healthy males (control group) were enrolled and took 3 cps/day of OFS for 5 weeks. At the end of the study, the nephropathic patient group showed a statistically significant reduction in the following laboratory parameters: total cholesterol (TC) (p = 0.044), atherogenic index TC/high-density lipoprotein cholesterol (p = 0.010), inflammatory parameters , systolic (p = 0.044), and diastolic arterial blood pressure (p = 0.003). Regarding body composition, there was an increase in total body water % (p = 0.035) with redistribution of extracellular water % (p = 0.030) and intracellular water % (p = 0.049). In the control group, there was a reduction in fat mass % (p = 0.017) and extracellular water % (p = 0.047). Therefore, this OFS may represent a valid adjunct therapy to counteract comorbidities related to uremia.Nephropathic patients show elevated cardiovascular morbidity and mortality compared to the general population. In order to delve deeper into the understanding of this phenomenon, it is necessary to recognize risk factors that are distinctive to the uremic state, such as oxidative stress and chronic low-grade inflammation. Moreover, gender differences have been reported in nephrology, as it has been observed that chronic kidney disease has higher prevalence in males than in females. The use of an oral food supplement (OFS) containing natural active compounds from  During the last century, a substantial increase in the incidence of chronic noncommunicable diseases (NCDs), such as cardiovascular diseases (CVD), chronic kidney disease (CKD), diabetes mellitus (DM), and cancer, has been observed , 2.Up to this day, NCDs represent the primary cause of death in both developed and developing countries . In thisPatients affected by CKD frequently present a series of comorbidities, prevalently at the cardiovascular (CV) level; therefore, a new clinical entity has been defined as “type IV cardiorenal syndrome,” characterized by the presence of chronic renal failure which induces a reduction in cardiac function, left ventricular hypertrophy, and increased risk to develop CV complications .Amongst factors related to cardiac dysfunction in CKD patients , volume In fact, CKD patients show an elevated prevalence of AH, principally correlated with extracellular volume expansion ; in turnOther CV risk factors typical of the uremic state are chronic low-grade inflammation, hyperhomocysteinemia , 16, insUremic toxins can precipitate in the progression of CKD, through various mechanisms such as renal fibrosis, loss of antioxidant defenses, dysfunction, and apoptosis of renal tubular cells and endothelial cells, contributing to the generation and propagation of the chronic low-grade inflammatory state which characterizes this pathology –24.Regarding the increment in oxidative stress (OS), which can be observed in CKD patients , it is iInterestingly, gender differences have been documented in the field of nephrology and in this regard women seem to be protected from developing end-stage renal disease (ESRD) , 31.A screening study has highlighted how the cumulative incidence of ESRD is lower in women during reproductive age and starts increasing 10 years later than in men . This hain vitro and in vivo studies have focused on researching natural bioactive compounds, which would be ideally free from side effects and would increase the therapeutic potential of standard treatments, as well as having a preventive role in the development of CKD comorbidities ; a value < 0.5 is considered as the threshold value above which there is an increased atherogenic risk in both sexes , 52.The atherogenic indices were calculated as described:These indices were determined in order to optimize the predictive capacity of the lipidic profile. In fact, such ratios can supply additional information on CV risk factors which are difficult to quantify with routine laboratory analysis. Moreover, they can depict a more precise picture regarding metabolic and CV alterations, which are closely correlated to lipidic fractions.2).Anthropometric parameters of all the participants were recorded according to standard methods . Body weFor the evaluation of body composition, all enrolled subjects performed bioelectrical impedance analysis (BIA). Resistance, reactance, impedance, and phase angle at 50 kHz frequency were measured using a BIA 101S instrument (Akern/RIL System-Florence). Body composition analysis was assessed through total body water (TBW), intracellular water (ICW), extracellular water (ECW), body cell mass index (BCMI), fat-free mass (FFM), fat mass (FM), and muscle mass (MM) .Systolic and diastolic blood pressure (BP) was monitored at T0 and T1. Patients were made to sit in a relaxed position for 5 minutes, and then the measurement was taken. The arm cuff was positioned at the level of the heart. BP was measured thrice between intervals of 1-2 minute duration. Ulterior measurements were taken only if the first two presented a difference above 10 mmHg between each other. The reported value was the average between the last two measurements, for both systolic and diastolic BP. During the first visit, BP was measured in both arms; in case of any differences between the two, the highest one was recorded. Additionally, the heart rate was recorded to exclude the presence of eventual arrhythmias .The carotid intima-media thickness (CIMT) was measured at the beginning and the end of the study. All ultrasound examinations were performed by the same operator (A.N. with 10 years of experience in ultrasound). In our study, a MyLab70 VXG ultrasound device , with a linear LA523 probe, at a 2–9 MHz frequency range, was used to achieve all examinations. The CIMT was assessed with an ultrasound examination in B-mode, at the level of the right common carotid artery. A longitudinal section of the right common carotid artery was obtained; three different CIMT measurements were performed, about 1 cm below the bifurcation, in the plaque-free area, on the distal wall of the right common carotid artery, using a semiautomatic application. The CIMT thickness was the result of the average value of the three measurements obtained. This procedure was executed in accordance with the Mannheim protocol .Two questionnaires were administered to the enrolled subjects: PREDIMED and IPAQ at T0 and T1.The PREDIMED was administered to assess adherence to the Mediterranean diet and in order to make sure that any changes in body composition, inflammatory status, or other laboratory parameters observed in enrolled subjects were really due OFS administration rather than to changes in dietary habits.The IPAQ was administered to evaluate the degree of physical activity before, during, and after OFS treatment, in order to exclude possible laboratory and body composition changes induced by a different degree of physical activity.t-test. The minimal level of significance of the differences was fixed at p < 0.05. Comparison among groups was performed with the univariate ANOVA with a covariate for continuous parametric variables. Furthermore, the short matrices of data of PREDIMED, IPAQ, and CVD comorbidities were analyzed with McNemar's test [Data is reported as means ± standard deviation for parametric variables. All continuous variables were checked for normality using the Kolmogorov-Smirnov test. Differences between the baseline and the final outcomes for parametric values were tested with a paired r's test . This an· test, which accounts for the antiradical activity of the sample. The data is reported in per gram of food supplement is equal to 7.28 GAE expressing a good total antioxidant capacity. Such result can be correlated with the in vitro antioxidant capacity on human LDL [Regarding total polyphenol content, antioxidant, and antiradical activity, data was considered from two tests: the Folin-Ciocalteu reagent test, which is related to the antioxidant activity of the commercial product, and the DPPHuman LDL –45. The The epidemiologic characteristics of the population studied, coupled with a homogeneity evaluation of the two groups relative to age and body composition, are reported in p = 0.044) was observed in CKD patients. Moreover, in nephropathic patients, an improvement in the inflammatory status was also observed at T1, shown by the significant reduction in both C-reactive protein (CRP)  and erythrocyte sedimentation rate (ESR) .p = 0.010) in CKD patients. Other indices presented no variation secondary to OFS administration. In Regarding the atherogenic indices, as reported in p = 0.001) was highlighted. Regarding body water content, a significant increase in TBW was observed at T1  with a better redistribution of water from the extracellular  to the intracellular compartment . A significant increase in FFM  was also noted. The improvement in TBW redistribution has a favorable effect on the systolic and diastolic BP values, as reported in With the aim to exclude the influence on the examined parameters induced by possible lifestyle modification, and in order to evaluate the real effects of the OFS, the PREDIMED and IPAQ questionnaires were administered at T0 and at T1. The PREDIMED evaluated adherence to the Mediterranean Diet, whilst the IPAQ monitored changes in physical activity of enrolled subjects. As highlighted in Tables p = 0.017) associated with a significant reduction in ECW  (p = 0.014) was observed.Regarding the healthy control group, as shown in Tables = 0.047)  and FM  and induce nitric oxide (NO) production in human vascular endothelial cells [Moreover, it has been estimated, by analyzing urea nitrogen urinary excretion and 24 h sodiuria, that protein and salt intake are lower in female subjects compared to males . Therefoal cells . The resal cells .Centella asiatica L., it is hypothesized that its antihypertensive effect is produced by the flavonol quercetin. Such hypothesis was confirmed in an animal study on male Wistar rats, in which hypertension was induced by N-nitro-L-arginine methyl ester (L-NAME) administration. After 30 minutes of L-NAME administration, a Centella asiatica L. extract was given, which induced the lowering of systolic and diastolic BP values by acting on eNOS and NO production [Regarding oduction .Capsicum annuum L. In fact, the active compound present in its extract, named capsaicin, inhibits angiotensin-converting enzyme (ACE) [2+ channels present on smooth muscle cells [An ulterior antihypertensive effect could be correlated to me (ACE)  and L-tyle cells . Moreovele cells . Such efCapsicum annuum L., characterized by the activation of thermogenesis, induction of satiety, fat oxidation [In the healthy control group, the present study highlighted a significant reduction in FM% after OFS administration; such result may be correlated with the antiobesogenic effects of xidation , increasxidation , inhibitxidation , and modxidation . Moreovexidation . Consequxidation .Capsicum annuum L. extracts. In fact, artichoke was proven to act upon lipid metabolism by inducing a reduction in cholesterol production, by reducing its biosynthesis through the inhibition of β-hydroxy β-methylglutaryl-CoA (HMG-CoA) reductase [Capsicum annuum L., both in vitro and in vivo studies have demonstrated how it can reduce TC, triglycerides, and LDL-C, while causing a possible increase in HDL-C [in vitro study, how capsaicin is able to induce a moderate transactivation of a peroxisome proliferator-activated receptor (PPARα), thus positively acting on the lipid profile. This data supports the in vivo study by Kwon et al. [Capsicum annuum L. A series of studies have showed the anti-inflammatory properties of capsaicin, capable of inhibiting inflammatory mediators such as interleukin-6, tumour necrosis factor-α, and E2 prostaglandins. Additionally, an animal study has highlighted how Capsicum Baccatum L. juice may exert an anti-inflammatory action by inhibiting cytokine production in proximity of the inflammation site by reducing the recruitment of neutrophils and proinflammatory cytokines in the exudate [In this study, TC and atherogenic risk index TC/HDL-C reduction in CKD patients could be attributed to the hypolipidemic effects of artichoke and eductase  and by feductase , 78. Regin HDL-C . Muellerin HDL-C  have demn et al. . The autn et al. –84. The  exudate , 86.During the 9 weeks of OFS administration, we had not observed any CV event .In addition, at enrolment, CKD patients showed an increased CIMT with respect to the range of normality , 88, sugThe limitations of the present study reside in the exiguous sample size and the absence of a laboratory parameter monitoring specific oxidative stress biomarkers.Our data regarding male nephropathic patients highlighted a significant reduction in systolic and diastolic BP values, TC, and atherogenic index such as TC/HDL-C; moreover, a positive impact on the inflammatory status is observed. All these parameters contribute to the reduction of CV risk in the studied population.Consequently, the data obtained lays the foundation for the execution of a randomized clinical trial on a larger patient sample, so as to confirm the cardioprotective and anti-inflammatory action exerted by the OFS on nephropathic patients. Moreover, it would be interesting to test the same OFS on patient populations affected by other NCDs like cancer and/or DM.