Diabetic kidney disease (DKD) is the primary cause of end-stage renal disease, raising a considerable burden worldwide. Recognizing novel biomarkers by metabolomics can shed light on new biochemical insight to benefit DKD diagnostics and therapeutics. We hypothesized that serum metabolites can serve as biomarkers in the progression of DKD.A cross-sectional study of 1,043 plasma metabolites by untargeted LC/MS among 89 participants identified associations between proteinuria severity and metabolites difference. Pathway analysis from differently expressed metabolites was used to determine perturbed metabolism pathways. The results were replicated in an independent, cross-sectional cohort of 83 individuals. Correlation and prediction values were used to examine the association between plasma metabolites level and proteinuria amount.Diabetes, and diabetic kidney disease with different ranges of proteinuria have shown different metabolites patterns. Cysteine and methionine metabolism pathway, and Taurine and hypotaurine metabolism pathway were distinguishable in the existence of DKD in DC (diabetes controls without kidney disease), and DKD with different ranges of proteinuria. Two interesting tetrapeptides (Asn-Met-Cys-Ser and Asn-Cys-Pro-Pro) circulating levels were elevated with the DKD proteinuria progression.These findings underscore that serum metabolomics provide us biochemical perspectives to identify some clinically relevant physiopathologic biomarkers of DKD progression. Diabetic kidney disease (DKD), accounts for 30–50% of chronic kidney disease at present, and the prevalence of which continues to increase without any sign of mitigation . Aside fGiven DKD was initiated by hyperglycemia-induced metabolic variation , high-thTo address these problems, here we use untargeted metabolic profiling in conjunction with targeted metabolomics from healthy control, diabetes control, and diabetic kidney disease patients in a discovery set, further replicated in an independent validation set. We identified perturbed cysteine and methionine metabolism, and hypotaurine metabolism pathways in DKD patients with moderate and heavy proteinuria. Two short peptide elevations in circulation correlated with the proteinuria severity, which may serve as novel predictors of progressive diabetes.All procedures performed in this study involving human participants followed the Declaration of Helsinki. The study was approved by the Ethical Committee of the First Affiliated Hospital of Zhejiang University School of Medicine. All subjects  provided written informed consent for blood collection.n = 30) group including patients with T2D, no microalbuminuria  and normal renal function (n = 30) group consisted of people with no history of disease or current medication. Estimated glomerular filtration rate (eGFR) was evaluated using Chronic Kidney Disease Epidemiology Collaboration (CDK-EPI) equation, eGFR = 141 × min α× max −1.209 × 0.993Age × 1.018 , where: sCr is serum creatinine in mg/dL, κ is 0.7 for women and 0.9 for men, α is −0.329 for women and −0.411 for men. The clinical baseline characteristics of subjects for screening included in this study is shown in The patients' study groups consisted exclusively of patients with type 2 diabetes (T2D). T2D was defined by disease onset after age 30, treated by diet and insulin or oral hypoglycaemic medication. The DKD group (n = 29) consisted of the patients with T2D and microalbuminuria  or biopsy-proven DKD. The DKD group was further divided into two groups according to 24h-hour urine protein, or calculated as urine protein/creatinine ratio: one group consisted of 17 patients with heavy proteinuria (≥3.5 g/g), and the other group consisted of 12 patients with moderate proteinuria (<3.5 g/g). Diabetes controls without kidney disease  and an internal standard   . After dMass spectrometry (MS) was performed in both positive and negative ion modes, and the instrument parameters were as follows: the capillary voltage was 3 kV in positive mode and 2.6 kV in negative mode with the cone voltage was set at 40 V. The source and desolvation temperature were 110 and 500°C, respectively. MS analysis that simultaneously acquires both precursor and fragment mass spectra was performed on the mass spectrometer with a low collision energy of 10 eV and a ramp of 20–55 eV for high collision energy. The MS acquisition rate was set to 0.3 s with a 0.01 s interscan delay. MS data were collected in full scan mode ranging from 50 to 1,000. Nitrogen was used as both the desolvation gas (800 L/h) and the cone gas (50 L/h). The time of flight analyzer was used in Resolution mode. Leucine-enkephalin was used as the reference compound (m/z 556.2771 in ESI+ mode and m/z 554.2615 in ESI-mode) at a concentration of 200 ng/ml with a flow rate of 5 μl/min . Metaboln = 60) included the patients with a history of T2D and presence of microalbuminuria  or biopsy-proven DKD. The DKD group was further divided into two groups according to the Urine protein/creatinine ratio: one group consisted of 35 patients with heavy proteinuria , and the other group consisted of 25 patients with moderate proteinuria . The healthy control  group included the people with no history of disease or current medication.The diabetic kidney disease (DKD) group , Asn-Cys-Pro-Pro (NP)] were quantitated by LC-MS with a triple quadrupole mass spectrometer . Peptide standards synthesized and purchased from GL Biochem were used to develop and optimize multiple reaction monitoring (MRM) transitions. Peptide standards were separated chromatographically on a C18-based column with polar embedded groups  using an ABSCIEX enhanced high-performance hybrid triple quadrupole mass spectrometer with an autosampler. The flow rate was 0.4 ml/min using the following flow program: Buffer A: 99.9% Hhttp://www.metaboanalyst.ca). Benjamini-Hochberg's step-down approach was used for false discovery rate correction during multiple comparisons. Normalization was carried out by using median, log transformation, and mean centering to standardize the data and make the features more comparable.Statistical analysis for the baseline characteristics of participants was performed using GraphPad Prism 9.0.0 software . All data are presented as the mean± SEM. Chemometrics analysis such as PCA and OPLS-DA analysis, univariate volcano plot analysis, cluster heatmap analysis was carried out by MetabAnalyst 5.0 . Non-normally distributed data or data with a heterogeneity of variances was analyzed by using a non-parametric test . Spearman's tests were applied to determine the correlation of multiple variables with Metabolites peak area in DKD patients. A receiver operating characteristic (ROC) curve was used to evaluate the prediction value. All P values were two-tailed, and P <0.05 was considered statistically significant.Kolmogorov-Smirnov test was used to assess for normal distribution of the data. Normally distributed data with homogeneity of variances was analyzed by using a parametric test .The baseline demographics and clinical data of the patients and controls are shown in A clear separation between healthy controls (HC), diabetic controls (DC), and diabetic kidney disease patients (DKD) was displayed in the unsupervised Principal Component Analysis (PCA), with PC1 at 24.1% and PC2 at 7.5% . The sigP-value corrected applying the Benjamini-Hochberg procedure, differentially expressed metabolites (DEMs) of these groups were defined as metabolites with a significance level of <0.05 (FDR) and absolute fold-change >1.5 or < 0.67, we obtained the differentially expressed metabolites (DEMs) of these groups.On the whole, 1,043 metabolites were relatively quantified using LC/MS after strict quality control, 368 metabolites had >20% missing observations were excluded from the analysis. An overview metabolite profiles heatmap between three groups, ie. healthy controls (HC), diabetic controls (DC), diabetic kidney disease patients (DKD) is shown in P-value, HMDB number, and KEGG ID are provided in Of these, 113 metabolites were significantly upregulated and 166 metabolites were significantly downregulated between DC and HC groups . Similarp <0.05  to screen the differential metabolites in the comparison of diabetic kidney disease (DKD) vs. diabetic control (DC) and diabetic kidney disease with heavy proteinuria (DKD-H) vs. diabetic kidney disease with moderate proteinuria (DKD-M). That is to say, to identify disturbed pathways that perturbed in the onset of DKD, and altered continuously in the progression of DKD. Among the identified enriched pathways from the differential metabolites, the hypotaurine metabolism pathway, cysteine, and methionine metabolism pathway were found with the significance of p <0.05 . Serum Lp <0.05 . Althougp <0.05 . Taurinep <0.05 , 19, whiDuring the process of the above pairwise comparison, to find metabolites associated with the progression of DKD, we focused on the two comparisons, DKD vs. DC and DKD-heavy vs. DKD-moderate, in purpose to detect who was susceptible to kidney disease in diabetes condition and who were vulnerable to progressive proteinuria under DKD. Eleven collective metabolites were significantly upregulated in DKD compared to DC and in DKD-H compared to DKD-M, and seven common metabolites that downregulated in DKD compared to DC and in DKD-H compared to DKD-M were found (fold change > 1.5) .To simplify the metabolite biomarker panel for possible clinical application, we concentrated on the metabolites that: (1) have commercially available reference compounds and (2) have a higher difference in the two comparisons (fold change>2 or fold change <0.5). Among the 4 metabolites , Asn-MetTwenty-three healthy controls and sixty diabetic kidney disease patients were recruited for further validation. The baseline demographics and clinical data of the patients and controls in verification group are shown in p <0.01), while Asn-Cys-Pro-Pro was independent of urine protein and UACR level in DKD patients  and UACR (g/mol·Cr) , diabetic kidney disease (DKD) brings a substantial burden worldwide . It is uvia the methionine cycle, or turned into cysteine via the transsulfuration pathway , cysteine and methionine metabolism pathway and hypotaurine metabolism pathway have drawn our attention. Although circulating cysteine itself elevated 1.5-fold compared DKD to DC, and does not seemto show much alteration between the two different proteinuria groups of DKD, it must be taken into account that being “unchanged” may be an illusion caused by alteration in the same direction in the synthesis and breakdown. Homocysteine was widely researched in the past decades, whether it is an independent risk factor in DKD is controversial . Homocys pathway . The ele pathway , these p pathway , 25.Disturbed taurine and hypotaurine metabolism pathway in STZ-induced diabetic mice was discovered by Nuclear magnetic resonance (NMR) spectroscopy . Taurinep-value <0.05) in both comparisons of DKD vs. DC and DKD-H vs. DKD-M. Finally, two tetrapeptides, Asn-Met-Cys-Ser and Asn-Cys-Pro-Pro were chosen in the next validation. In another population made up of 23 healthy controls, 35 DKD with heavy proteinuria patients and 25 DKD with moderate proteinuria patients, serum Asn-Met-Cys-Ser levels were correlated with the severity of proteinuria, while Asn-Cys-Pro-Pro seems similar in the two sets of proteinuria group. Dietary protein does not need to be hydrolyzed completely into amino acids before they are absorbed in the gastrointestinal tract. Food digestion produces a huge number of short peptides (oligopeptides), every possible di-peptides and tri-peptides digested by peptidases can enter into intestinal endothelium via the PepT1 transporter and have access to the hepatic portal system  can be found below: The studies involving human participants were reviewed and approved by Ethical Committee of the First Affiliated Hospital of Zhejiang University School of Medicine. The patients/participants provided their written informed consent to participate in this study.XP, XS, and HJ designed this project. XP and XW performed experiments with help of YW, SF, and CW. CY, XP, and XS prepared the figures and wrote the manuscript. JC and HJ supervised work and acquired funding. All authors participated in discussions about this study and approved the final version to be published.This work was supported by grants from the National Key Research and Development Plan (2018YFC1314003).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Hypernatremia often occurs in patients with brain death. This study summarizes its characteristics.We recorded 57 patient's highest blood sodium value, as well as daily NT‐proBNP, blood creatinine, and urine output. Further, we analyzed the time of the first rise in blood sodium, and the relationship between NT‐proBNP, serum creatinine, urine output, and serum sodium.There was no hyponatremia in these patients, and only seven of the 53 patients registered blood sodium between 137 and 150 mmol/L. We found that blood sodium started to rise at 36.0 (28.5–52.3) h, reaching the highest value in 79.0 (54.0–126.0) h. Urine volume and creatinine have no correlation with serum sodium level, while NT‐proBNP has a significant correlation with serum sodium level.It is necessary to conduct volume assessments and urine electrolyte testing on patients with brain death. BNP has a protective effect on water and electrolytes to prevent hypernatremia. It is necessary to conduct volume assessments and urine electrolyte testing on patients with brain death. BNP has a protective effect on water and electrolytes to prevent hypernatremia. All patients underwent electroencephalogram (EEG), evoked potentials, transcranial Doppler (TCD), and breath provocation tests. We recorded each patient's highest blood sodium value, as well as each day's NT‐proBNP, blood creatinine, and urine output . Written informed consent was obtained from all included patents’ family.Statistical analyses were performed using the SPSS software . Correlations of quantitative variables were analyzed by Spearman rho correlation tests. Differences between the groups were assessed by the 33.1ẋ of age was 41.92 ± 13.64 years old. The age range was from 14 to 66 years  h. Forty‐three patients were included in the statistics in the maximum ground 79.0 (54.0–126.0) h , thereby suggesting that the patient's NT‐proBNP level decreased as the patient's serum sodium increased  mmol/L, and the median (interquartile) value was 163.5 (153.3–170.0) mmol/L. The lowest value of NT‐proBNP was 5 pg/ml, and the highest value was 19,903 pg/ml, the median (interquartile) of NT‐proBNP was 1057.5 (298.3–2047.8) pg/ml. Their distribution was as follows: the abscissa was the blood sodium concentration (mmol/L), and the ordinate was the NT‐proBNP concentration (pg/ml). Spearmen correlation analysis showed that there was a significant correlation between high serum sodium levels and NT‐proBNP, and the difference was statistically significant (3.4p = .683)  mmol/L; the minimal urine output is 500 m/12 h, and the maximum urine output is 3235 ml/12 h [2048.0(1380.0–2500.0) ml/24 h]. Their distribution was as follows: the abscissa was the blood sodium concentration (mmol/L), the ordinate was the urine output (ml/12 h). Spearmen correlation analysis showed that there was no significant correlation between high serum sodium levels and urine output, and the difference was not statistically significant   pg/ml. Their distribution was as follows: the abscissa was the blood sodium concentration (mmol/L), the ordinate was the creatinine (umol/ml). Spearman correlation analysis showed that there was no correlation between high serum sodium levels and creatinine . There was no statistical difference between the two groups , and 15 in the nonmannitol group (163.60 ± 9.69 mmol/L). To record the highest blood sodium value while recording the blood creatinine value, we performed an independent sample 4The important goal in the care of brain‐dead potential organ donors is to stabilize their hemodynamic status  h, we found that blood sodium started to rise, reaching the highest value in 79.0 (54.0–126.0) h. Hypernatremia in patients with brain death mainly leads to internal environmental disorders that can lead to organ dysfunction, which presents a challenge in the protection of donor organs . Our data only considers urine output. In this study, the urine output of patients is generally too large.Second, there is no correlation between our serum creatinine and serum sodium. The possible reason is that the patients in this study generally have large urine volumes and the original renal function is normal. Patients with brain death are likely to experience acute kidney injury due to insufficient capacity. In acute kidney injury, renal tubular function is impaired, and hyponatremia is caused by decreased sodium retention capacity. Studies have shown that in acute renal ischemia, the expression of sodium transporter in the proximal tubules and distal tubules of the kidney decreases during perfusion, which leads to the decline of the renal sodium retention capacity  is a 32 amino acid cardiac natriuretic peptide hormone originally isolated from porcine brain tissue. NT‐proBNP (76 amino acids) can be measured by immunoassay in human blood. Under the action of proBNP endodicerase, it is cleaved into BNP with beneficial sodium, diuretic, vasodilator, and other biological activities, and nonbiologically active N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) (Maisel et al., Natriuretic peptides are molecules that normally defend against periods of excess water and salt retention by antagonizing the RAAS system, promoting vascular relaxation, and inhibiting excess sympathetic outflow and the generation of vasoconstrictor peptides (Yee et al., None.The authors declare no conflict of interest.WX‐G is responsible for the experiment and drafting the manuscript. XL‐L assisted in the experiment. ZH‐W assists in conceiving and drafting manuscripts. PH‐H helps to analyze experimental data. XB‐W assisted in completing the manuscript. SH‐W helped to revise the manuscript. Everyone has read and agreed to the final manuscript.https://publons.com/publon/10.1002/brb3.2574.The peer review history for this article is available at


In this study, two categories of persons with normal and high ABP are subjected to the bicycle stress test . All persons are physically active men but not professional sportsmen. The mean and the standard deviation of age is 41.11 ± 10.21 years; height 178.88 ± 0.071 m; weight 80.53 ± 10.01 kg; body mass index 25.10 ± 2.06 kg/m The lefThe mathematical classification of the person’s behavior during the stress test is based on a linear approximation inside the variation interval with cut outliers. The formula describing the classification is presented in Now that we have the machine learning algorithms tuned up to the extracted knowledge from the two cohorts, we can demonstrate the efficiency and usefulness of the classification strategy by introducing new candidates. The self-organization of the cardiovascular systems of the two candidates during the load phase of the stress test is investigated by means of the developed machine learning algorithms.For the first candidate, the graph of the RR/JT algebraic relationship and the graph of the arterial blood pressure are overlapped in The classification of slope coefficient of the new candidate into the category of the persons with an elevated ABP rate tells us that that his cardiovascular system is incapable of handling higher loads, and the pressure rises during the load to the limit point of the person’s regulatory system. It is worth noting that despite appearing to have normal ABP, the individual’s physiological response to the load was insufficient. The primary goal of this study is to develop such algorithms which are capable of highlighting such subtle differences.Such situations may arise during antihypertensive therapy, when ABP is normal at the start of the load. However, as the load increases, ABP rises quickly, potentially leading to a slew of pathologic statements . The subtle difference of the individual in this case highlights the peculiarities of the cardiovascular system of a person while during the exercise—especially during the load—and this may help to generate an early warning for an individual.For the second individual, the RR/JT algebraic relationship and ABP data are presented in It is also worth mentioning that we already have a dataset with a sample of individuals who had indications of the conditions known prior to the experiment—these conditions are the cohorts of people with normal ABP and the other cohort of people with increased ABP . This clThe confusion matrix, the sensitivity, the specificity, the accuracy, and AUC-ROC curves could be used for the characterization of a classifier. Slope coefficients reconstructed from the data collected from 19 persons are used to build the model in this paper. However, the most important objective of this study is not the binary classification of the new candidate. The proposed triangular coordinate system d is not A technique for assessing blood pressure regulation in a stress test is presented in this paper. Two categories of persons with normal and elevated blood pressure are exposed. Machine learning algorithms are used to build a set of rules and performance measures during a stress test. Heart rate, JT interval and blood pressure readings are observed during the loading and recovery phase of the exercise. This paper proves that subtle differences in the self-organization of the human cardiovascular system during the stress test are measurable and essential for detecting the individual performance of the candidate. The introduced coordinate system helps to determine whether the new candidate’s cardiovascular response will be more marked by an increase in heart rate or an increase in blood pressure during a stress test. The developed approach provides valuable information about the human cardiovascular system during the exercise.This research study paves the way for identifying ABP dynamics during physical activity and avoiding cases where a sudden increase in ABP occurs or a person experiences hypertensive reactions and enters a hypertonic state. The establishment of such an early warning system based on machine learning algorithms can be especially beneficial for those who use antihypertensive medicines to control their blood pressure. Although blood pressure is kept under control, there may come a time when the cardiovascular system cannot handle the load and all self-regulating systems collapse, causing the blood pressure to rise and lead into an alarming health condition. This study leads to the identification of self-regulating system control mechanisms in the cardiovascular system and thereby could save lives.


Family IA/SAH history was confirmed in 18.1% of the patients, and 54.3% of the patients had hypertension. The IA point prevalence was 12.5%. During clinical follow up of 3104 patient-years, de novo IA was detected in 29 patients (0.93% patient-years). The IA period prevalence was 18.1% . Multivariable logistic regression demonstrated that total kidney volume (TKV) ≥ 1000 mL (odds ratio [OR] = 2.81), height-adjusted TKV ≥ 500 mL (OR = 2.81), Mayo imaging classification Class 1D–1E (OR = 2.52), and chronic kidney disease stages 3–5 (OR = 2.31) were significantly associated with IA formation. IAs in patients with ADPKD may be associated not only with general risk factors for IAs but also with declining kidney function and increased KV. Kidney disease progression may contribute to effective IA screening and treatment planning in patients with ADPKD.Presently, only personal or family history of intracranial aneurysm/subarachnoid hemorrhage (IA/SAH) has been established as a risk factor for IA in autosomal dominant polycystic kidney disease (ADPKD). This study aimed to verify the association between kidney function/volume and IAs in patients with ADPKD. This study included 519 patients with ADPKD. At baseline IA screening, the median age and estimated glomerular filtration rate were 44 years and 54.5 mL/min/1.73 m Female sex, increased age, subarachnoid hemorrhage (SAH) history, and ADPKD10 have been identified as IA risk factors in the general population; nonetheless, to date, only personal or family IA/SAH history has been established as a risk factor for IA in patients with ADPKD11. Until recently, universal IA screening in patients with ADPKD was not recommended by nephrologists13. Therefore, in regions where targeted screening is performed, understanding the overall IA picture in patients with ADPKD can be difficult because it is strongly affected by selection bias. In contrast, universal IA screening for patients with ADPKD has generally been conducted and recommended in Japan15. ADPKD itself is a risk factor for IA formation in the general population10, and mutation in PKD1 and PKD2 and its genotypes affect total kidney volume (TKV)16, kidney disease severity21, and IA23, which suggests that factors associated with ADPKD, including mutations in PKD1 and PKD2, TKV, and kidney function are also probable risk factors for IA in patients with ADPKD. We hypothesized that owing to its genetic etiology, increased KV and declining kidney function would be responsible to a greater degree for IA formation in patients with ADPKD compared to general IA risk factors . In this study, we analyzed the IA/SAH point and period prevalence, novel IA/SAH incidence, and risk factors for IA in a relatively large cohort of patients with ADPKD at a single Japanese institution.The prevalence of intracranial aneurysm (IA) is higher in patients with autosomal dominant polycystic kidney disease (ADPKD) (9–23%)2, and 1054.3 mL, respectively. Family IA/SAH history was confirmed in 94 (18.1%) patients, and 282 (54.3%) patients had hypertension. The IA prevalence and SAH point prevalence among the 519 patients with ADPKD at baseline screening were 12.5% (65 patients) and 3.1% (16 patients), respectively. During a clinical follow up of 3104 patient-years in these 519 patients, de novo IAs were detected in 29 patients , 0.62–1.34%] patient-years for saccular IAs) and three patients had IA rupture . Accordingly, at the time of the last follow up , the IA and SAH period prevalence among the 519 patients with ADPKD was 18.1% (94 patients) and 3.7% (19 patients), respectively.The entire cohort’s patient characteristics are summarized in Tables P = 0.0032). Baseline hypertension  was more frequent and the patients were older on average  in the aneurysm group. Regarding kidney findings during baseline IA screening, the median eGFR was significantly lower in patients with IA (35.2 mL/min/1.73 m2) than in those without , and the median TKV was significantly higher in patients with IA than in those without . The proportions of patients with chronic kidney disease (CKD) stages 3–5  and those with Mayo imaging classification Class 1D–1E  were higher in the aneurysm group.Comparative analyses of the data of patients with and those without IA revealed that the frequency of family IA/SAH history was higher among patients with IAs than among those without , height-adjusted TKV (htTKV) , Mayo imaging classification , and CKD stages , were examined using age-adjusted logistic regression analyses Table , Fig. 1.P = 0.0006) and family history of IA/SAH  were significantly associated with IA formation . Adding TKV to the model of general risk factors increased the AUC to 0.72 and the pseudo-R2 value to 0.11. The TKV  was significantly associated with IA formation, indicating that adding TKV improved the model’s discriminatory ability and goodness-of-fit to predict IAs. Similarly, adding htTKV, Mayo 1D–1E, and eGFR to the model of general risk factors also increased the AUC  and pseudo-R2 value . The htTKV , Mayo 1D–1E , and eGFR  were significantly associated with IA diagnosis. Therefore, adding htTKV, Mayo 1D–1E, and eGFR improved the model’s discriminatory ability and goodness-of-fit to predict IAs. Similarly, multivariable logistic regression analyses based on binary data confirmed ADPKD-related factors, including TKV ≥ 1000 mL , htTKV ≥ 500 mL , Mayo 1D–1E , and CKD stages 3–5  to be significantly associated with IA formation .In the age-specific Kaplan–Meier model, which was based on the age at IA confirmation Fig. , the IA-24, causes cyst formation in the kidneys, leading to various extrarenal complications, including liver cysts25, hypertension, and IAs. Generally, patients with ADPKD carry a germline mutation in one allele of either PKD1 or PKD219. This study revealed multiple IA risk factors in patients with ADPKD. To the best of our knowledge, this was the first study to confirm the association between IA/SAH and kidney function in patients with ADPKD. Multivariable analyses demonstrated that a family history of IA/SAH, hypertension, TKV/htTKV increase (or TKV ≥ 1000 mL/htTKV ≥ 500 mL), Mayo 1D–1E, and decrease in eGFR (or CKD stages 3–5) were significantly associated with IA diagnosis.ADPKD, the most common progressive hereditary kidney disease13. However, the considerable variability in IA prevalence (9–23%) in patients with ADPKD3 indicates the need to further examine this issue. First, it is difficult to accurately determine the IA prevalence and risk levels in patients with ADPKD who have undergone targeted screening, which is theoretically prone to selection bias. Furthermore, accurate information regarding family history of IA/SAH is indeterminable without universal IA screening. Therefore, research reports from regions where universal IA screenings are conducted may be useful.Thus far, as IA prevalence and the risk of small IA ruptures have been considered to be low, indications for IA screening in patients with ADPKD have been limited to those with a family history of IA/SAH, previous IA rupture, a high-risk profession , and anxiety despite adequate information1; TKV (265 patients in Japan)5; age, female sex, intracranial arterial dolichoectasia, and mitral inflow deceleration time for a limited subgroup of high-risk aneurysms (926 patients in Korea)6; and age > 45 years (83 patients in Poland)3. However, no reports have confirmed the association between kidney function and IA/SAH in patients with ADPKD. That said, Yoshida et al.5 found a significant association between TKV and IA/SAH in patients with ADPKD, but not kidney function expressed as eGFR (P = 0.07), which may have been influenced by their smaller study scale (265 patients) than ours (519 patients). In this study, age, female sex, hypertension, TKV, htTKV, Mayo imaging classification of ADPKD, and kidney function showed independent associations with IAs in patients with ADPKD, and our cohort’s large size probably contributed to the results. Hypertension, TKV, htTKV, Mayo imaging classification of ADPKD, and kidney function showed independent associations with IA in all evaluated models, while associations of age or female sex with IA were model dependent. As adding ADPKD-related risk factors to general IA risk factors improved the model’s discriminatory ability and goodness-of-fit to predict IAs, ADPKD-related risk factors such as kidney function/volume could be potentially more important IA risk factors in patients with ADPKD than are general IA risk factors.Recently reported risk factors for IA in patients with ADPKD based on the results of multivariable analyses include: family history of hemorrhagic stroke or IA (355 patients in China)23. As splicing/frameshift mutations are significantly associated with large TKV16, advanced classes of the Mayo imaging classification16, and a poor renal prognosis20, patients with ADPKD with progressive kidney dysfunction or increasing TKV could have splicing/frameshift mutations and consequently be at risk of IA formation. Interestingly, though splicing mutations were significantly associated with IA formation not only in the entire cohort but also in patients with CKD stages 1–3, substitutions showed significant interactions with CKD stages 4–5 and showed a significant association with IA formation only in the sub-cohorts of patients with CKD stages 4–523. This result regarding ADPKD with substitutions suggested the possibility that kidney function itself affects IA formation. Findings in the baseline IA screening of the present study show that eGFR was significantly lower in patients with IA (35.2 mL/min/1.73 m2) than in those without (59.0 mL/min/1.73 m2) and two recent reports on high prevalence of IA in ADPKD patients with end-stage kidney disease  may suggest such an association.We recently conducted a detailed analysis of genetic factors, including mutation types, in patients with ADPKD and IA and found an association between mutation type such as splicing/frameshift mutations and IAs in patients with ADPKD28. However, regardless of whether universal29 or targeted screenings30 are used, it is important to clarify the risk factors for IAs13 and for patients with ADPKD to be informed of their risk of IA formation. As genotypes and mutation types of ADPKD affect total kidney volume (TKV)16, kidney disease severity21, and IA23, genetic tests may contribute to personalized medicine/precision medicine for patients with ADPKD23. Reducing costs of genotyping could make it more accessible for genetic tests, and genotypes and mutation types of ADPKD would be included in the indication criteria for IA screening in future23. However, kidney dysfunction itself has an association with IA formation. Markers of kidney cystic progression and kidney function decline would be a widely applicable criterion for the time being and could be used for screening.Currently, no consensus has been formed for universal screening of IA in patients with ADPKDThis study has some limitations. First, it was an observational study, and a causal relationship could not be proven based on our observations. TKV values were calculated using an ellipsoid formula instead of manual planimetry. No correction was made for the multiplicity of testing, given the exploratory nature of the study. Furthermore, although this study’s strength was its ability to evaluate the vast amount of data stored in the electronic medical records, smoking history was not evaluated.In conclusion, in this study, IA in patients with ADPKD was associated with general risk factors for IA and with declining kidney function and increased KV. The factors observed to be associated with IA in our study may contribute to effective IA screening and treatment planning in patients with ADPKD.31. After excluding 67 patients who did not undergo an MRA intracranial examination, 519 patients were included in the study , between July 2003 and July 2019. Our facility has been conducting universal IA screening since the 2000s. Universal screenings have been conducted every 3–5 years in patients with ADPKD; if IAs are detected, follow-up magnetic resonance angiography (MRA) is performed every 1–2 years32. IA and TKV assessments and comorbidity definitions are presented in Supplementary Methods.During a regular outpatient clinic visit, anthropometric and physical examinations were conducted, including blood-pressure, height, and weight assessments. All biochemical analyses were performed on samples obtained from patients after overnight fasting. The eGFR for Japanese patients was calculated using a previously described formulaThe primary endpoint was IA formation/SAH confirmed with universal MRA screening or based on the medical records. The risk of de novo IA formation was calculated as de novo saccular aneurysm formation based on MRA screening divided by the mean follow up in years. Similarly, SAH risk per patient-year was calculated as SAH incidence in the entire population divided by the mean follow up in years.33, we constructed four multivariate logistic models separately, considering multicollinearity34. Standard methods were used to estimate the sample size for multivariable logistic regression with ≥ 5 outcomes required for each independent variable36. Discriminatory ability was measured using AUCs. Goodness-of-fit was assessed using McFadden’s pseudo-R-squared (pseudo-R2)37 and the small-sample-corrected Akaike’s information criterion38. The time from birth to IA diagnosis was computed using the Kaplan–Meier method and evaluated using the log-rank test. Considering the study’s exploratory nature, we did not adjust for multiplicity. Statistical significance at 5% was considered a marker for potential further investigation. All statistical tests were two-tailed, and all statistical analyses were performed using JMP Pro software .Continuous variables are expressed as means ± standard deviations or medians (range), while discrete variables are expressed as percentages. The Mann–Whitney U-test or unpaired t-test was performed for continuous variables after assessing data normality. The chi-square or Fisher’s exact test was used to analyze categorical variables. Logistic regression analyses were performed to determine factors associated with IA diagnosis. Multivariable logistic regression models were used to estimate the associated risk of IA diagnosis. The variables of interest and general risk factors for outcomes based on existing knowledge were included in the multivariable model. Since KV, Mayo imaging classification, and kidney function demonstrated strong correlationsSupplementary Information.


A significant decrease was seen in MetS, BMI, FRS, SBP, DBP, Hba1c, LDL, triglycerides, cholesterol, and liver enzymes, with a significant increase in high-density lipoprotein levels 12 months postoperatively (p < 0.001). At 12 months, the prevalence of MetS, DM, and HTN and the FRS significantly decreased from 72.5%, 43.1%, 78.1%, and 11.4 to 16.3%, 9.4%, 22.5%, and 5.4, respectively. In addition to achieving substantial weight loss, BS improves MetS prevalence and cardiovascular risk profiles.Bariatric surgery (BS) has been demonstrated to achieve sustained weight loss with significant metabolic improvement, including a reduction in cardiovascular disease and diabetes. The aim of this retrospective study is to measure the effect of BS on the Framingham risk score (FRS) and metabolic syndrome (MetS) among patients who underwent bariatric surgery. Additionally, we determine the effect of BS on thyroid-stimulating hormone (TSH) among euthyroid obese patients. A retrospective follow-up study was conducted at King Abdullah Medical City, Makkah, Saudi Arabia. A total of 160 patients underwent BS and completed one-year follow-up visits. Medical history, anthropometric, biochemical, and hormonal parameters were evaluated at baseline and 3–12 months after BS. The International Diabetes Federation (IDF) criteria were used to diagnose MetS. There was a significant decrease in systolic blood pressure (SBP), diastolic blood pressure (DBP), glycated hemoglobin (Hba1c), TSH, low-density lipoprotein (LDL), triglycerides, and total cholesterol ( Obesity is one of the most prominent epidemics of the twenty-first century; in 2016, more than 650 million were classified as obese worldwide [MetS is strongly associated with the development of diabetes and cardiovascular disease (CVD). To prevent the occurrence of MetS among the obese population, weight loss is a key factor. Lifestyle modifications, dieting, and exercising require long-term commitment . HoweverExcessive weight loss following BS has a positive impact on hypertension control. It has been observed that blood pressure is approximately 84% lower, while 51% of the BS group experienced remission of hypertension compared to 13% of the non-surgical group receiving medication therapy . FavorabFurthermore, thyroid hormone (TH) requirements increase with obesity, which can cause or worsen pre-existing thyroid insufficiency . Obesity2 and obesity related co-morbidities who had not achieved substantial, durable weight loss and co-morbidity improvement with reasonable nonsurgical methods or higher BMI (≥35 kg/m2). Patients with incomplete data records and those with major complications postoperatively were excluded. The study was approved by the KAMC Institutional Review Board (IRB number 21-757). A retrospective follow-up study was conducted among patients who underwent BS at King Abdullah Medical City (KAMC) in Makkah, Saudi Arabia, between January 2016 and December 2019. Inclusion criteria were subjects who underwent BS at KAMC and had completed 12 months of medical and nutritional follow-up visits. Additional criteria included subjects who were aged between 18 and 65 years who had undergone BS and had obesity class 1 with BMI from 30 to 35 kg/mData were collected from the hospital’s medical records and health information system, “Trakcare”. Demographic information and surgery type were recorded for all participants. Data included medical history, BMI, blood pressure, and laboratory results. All data were collected at baseline (preoperatively) and three months and 12 months postoperatively. The medical history of patients who were on diabetic, hypertensive, or dyslipidemia medication or thyroxine hormone replacement, or had been previously diagnosed with one of these diseases, was recorded. Laboratory results included glycated hemoglobin (Hba1c), thyroid stimulating hormone (TSH), liver enzymes  and aspartate aminotransferase (AST)), and lipid profile , and total cholesterol). Fasting blood glucose was not included as the majority of the participants did not have the test postoperatively. All procedures were performed by the same group of surgeons using the same standardized techniques and instruments. For vertical sleeve gastrectomy, they used bougie calibration tube size 36 Fr. in all cases as an optimal choice to balance the effectiveness and perioperative safety of LSG. Moreover, they completely mobilized the gastric funds up to the phreno-esophageal ligament. Regarding the length of the common channel, they do not usually measure the whole length of the bowel except in revision cases; as common practice, they exclude around 100 cm as BP limb and another 100 cm as alimentary limb leaving the rest of bowel as the common channel. Risks and side effects vary by bariatric procedure. Post-op risks and side effects associated with LSG include: blood clots, gallstones , hernia, internal bleeding or profuse bleeding of the surgical wound, leakage, perforation of stomach or intestines, stricture, vitamins, and iron deficiency. The risks of RYGB include: dumping syndrome, gallstones, perforation of stomach or intestines, pouch/anastomotic obstruction or bowel obstruction, protein or calorie malnutrition, and stomach or intestine ulceration. Our group of patients was informed and signed the surgery consent form, including the potential side effects. To reduce the procedure side effects, patients follow a very low calorie diet program at least two weeks pre-op to decrease BMI, with a strict instruction to stop smoking.2, central obesity can be assumed and waist circumference does not need to be measured), plus any two of the following four factors: (1) raised TG ≥ 150 mg/dL (1.7 mmol/L) or specific treatment for this lipid abnormality; (2) reduced HDL-cholesterol < 40 mg/dL (1.03 mmol/L) in males or <50 mg/dL (1.29 mmol/L) in females or specific treatment for this lipid abnormality; (3) raised systolic BP ≥ 130 or diastolic BP ≥ 85 mm Hg or treatment of previously diagnosed hypertension; and (4) raised fasting plasma glucose (FPG) ≥ 100 mg/dL (5.6 mmol/L) or previously diagnosed type 2 diabetes. A Framingham Heart Study online calculator was used to calculate the FRS to estimate the risk of developing CVD [MetS was diagnosed using the five components described by the International Diabetes Federation (IDF) , includip-value was set below 0.05. Due to nonparametric data, p-values were determined by the Friedman test, with the Games-Howell post hoc test used to compare between groups. Spearman correlation was used for associations between continuous variables.Frequency and percentages were used to present categorical variables. Minimum, maximum, and mean ± SD were used to present continuous variables. The Kolmogorov–Smirnov test was used to determine the data normality. A significant A total of 160 participants (65 (40.6%) males and 95 (59.4%) females) were included in the study. The mean age was 41.9 ± 10.6 years. The mean BMI was 48.8 ± 7.3, while 27 (16.9%) patients were active smokers. There were 136 (85%) patients who had undergone laparoscopic sleeve gastrectomy, 10 (6.3%) had undergone Roux-en-Y gastric bypass, and 14 (8.8%) had undergone mini-gastric bypass. The medical history of the participants is presented in Hypertension was diagnosed if systolic blood pressure was ≥140 mmHg on two different days and/or the diastolic blood pressure readings on both days were ≥90 mmHg; diabetes was diagnosed if blood glucose was ≥200 mg/dL 2 h after an Oral Glucose Tolerance Test (OGTT), and hypothyroidism was diagnosed if the TSH value exceeded 4.5 mU/L.p < 0.001) was seen 12 months postoperatively (126.7 ± 22.5 vs. 84.5 ± 13.4). The mean percentage of weight loss was 32.6 ± 7.7. A significant decrease in BMI was also noted (p < 0.001) 12 months postoperatively (48.8 ± 7.3 vs. 32.7 ± 5.5). A significantly lower FRS was recorded (p < 0.001) 12 months postoperatively (11.4 ± 10.5 vs. 5.4 ± 4.7).p < 0.001). A significant decrease in AST (p = 0.022) and ALT (p = 0.012) was noted 12 months postoperatively. However, there was no significant change in TSH.p < 0.001), and total cholesterol (p < 0.002). There was no significant change in mean HDL.p < 0.001 *).p = 0.7) or 12 months postoperatively .The correlation between TSH and BMI showed no significant results either preoperatively .


We conducted a proof of concept study where Anapnoguard endotracheal tubes and its control unit were used in 15 patients with COVID-19 acute respiratory distress syndrome. Anapnoguard system provides suction, venting, rinsing of subglottic space and controls cuff pressure detecting air leakage through the cuff. Alpha-amylase and pepsin levels, as oropharyngeal and gastric microaspiration markers, were assessed from 85 tracheal aspirates in the first 72 h after connection to the system. Oropharyngeal microaspiration occurred in 47 cases (55%). Episodes of gastric microaspiration were not detected. Patient positioning, either prone or supine, did not affect alpha-amylase and pepsin concentration in tracheal secretions. Ventilator-associated pneumonia (VAP) rate was 40%. The use of the AG system provided effective cuff pressure control and subglottic secretions drainage. Despite this, no reduction in the incidence of VAP has been demonstrated, compared to data reported in the current COVID-19 literature. The value of this new technology is worth of being evaluated for the prevention of ventilator-associated respiratory tract infections. Microaspiration of secretions contaminated with oropharyngeal and gastric pathogens is observed in up to 88% of mechanical ventilated intensive care unit (ICU) patients, representing a key-factor in the pathogenesis of ventilator-associated pneumonia (VAP) , 2. ThisAmong the strategies developed to prevent microaspiration, many efforts have been focused to optimize subglottic secretion drainage and continuous cuff pressure control.Subglottic secretions are collected in the space between endotracheal tube cuff and vocal cords. They represent a bacterial reservoir and keeping this space tidy appears to be a useful strategy to reduce the incidence of microaspiration .Likewise, cuff pressure control allows a significant reduction in overinflation and underinflation of the tracheal cuff, recognized risk factors for mucosal damage and microaspiration of contaminated secretions, respectively.In a previous pilot randomized trial, we showed that a new integrated airway system (AnapoGuard-100 ET and control unit) was safe and effective in terms of cuff pressure control and subglottic secretions evacuation, with a strong trend in reducing microbiologically confirmed VAP .We designed this proof of concept study to assess the rate of microaspiration, defined by the dosage of alpha-amylase and pepsin in tracheal secretions, collected from patients with COVID-19 ARDS undergoing pronation.2O; oral hygiene with chlorhexidine, daily evaluation for weaning and bed elevation of 30° during supine positioning were observed as a VAP prevention bundle. No selective digestive decontamination policy was applied, whereas all patients had a nasogastric tube and were fed with continuous enteral nutrition.Fifteen patients with COVID-19 ARDS were intubated with AnapnoGuard (AG) polyvinyl chloride ETs (ID 8.0/7.5 mm), after failing noninvasive ventilatory support. The number of 15 was a convenience sample size, patients were included from 21 October to 14 December 2021. All patients underwent invasive mechanical ventilation with a positive end-expiratory pressure (PEEP) of at least 5 cmH2) levels above the cuff with cycles of a few minutes. The user is asked to set upper and lower pressure limits, then the AG-100 control unit adjusts cuff pressure in two layers. The first control layer consists of keeping the target pressure constant, similarly to electronical manometers. With the second control layer, the device automatically adjusts the target pressure based on the CO2 levels that correlate to leaks , 35 [29–44] and 4 [4], respectively. All patients underwent invasive mechanical ventilation, continuous neuromuscular blocking and at least one 18-h pronation cycle. Enteral nutrition was equally delivered during prone and supine positioning (at least 1500 mL per day), without interruption. Alpha-amylase and pepsin were measured in 85 (100%) and 75 (88%) tracheal aspirates, respectively, since a small part of these samples was not quantitatively or qualitatively suitable for detecting pepsin levels. The median number of samplings was 6  per patient and 21 (25%) were collected during prone positioning, since most of patients underwent only one 18-h pronation cycle in the predefined sampling time frame. Cuff pressure values were stable between 25 and 30 cmHWe studied the occurrence of microaspiration in 15 COVID-19 ARDS patients intubated with AG ET and connected to AG-100 control unit.2 leaks above the ET cuff, provides an accurate control of ET cuff pressure, regardless of prone positioning and variations in PEEP level.Previous randomized trials showed the efficacy of automatic cuff pressure control to minimize ET cuff underinflation and microaspiration , 7. HowePatients’ subglottic secretions intermittent drainage, either manual or automatic, are now considered an effective intervention to reduce VAP . HoweverWe observed that this new technology can provide cuff pressure control and subglottic secretions drainage, with good potential to reduce the incidence of oropharyngeal and gastric microaspirations, both in supine and prone position. Current literature shows microaspiration rates ranging from 0 to 50% for gastric content and from 50 to 80% for oropharyngeal content, according to the study population and the adopted preventing measure . Our resConversely, the incidence of VAP (40%) has not been proven to be inferior to data reported in the current literature.In fact, as far as is known that patients with SARS-COV-2 infection are more likely to develop ventilator-associated lower respiratory tract infections, the incidence of VAP in a cohort of patients recently investigated by Rouzé et al. was 36.1% . It cannOur study has some limitations. Mainly, the small sample size and the observational nature of the design, without a control group, do not allow to generalize our results and to perform comparisons inside the cohort; in addition, no microbiological samples to detect bacterial tracheobronchial colonization were collected. Finally, we cannot exclude that the polyurethan cuff ‘per se’ may have consistently contributed to the observed results.However, this is the first study where oropharyngeal and gastric microaspiration was investigated in COVID-19 ARDS patients using a new automatic ET cuff pressure control and subglottic secretions drainage, during supine and prone position.In COVID-19 ARDS patients undergoing pronation, the use of the AG system, although limiting the amount of oropharyngeal and gastric microaspiration, did not reduce the incidence of VAP compared to current COVID-19 literature. These preliminary results represent a proof of concept to better investigate the efficacy of this new technology for VAP prevention.


Conclusions: preoperative RIPC did not significantly affect the metabolome 24 h after vascular surgery. The positive linear correlation of kynurenine/tryptophan ratio with heart and kidney injury markers suggests that the kynurenine–tryptophan pathway can play a role in RIPC-associated cardio- and nephroprotective effects.Background: remote ischemic preconditioning (RIPC) is a phenomenon in which short episodes of ischemia are applied to distant organs to prepare target organs for more prolonged ischemia and to induce protection against ischemia-reperfusion injury. This study aims to evaluate whether preoperatively performed RIPC affects the metabolome and to assess whether metabolomic changes correlate with heart and kidney injury markers after vascular surgery. Methods: a randomized sham-controlled, double-blinded trial was conducted at Tartu University Hospital. Patients undergoing elective open vascular surgery were recruited and RIPC was applied before operation. Blood was collected preoperatively and 24 h postoperatively. The metabolome was analyzed using the AbsoluteIDQ p180 Kit. Results: final analysis included 45 patients from the RIPC group and 47 from the sham group. RIPC did not significantly alter metabolites 24 h postoperatively. There was positive correlation of change in the kynurenine/tryptophan ratio with change in hs-troponin T ( Remote ischemic preconditioning (RIPC) is a phenomenon in which short controlled non-lethal episodes of ischemia are applied to distant organs or limbs to prepare target organs for more prolonged ischemia and to induce protection against ischemia-reperfusion injury . PreviouUnderstanding RIPC’s precise mechanisms of action can help draw solid conclusions about its usefulness in reducing preclinical and clinical injury to ischemia-sensitive organs. Although extensively studied, the exact mechanisms of RIPC remain unclear. It is suggested that humoral and neural mechanisms, circulating immune cells, and activation of hypoxia-inducible genes may facilitate its effects . Less foIt is suggested that the effects of RIPC are mediated by changes in amino acid and energy metabolism. Studies on rats have shown that alanine, aspartate, glutamate, arginine, and proline metabolism might be involved in the beneficial effects of RIPC ,7,8. RIPAlong with participating in energy metabolism, some amino acids mediate the effects of RIPC through different pathways. RIPC has been associated with increased carnosine levels . CarnosiSeveral of RIPC’s beneficial effects in organ protection have been found to be mediated through pathways related to amino acid and energy metabolism ,6,7,8. HFrom 1 January 2016, to 8 February 2018, a randomized sham-controlled double-blind clinical trial was conducted at Tartu University Hospital’s Clinic of Surgery, Department of Vascular Surgery ,4,5.Patients undergoing elective open surgical repair of an infra-renal abdominal aortic aneurysm (AAA), carotid endarterectomy or surgical lower limb revascularization surgery  femoral or femoropopliteal or femorotibial or iliofemoral bypass surgery) were enrolled in the study. Each patient signed an informed consent form prior to the study. The study’s research protocol was approved by the University of Tartu’s Research Ethics Committee and entered in the ClinicalTrials.gov database (NCT02689414).2, previous history of upper limb vein thrombosis or vascular surgery in the axillary region, and inability to follow the study regimen were the exclusion criteria.Age under 18 years, pregnancy, malignancy in the previous five years, permanent atrial fibrillation or flutter, symptomatic upper limb atherosclerosis, home oxygen therapy, preoperative estimated glomerular filtration rate (eGFR) under 30 mL/min/1.73 mPatients were allocated to the sham or RIPC groups at random and in equal numbers. A stratified block design with a block size of 2 or 4 was used. The computer application WINPEPI (PEPI-for-Windows) generated a random sequence. Patients were stratified based on their age (under or over 65 years) and physical status classes 2, 3, or 4 of the American Society of Anesthesiologists (ASA). Randomization and opaque sealed envelopes were prepared by a third party. The envelopes were opened right before intervention.The RIPC protocol comprised four 5-min ischemia episodes followed by a 5-min reperfusion phase. Ischemia was induced by placing a blood pressure cuff on the patient’s arm and elevating cuff pressure to 200 mmHg. If the patient’s blood pressure was above 180 mmHg, cuff pressure was increased to 20 mmHg higher than the patient’s systolic blood pressure. The achievement of successful ischemia was confirmed by witnessingskin color change and monitoring of the patient’s blood pressure on the other arm to maintain sufficient pressure in the cuff. In the sham group cuff pressure was kept at the same level as venous pressure (10–20 mmHg). Intervention began along with the operating room’s preparation for anesthesia. Other components of surgery, such as anesthesia and medication administration, were unaffected.The study intervention was blinded from the patient, his or her physician, surgeon, anesthesiologist, and the rest of the surgical team. The scale of the manometer was kept covered. The statistician was not aware of the significance of the group affiliation.Blood samples for the analysis of metabolites were taken on the morning of surgery and approximately 24 h postoperatively. The last blood collection was set as close to 24 h post-surgery as possible, on the condition that the patient had fasted for at least three hours. The blood samples were centrifuged, and serum was separated and stored at −80 °C in the refrigerator.The AbsoluteIDQp180 kit  was used to measure the levels of the different metabolites. The analytical procedure was performed according to the manufacturer’s standard protocol at the laboratory of the Department of Biochemistry, University of Tartu. Measurements were carried out using a QTRAP 4500 , linked to an Agilent 1260 series HPLC  with a C18 column, and flow injection analysis.Blood samples were taken preoperatively and about 24 h after surgery for measurement of high sensitivity troponin T (hs-TnT), N-terminal pro-brain natriuretic peptide (NT-proBNP), creatinine (Cr), cystatin C (cysC), and beta-2-microglobulin (B2M), which were used to calculate correlations. The levels of cardiac and kidney function biomarkers were measured at Tartu University Hospital’s United Laboratories.Sandwich electrochemiluminescence immunoassays (ECLIA), specifically the Elecsys troponin T high-sensitive assay, STAT version , and the Elecsys proBNP II  were employed according to the manufacturer’s protocol for analysis of hs-TnT and NT-proBNP. The Creatinine plus ver. 2 enzymatic method , the Tina-quant Cystatin C Gen. 2 particle enhanced immunoturbidimetric assay , and the Tina-quant β2-Microglobulin (serum/plasma application) immunoturbidimetric assay method  were used according to the manufacturer’s instructions for assessment of creatinine, cystatin C, and beta-2-microglobulin, respectively.All patients were enquired about their medical history and medications. An electronic health database and surgery protocols were used to obtain a thorough anamnesis.t-test, and the Wilcoxon rank-sum or Chi-square test. Student’s t-test was used in the case of a normal distribution and the Wilcoxon rank-sum test was applied in the case of a non-normal distribution. The Kolmogorov-Smirnov test was used to test for normality. Correlations were calculated using the Pearson or Spearman correlation coefficient. p-values below 0.05 were considered significant for comparison of baseline characteristics. Because of multiple comparisons, the Benjamini-Hochberg procedure was used to control false discovery rate. According to the Benjamini-Hochberg procedure, a new significance level was calculated, and p-values below 0.0012 were considered significant for comparing changes in the metabolites and assessing correlations of the metabolites with heart and kidney injury markers. Metabolite enrichment analysis was performed with MetaboAnalyst 5.0 by using SMPDB and KEGG databases for which at least two intermediates were present.The RIPC and sham groups were compared using Student’s A total of 98 patients were enrolled and randomized into study groups. Final analysis included 45 patients from the RIPC group and 47 patients from the sham group. Detailed patients’ flow is shown in p = 0.057) between the RIPC  and the sham group . The baseline characteristics of patients did not differ significantly between the study groups  carnitines, 14 lysophosphatidylcolines, 76 phosphatidylcholines, and 15 sphingomyelins. In this study, 103 of these metabolites and 20 metabolic ratios were included in the final analysis. A complete list of the analyzed metabolites is provided in The AbsoluteIDQThe baseline values of the analyzed metabolites were similar in both groups . The exar = 0.496, p < 0.001). Changes in different glycerophospholipids and sphingolipids did not correlate with changes in cardiac markers. Among the metabolic ratios, change in the kynurenine/tryptophan ratio showed positive linear correlation with change in hs-TnT  and change in NT-proBNP . These correlations were only seen in the RIPC group.In the RIPC group, there were no significant correlations between change in amino acid levels and change in heart injury markers. Regarding biogenic amines, change in total DMA level was positively correlated with shift in hs-TnT  and beta-2-microglobulin . These correlations were not observed in the sham group.In the RIPC group, there were no significant correlations of change in amino acids, biogenic amines, glycerophospholipids, or sphingolipids with change in kidney injury markers. However, among the metabolic ratios, there was a significant positive linear correlation of change in the kynurenine/tryptophan ratio with cystatin C  and beta-2-microglobulin .In the sham group, no significant correlations were detected between alterations in amino acids and heart and kidney injury markers. Nor were there significant correlations between change in biogenic amines and change in hs-TnT or NT-proBNP. However, there was a significant positive linear correlation between change in total DMA and the change in creatinine , between change in the Cit/Arg ratio and change in beta-2-microglobulin  and, between change in the putrescine/ornithine ratio and change in creatinine .There occurred no significant correlation of different glycerophospholipid and sphingolipid level with change in heart and kidney injury markers. Among the metabolic ratios, there was a significant positive linear correlation between change in the ADMA/Arg ratio and change in hs-TnT  and the kynurenine pathway ,14. OnlyIn addition to the presence of TDO, increased activity of IDO enhances formation of kynurenine and related products ,15. IDO These findings suggest that kynurenine is the tryptophan’s cardioprotective metabolite, which could play a role in RIPC-induced cardioprotective effects ,10,12. A+ in the post-ischemic kidney [+ via cellular energy restoration has a critical role in renal resistance against ischemic insults by connecting oxidative metabolism in the epithelium to overall organ function [To our knowledge, there are not many studies evaluating the associations between the TRP-KYN pathway, RIPC, and nephroprotection. However, a recent study on mice found that hypoxic preconditioning increases serum kynurenine levels and stimulates kynurenine biotransformation, leading to the preservation of NADc kidney . NAD+ vifunction .The TRP-KYN pathway also plays a role in acute kidney injury (AKI). The TRP-KYN pathway is activated in AKI, showing usually an increase in its metabolites ,18. UpreAnother metabolite that had several correlations with different heart and kidney markers in both groups was total dimethylarginine (DMA). Total DMA is the sum of asymmetric DMA (ADMA) and symmetric DMA (SDMA) . ADMA isTo conclude, this study brought out the above-described correlations of metabolites with heart and kidney injury markers. However, we did not find any statistically significant changes in the metabolites in response to RIPC 24 h postoperatively, which could be explained as follows. First, the patient’s metabolic profile can be affected by different types of surgery that involve different degrees of tissue damage. It can be assumed that patients undergoing open surgical repair of abdominal aortic aneurysm had more serious tissue damage and had to deal with a greater extent of ischemia and reperfusion compared to patients with peripheral artery disease (PAD) undergoing lower-limb revascularization surgery. Therefore, the involvement of different surgeries could have significantly affected the results. However, we tried to minimize it by matching the number of various surgeries across groups. Second, it has also been suggested that patients with different stages of PAD have distinct metabolic profiles . The hetIn this study, preoperatively performed RIPC did not significantly affect patients’ metabolome 24 h after vascular surgery. However, the kynurenine/tryptophan ratio showed significant correlation with heart and kidney injury markers in the RIPC group. These findings suggest that the kynurenine–tryptophan pathway can play a role in RIPC-associated cardio- and nephroprotective effects. Further larger studies would be beneficial for drawing definite conclusions about whether RIPC influences the metabolome and how these metabolomic changes correlate with heart and kidney injury markers.


A decreased 24-hour time domain HRV parameter, SDANN, was strongly associated with both eGFR and UACR among Chinese T2DM.To evaluate whether heart rate variability (HRV) as a measure of cardiac autonomic neuropathy (CAN) is associated with chronic kidney disease (CKD) in Chinese adults with type 2 diabetes mellitus (T2DM) in China. 392 individuals of T2DM were entered in this study, all these subjects undertook the Holter electrocardiogram for 24 hours to get the HRV parameters. Of these T2DM patients, 126 (37.3%) had CKD, and most of the HRV parameters were lower in this group than in those without CKD. Decreased HRV parameters were strongly related with CKD in Spearman's correlation analysis. After adjustments for variables, the logistic regression showed that standard deviation of the averaged normal RR intervals for all 5-minute segments (SDANN) was independently associated with decreased estimated glomerular filtration rate (eGFR < 60 mL/min/1.73 m Type 2 diabetes mellitus (T2DM) associated chronic kidney disease (CKD) becomes the major contributor of end-stage renal disease and is strongly associated with cardiovascular events and death . There hCardiac autonomic neuropathy (CAN) is often overlooked though it is known as a common complication of diabetes mellitus –5. This Although the relationship between CAN and renal dysfunction was discussed in several studies, the results had been inconsistent. As for the different characteristics of the researches, the races of most studies were Caucasians and the scales of these studies were small. Many of the researches had focused on patients of type 1 diabetes; the indices of CKD were different, such as glomerular filtration rate, albuminuria, or both; and the markers of CAN were also diverse and complicated –13. Yet,This study focused on an association between HRV analyses including time and frequency domain parameters and two CKD markers (estimated glomerular filtration rate (eGFR) and albuminuria) in Chinese patients of T2DMThis was a cross-sectional study that included 446 participants with T2DM in the inpatient department of Kunming First People's Hospital between February 2013 and April 2015. The including criterions were adults with T2DM, and all the participants had carried Holter monitoring for 24 hours. The excluding criterions were as follows: acute complications of T2DM, severe acute or chronic infection, dialysis or kidney transplantation, or any severe comorbidity affecting life expectancy. A total of 392 patients were finally analyzed.https://clinicaltrials.gov/(NCT02996539).Informed consent was signed by all the patients in our study. T2DM was diagnosed according to the Chinese Diabetes Society criteria . CKD was2). A smoker was regarded as a subject smoking ≥ 1 cigarette per day, continuous or accumulated for 6 months. An alcohol drinker was defined as a subject consuming >20 g of alcohol per day in the past month. We defined the following conditions as hypertension: if the subject's systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg, or the subject has history of taking antihypertensive drugs. Diabetic retinopathy (DR) was evaluated by an ophthalmologist.A physician interviewed the medical history of the subjects including history of hypoglycemic episodes, drinking, and smoking habit and medication history. The anthropometric measurements were measured by a trained medical worker including the blood pressure, height, and weight of the subjects. The calculation formula for body mass index (BMI) was body weight, in kg, t divided by height in meters squared  and picric acid method to analyze serum creatinine (SCr), respectively. An enzymatic colorimetric method was used to detect serum uric acid. Immunoturbidimetric analysis and enzymatic method were used to analyze urine albumin and creatinine, respectively. All these were analyzed by automatic biochemical analyzers . High-performance liquid chromatography assay was used to analyze serum hemoglobin A1c (HbA1c) .2 calculated by the modification of diet in renal disease (MDRD) equation in Chinese [2), high-eGFR (≥60 mL/min/1.73 m2) and UACR1 , UACR2 (30-299 mg/g Cr), or UACR3 (>300 mg/g Cr).CKD was diagnosed based on eGFR and albuminuria: the levels of eGFR less than 60 mL/min/1.73 m Chinese , or the A 3-channel digital Holter monitor  was used for all subjects for 24 hours to obtain the HRV measurements. A trained operator who was ignorant of the patients' clinical status reviewed and analyzed the data. QRS complex were detected and flagged by the specially designed software .HRV analysis consists of time-derived and frequency-derived parameters. Regarding the time-derived, 4 indices were measured, each in milliseconds (ms): SDNN, standard deviation of the RR interval; SDANN, standard deviation of the averaged normal RR intervals for all 5-minute segments; SDNN index, the mean of the standard deviations of all normal RR intervals for all 5-minute segments; and RMSSD, the root mean square difference of successive RR intervals. The frequency-derived measures were as follows: low frequency , high frequency , and the ratio of low-to-high-frequency power (LF/HF). SDNN and LF/HF reflect the sympathovagal balance. SDANN, SDNN index, and LF reflect the activity of sympathetic nerve. RMSSD and HF reflect the activity of vagal nerve , 18.t-test or Mann–Whitney U test. Trivariate parameters among patients in different UACR groups were compared by ANOVA test or Kruskal-Wallis test. Categorical variables were compared using the chi-squared test. Spearman's test was used to assess univariate correlations between HRV parameters and different clinical characteristics. Binary logistic regression (for eGFR and UACR) was used to reveal the independent association between HRV and CKD. This included HRV parameters (described above) and the following potential risk factors as confounders: age, gender, BMI, duration of T2DM, drinking status, smoking status, hypertension, DR, the prevalence of hypoglycemia, HbA1c levels, and use of insulin, renin-angiotensin-aldosterone system (RAAS) inhibitor, diuretic, or beta-blocker. Statistical analysis were carried out in SPSS version 22.0 . A two-tailed P value below 0.05 was considered in a statistical sense.Our results are showed as mean ± standard deviation or median (25th-75th percentiles) for continuous variables and number (percentage) for categorical variables. Bivariate parameters between patients with relatively low or high eGFR were compared by Student's We finally analyzed 392 T2DM patients, 53.1% of them were women; the average age of the subjects was 59.1 ± 0.59 years; the mean diabetes duration was 5.99 ± 0.34 years; and the mean level of HbA1c was 8.8 ± 0.1%. The prevalence of CKD was 37.3% of the enrolled patients.Baseline eGFR measurements were available for 384 patients. Of these, 13% (50/384) were in the low-eGFR group . Patient1), 29.7% (102/344) were in the higher UACR groups (UACR2 and UACR3), and 8.7% (30/344) were specifically in the UACR3 group  were considered to have normal UACR , RMSSD (P = 0.032), SDANN (P = 0.005), SDNN index (P ≤ 0.001), and LF (P = 0.028). The patients of the UACR2 group only had lower levels of SDNN than these of the UACR1 group (P = 0.031).The patients in the UACRollowing : SDNN, Pr = −0.193, P ≤ 0.001), SDANN , and SDNN index  in Spearman's correlation analysis , SDANN , SDNN index , LF , and LF/HF , and eGFR was positively associated with LF/HF . We also found that age, BMI, diabetes duration, presence of DR, prevalence of hypoglycemia, HbA1c levels, smoking, drinking, and use of insulin, a RAAS inhibitor, diuretic, or beta-blocker were closely associated with HRV parameters.The prevalence of CKD was negatively correlated with SDNN , older age (P ≤ 0.001), and high levels of BMI (P = 0.011) were associated with increased risks for eGFR < 60 mL/min/1.73 m2. Low levels of SDANN (P = 0.015) and DR (P ≤ 0.001) were strongly associated with increased risks for albuminuria (UACR ≥ 30 mg/g Cr). This shows that reduced SDANN was independently associated with lower eGFR and higher UACR.Binary logistic regression analysis was performed to investigate an independent association between HRV and CKD , with co2, UACR3) relative to the high-eGFR and UACR1 groups, respectively. Moreover, we found that SDANN was closely associated with both lower eGFR and higher UACR, the 2 important markers of CKD, and this relationship still established independently after adjusting for many common hazard factors, such as age, gender, BMI, diabetes duration, drinking status, smoking status, presence of hypertension and DR, prevalence of hypoglycemia, HbA1c levels, and use of insulin, RAAS inhibitors, diuretics, or beta-blockers. As the SDANN mainly reflects the imbalance of cardiac autonomic function and is related to increasing the activity of sympathetic nerve and decreasing the activity of vagal nerve, our results revealed that the sympathovagal imbalance was involved in CKD in Chinese patients of T2DM.The associations between CKD and 24-hour HRV parameters (time and frequency domains) among Chinese T2DM patients was explored in this study. It was found that most of the time and frequency domain HRV indices were less in both the low-eGFR group and higher UACR group (UACRAlthough the similar association between CAN and CKD in diabetes after adjust for several risk factors was demonstrated in a few previous study , 10, 13,An earlier Chinese study, which had focused on the association between time domain 24-hour HRV parameters and albuminuria, had also shown that reduced SDANN, SDNN index, and SDNN were linked with albuminuria . In our The underlying mechanisms by which CAN may contribute to the progression of CKD has been reported in previous studies , 22, 23.Most of the risk groups in our study had similar HbA1c levels. This pattern is different from many other studies that had reported that impaired glycemic control contributes to microvascular complications , 25. In A previous study of Chinese T2DM patients showed that DR was closely associated with both eGFR and UACR . HoweverAlthough we found that BMI was independently associated with eGFR, we did not find a similar result in the regression analysis of UACR. This is inconsistent with a previous research . In our In our study, we found age was closely associated with eGFR. However, no correlation between age and UACR was found in our study. This result was supported by a previous study that carried out among 47,204 Chinese adults for the China National Survey of Chronic Kidney Disease . A previThe present studied is limited by its cross-sectional design; we could not prove causation, and we studied only associations. Secondly, the subjects of the study population were mainly from the local Yunnan province and may not represent all Chinese ethnicities. In addition, although we recorded the prevalence of hypertension, we missed the exact blood pressure readings of the patients. Since it has been reported that blood pressure is involved in the mechanism underlying the association between HRV and nephropathy , we may In conclusion, our results show that a lower 24-hour time domain HRV parameter, SDANN, was associated with both eGFR and UACR in T2DM Chinese patients. This finding may supply understandings for the physiopathological mechanisms connecting early CAN to increased morbidity and mortality in CKD. Further prospective studies should investigate further these mechanisms and causal associations to explore new treatment strategies for CKD.


The study aims to elucidate the impact of mirabegron versus solifenacin on autonomic function and peripheral arterial conditions in women with overactive bladder syndrome (OAB). All consecutive women with OAB were randomized to receive 12 weeks of mirabegron 25 mg or solifenacin 5 mg once per day. Heart rate variability, cardio-ankle vascular index, ankle-brachial pressure index, blood pressure, and heart rate were compared between the two groups. There were 87 women  who completed 12-week treatment and underwent heart rate variability examination. Systolic blood pressure (median: − 4.5 to − 5.5 mmHg) and diastolic blood pressure (median: − 0.5 to − 3.5 mmHg) decreased after solifenacin treatment, and heart rate (median: + 2 bpm) increased after mirabegron treatment, despite of no between-group difference. In addition, posttreatment heart rate variability, cardio-ankle vascular index, and ankle-brachial pressure index did not differ compared with baseline; and there were no between-group differences. In conclusion, solifenacin might decrease blood pressure, and mirabegron might increase heart rate. Nonetheless, there were no significant impacts of 12-week mirabegron versus solifenacin treatment on autonomic function and arterial stiffness. Many theories, such as myogenic, neurogenic and autonomous theories, have been considered as possible etiologies of OAB2. Beta-3 agonists and antimuscarinics are the main medications for OAB.Overactive bladder syndrome (OAB) is characterized by the core symptom of urinary urgency, usually accompanied by frequency and nocturia3. Mirabegron is a beta-3 agonist; however, mirabegron may activate the beta-1 receptor4. Mo et al. found that mirabegron increases the force of atrial contraction through beta-1 receptor, but not beta-3 receptor5. Besides, beta-3 receptor was found in the vascular system4, and beta-3 agonists may affect the peripheral vascular system.Beta-1 and beta-2 adrenoceptors coexist in the human heart with beta-1 predominating with a ratio of approximately 70:30 in the atria and 80:20 in the ventricles6. Stimulation of cardiac M2 receptors modulates pacemaker activity and atrioventricular conduction and cardiac contraction7. In addition, the M3 receptor is associated with endothelium-dependent, acetylcholine-induced vasodilation8. In the thoracic aortic rings of M3 receptor knockout mice, the vasodilatory effect of the cholinergic agonists was greatly decreased8. Thus, the issue of whether solifenacin may affect heart and peripheral vascular system may be worth studying.Antimuscarinics, including solifenacin and tolterodine, remain the mainstay drugs for OAB. Solifenacin has a moderate selectivity for the M3 receptor; however, solifenacin could stimulate M2 receptors9. In addition, OAB women were found to have higher severity of autonomic dysfunction, compared with normal controls10. Some antimuscarinics  were found to be detrimental to autonomic function11. In addition, arterial stiffness and lower extremity atherosclerosis, which were associated with higher cardiac risk, have been used as a surrogate for peripheral arterial conditions13.Heart rate variability is frequently used to assess autonomic dysfunction. Higher cardiovascular risk was found in patients with autonomic dysfunction9. However, there was no report mentioning about the impact of mirabegron on the peripheral arterial conditions. Thus, we were interested whether mirabegron can affect the peripheral arterial conditions.It has been reported that antimuscarinics might improve arterial stiffness15; and the side effect of solifenacin is different to mirabegron16. Thus, probably related to side effects and cost considerations, monotherapy is frequently used as an initial treatment for women with OAB17. We were interested about the impact of mirabegron versus solifenacin monotherapy on autonomic function and peripheral arterial conditions. Thus, the main objective of this study was to investigate the impact of mirabegron versus solifenacin on autonomic function and peripheral arterial conditions .Combination treatment  has been found to have an additive effect, compared with monotherapyBetween September 2015 and May 2020, a total of 113 women were enrolled in this study. However, 21 women discontinued treatment during the 12-week treatment period and were excluded from the final analysis  who completed 12-week treatment. However, 5 patients did not receive heart rate variability examinations; thus, a total of 87 women  were analyzed  subscores and total score were improved after treatment Fig. b; howeveAfter 12-week treatment, all parameters of heart rate variability, including the standard deviation of the normal-to-normal (NN) intervals (SDNN), the square root of the mean squared differences of successive NN intervals (RMSSD), the number of pairs of adjacent normal-to-normal (NN) intervals differing by more than 50 ms in the entire recording (NN50 count), NN50 count divided by the total number of all normal-to-normal interval (pNN50), standard deviation of instantaneous beat-to-beat RR interval variability in the Poincaré Plot (SD1), standard deviation of continuous beat-to-beat RR interval variability in the Poincaré Plot (SD2), SD1/SD2 ratio, very low frequency (VLF), low frequency (LF), high frequency (HF), LF/HF ratio and total power did not differ compared with baseline; and there were no between-group differences in the changes from baseline (Table Posttreatment cardio-ankle vascular index (CAVI) and ankle-brachial pressure index (ABI) data did not differ compared with baseline; and there were no between-group differences in the changes from baseline Table . However18, but not solifenacin9. To our knowledge, there was no literature mentioned about the impact of mirabegron on heart rate variability. Taking together with the findings of a prior study 9 and the current study  and diastolic blood pressure  seems to be larger in our study. Moreover, mirabegron could increase blood pressure 20, and mirabegron is contraindicated to treat OAB patients with severe uncontrolled high blood pressure. Contrarily, a decrease of blood pressure was found in our OAB patients receiving solifenacin treatment. Thus, our findings justify that solifenacin is a good alternative for OAB women with hypertension.Systolic blood pressure and diastolic blood pressure decreased after solifenacin treatment Fig. c,d, but 21. The increase in heart rate is probably mediated by cross-activation of the β1-adrenoceptor4, as mirabegron has a greater affinity to the canine β1-receptor22. Therefore, mirabegron may be unsuitable for women whose resting heart rate is of concern.Heart rate increased after mirabegron treatment . The study design was prospective, randomized, controlled, and open labeled. This study has been registered with ClinicalTrials.gov .6. Exclusion criteria included clinically significant dysuria, severe stress urinary incontinence or mixed urinary incontinence with dominant stress incontinence, and other symptoms that were contraindications for antimuscarinic medication or beta-3 agonists6.The screening visit was designed as visit 0, and the inclusion criteria included: (1) women aged at least 20 years who had at least a 3-month history of OAB symptoms, including urgency, urinary frequency, nocturia or urgency incontinence; (2) an average of ≥ 8 micturitions per 24 h period26 were also performed between visit 0 and visit 1. Eligibility was determined at visit 1  using the results recorded in the 3-day bladder diary prior to visit 1. Patients were randomized into two groups using a computer-generated random number list to receive either mirabegron 25 mg or solifenacin 5 mg once a day for 12 weeks. The randomization sequence was created using Excel 2007  with a 1:1 allocation using simple randomization. Patients were followed up at week 4 (visit 2), week 8 (visit 3), and week 12 (visit 4).Urodynamic studies and a 20-min pad test27, standard 12-lead electrocardiography, 15 min of Holter monitoring, CAVI and ABI.The enrolled participants were requested to complete the following questionnaires, urodynamic studies, and the following examinations before and after 12 weeks’ treatment, including OABSS. The electrocardiographic signals were recorded for 15 min. The QRS complexes were automatically classified and manually verified as normal sinus rhythm, atrial or ventricular premature beats, or noise by comparison with adjacent QRS morphology. The R–R intervals were deduced from the adjacent normal sinus beats, and their interval time series were processed by a program written in the Matlab language 28.Heart rate variability was measured using a continuous ambulatory Holter electrocardiographic recorder  with a sampling rate of 250 Hz , HF power in normalized units (HF norm), and the LF/HF ratio were also obtained. The power spectral density was calculated by the nonparametric method . The efferent vagal activity is a major contributor to the HF component. LF component is considered as a marker of sympathetic modulation or both sympathetic and vagal influences31. CAVI is a new index of arterial stiffness and independent of blood pressure, which is compatible with conventional aortic pulse wave velocity. The procedure was performed as follows. After the participants sitting and resting for at least five minutes, the measurements were taken with the patients in the supine position, with monitoring cuffs attached to the right or left upper arm and ankle to detect brachial and ankle pulse waves. Heart sounds and electrocardiograms were also monitored. The pulse wave velocity from the heart to the ankle was calculated by measuring length from the aortic value to the ankle and dividing by time, which was determined according to the heart sound and the rise of the brachial and ankle pulse waves. Blood pressure was also measured at the brachial artery32. Thus, the CAVI can be calculated by the equation: a[(2ρ/∆P) × ln(Ps/Pd)PWV2] + b. 31, and the average of the left and right CAVI values was used for analysis9.Arterial stiffness was measured by the CAVI with the VaSera VS-1000 vascular screening system 33. A low ABI may indicate narrowing of the lower extremity arteries.The ABI is a noninvasive method to check peripheral artery conditions and an indicator of lower extremity atherosclerosis. The ABI was measured using the above device with cuffs that can simultaneously measure blood pressure levels in both arms  and both legs . The ABI was calculated separately for each leg, and the lower of the two ABI values was used for analysis1. The flow diagram was completed according to the CONSORT 2010 standard. Stata software  was used for statistical analyses. The Wilcoxon rank-sum test and Wilcoxon signed-rank test were used as statistical methods, as appropriate. A P value of less than 0.05 was considered statistically significant. The primary objective of this study was to compare the impact of mirabegron versus solifenacin on heart rate variability. Secondary objectives of this study included comparison of the CAVI, ABI, heart rate, and blood pressure between the mirabegron and solifenacin groups. Based on a previous study about the comparison of the impact of solifenacin versus tolterodine on heart rate variability9, we concluded that about 43 subjects in each group were required to test the null hypothesis.All terminology used in this paper conforms to the standards recommended by the International Urogynecological Association and International Continence Society joint reportThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Research Ethics Committee of National Taiwan University Hospital .Informed consent was obtained from all individual participants included in the study.