Hypertension is considered to be the most common condition in the general population. It is the most important risk factor for premature deaths in the world. Treatment compliance at every stage is a condition for successful antihypertensive therapy, and improving the effectiveness of treatment is a major goal in preventing cardiovascular incidents. Treatment noncompliance and lack of cooperation stem from numerous problems of older age, including frailty syndrome. To evaluate the effect of frailty syndrome on treatment compliance in older patients with hypertension. The study sample consisted of 160 patients  with hypertension aged 65 to 78 , hospitalized at the University Clinical Hospital due to exacerbation of disease symptoms. Standardised research tools were used: the Tilburg Frailty Indicator questionnaire and the questionnaire for the assessment of treatment compliance in patients with hypertension, the Hill-Bone Compliance to High Blood Pressure Therapy Scale. Frailty syndrome was diagnosed in 65.62% of patients: 35.62% with mild, 29.38% with moderate, and 0.62% with severe frailty. The treatment compliance was 36.14%. The prevalence of the FS and its three components  significantly affected (p <0.05) the global score of the Hill-Bone Compliance to High Blood Pressure Therapy Scale and all subscales: “reduced sodium intake”, “appointment keeping”, and “antihypertensive medication taking”. The coexistence of frailty syndrome has a negative impact on the compliance of older patients with hypertension. Diagnosis of frailty and of the associated difficulties in adhering to treatment may allow for targeting the older patients with a poorer prognosis and at risk of complications from untreated or undertreated hypertension and for planning interventions to improve hypertension control. Hypertension (HT) is the most important risk factor for premature deaths worldwide, and blood pressure levels (BP) indicate a linear correlation between mortality and morbidity in cardiovascular diseases  and renal failure . HT is cA successful antihypertensive treatment depends on the treatment compliance (“compliance” and “adherence”), and improving the effectiveness of treatment of hypertension is a major goal in the prevention of cardiovascular incidents. Unfortunately, only 30% of patients with HT comply with treatment plans; in Poland, the fraction is estimated at 5-15% . The terCorrelation of various concomitant diseases, older age, and disability may result in the development of FS. A widely used definition of FS proposed by Fried et al.  states iβ‐blockers [The older population comprised a special group of hypertensive patients due to the occurrence of ageing-related processes. An isolated hypertension is observed in systolic blood pressure (SBP), when diastolic blood pressure (DBP) values are below 90 mmHg. In the older population, SBP is a more significant risk factor for cardiovascular events than DBP. Chronically higher values of SBP lead to left ventricular hypertrophy . Despiteblockers .Frailty is defined as a biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems, causing vulnerability to adverse outcomes . Recent Considering the physiological alterations resulting from ageing and the presence of multiple comorbidities, treatment of hypertension in older patients poses a significant challenge to treatment teams . In clinThe aim of the study was to evaluate the influence of FS on treatment compliance in older patients with hypertension. It should be pointed out that our intention was to focus more on psychological and social factors than physical capacity including muscle strength, gait speed, postural control, and functional parameters.This was a cross-sectional study involving 160 patients being hospitalized in the Clinic of Angiology, Hypertension, and Diabetology at the University Clinical Hospital in Wrocław, Poland, due to exacerbation of disease symptoms. Participation was anonymous and voluntary and patients were told that they could withdraw at any time.The inclusion criteria for the study were as follows: hypertension lasting at least 1 year; age ≥ 65 years; hypertension treated with at least 1 antihypertensive drug; the patient's consent to participate in the study. Hypertension diagnosis was performed according to the Seventh Joint National Committee (JNC-7) classification of blood pressure for adults, as follows: normal for <120 SBP and <80 DBP, prehypertension for 120-139 SBP and 80-89 DBP, hypertension stage 1 for 140-159 SBP or 90-99 DBP, and hypertension stage 2 for ≥160 SBP or ≥100 DBP .The study was approved by the Bioethics Committee of Wroclaw Medical University (no. KB–114/2016). Signed informed consent forms were obtained from all patients who were included in the study. The study was conducted in accordance with the Helsinki Declaration and the European Medicines Agency Guidelines for Good Clinical Practice. The dignity and rights of participants were respected at all times.Standardised research tools were used in the study: the Tilburg Frailty Indicator (TFI) questionnaire and the questionnaire for antihypertensive treatment compliance, the Hill-Bone Compliance to High Blood Pressure Therapy Scale (HBCHTS).The Tilburg Frailty Indicator (TFI) questionnaire by Gobbens et al.  consistsThe Hill-Bone Compliance to High Blood Pressure Therapy Scale (HBCHTS) is comprised of 14 questions in 3 subscales: “reduced sodium intake” (3 questions), “appointment keeping” (2 questions), and “medication taking” (9 questions). The respondent has the following answers: “none of the time”, “some of the time”, “most of the time”, “all the time”, “not applicable”, and “do not know”. The maximum score is 56 points, meaning the higher the score, the poorer the treatment compliance. The Polish version of the questionnaire was used in this study .Statistical analysis of quantitative variables was performed by calculating means, standard deviations, medians, quartiles, and minimum and maximum values. Analysis of qualitative variables was performed by calculating the number of times and percentage of occurrences of each value. The correlation between two quantitative variables was analyzed using the Spearman's coefficient. Correlation coefficients were interpreted as follows: |r| ≥ 0.9, very strong correlation; 0.7 ≤ |r| < 0.9, strong correlation; 0.5 ≤ |r| < 0.7, moderately strong correlation; 0.3 ≤ |r| < 0.5, weak correlation; |r| ≥ 0.3, very weak (negligible) correlation. Normal distribution of variables was verified using the Shapiro-Wilk test. To further illuminate the relationship between frailty syndrome and patient's compliance, linear regression was conducted. Covariates were selected with a backward stepwise procedure, starting with full model  and removing the least significant one (excluding frail variable) until only statistically significant variables (and frail variable) were left. The significance level was set at 0.05. Therefore, all p values below 0.05 were interpreted as indicating significant correlation. The analysis was carried out with R 3.3 software.The study of the influence of FS on treatment compliance was carried out among 160 patients  with HT aged from 65 to 78 years . Basic sociodemographic and clinical characteristics are presented in FS was diagnosed in 105 out of 160 patients (65.62%). TFI has 3 subscales. Relatively, the most important contributor of frailty in the group studied was the social component . The physical component was slightly less important , and the psychological component was the least important . Detailed data are presented in The analysis of the TFI score allowed the researchers to grade FS severity into mild, moderate, and severe. Thus, 57 out of 160 survey participants (35.62%) had mild FS, 47 participants (29.38%) had moderate FS, and 1 participant (0.62%) had severe FS, determined with the TFI. Detailed data are presented in The global score of this questionnaire ranged between 14 and 56 points. The higher the score, the poorer the treatment compliance. The mean score obtained by study participants was 20.24 (SD = 4.01) and ranged from 14 to 32 points. The median was 19.5 points, meaning half of the participants obtained less, and half obtained more than 19.5 points. The first and third quartiles were 17 and 22, respectively, so the mean score in the studied group ranged between 17 and 22 points. Every Hill-Bone subscale has a different number of questions. Hence, each scale has a different range of values.The “sodium intake” subscale contains three questions (range 3-12), and the obtained mean score was 4.79 (SD = 1.08). The “appointment keeping” subscale contains 2 questions (range 2-8). On this subscale, the mean score was 3.35 (SD = 1.18). The “medication taking” subscale contains 9 questions (range 9-36) and the mean score obtained was 12.1 (SD = 3.05). Detailed data are presented in The prevalence of FS and its three components  were significantly correlated with (p <0.05) the global score of the HBCHTS questionnaire and all subscales: “reduced sodium intake”, “appointment keeping”, and “antihypertensive medication taking”. All these correlations were positive; i.e., the higher the score on the TFI questionnaire, the higher the score on the HBCHTS questionnaire.The correlation between FS , physical components, and treatment compliance was moderate and, in the case of psychological and social components, weak. Detailed data are presented in The backward stepwise method has selected three variables that significantly affect the relationship between frailty and compliance. They are sex, age, and education. After considering these variables in the model, the impact of frailty becomes irrelevant. Compliance of patients with mild and severe frail does not differ significantly from those with no frail. The linear regression model showed that the independent predictors of the global score of the HBCHTS questionnaire are as follows (p <0.05): (1) sex: in comparison with female, male increases the global score of the HBCHTS questionnaire (decreases compliance) by an average of 1.23 points; (2) education: compared with none or basic, a secondary education decreases the global score of the HBCHTS questionnaire (increases compliance) by an average of 0.95 points, and a higher one decreases the global score of the HBCHTS questionnaire (increases compliance) by an average of 2.02 points; (3) age: each additional year of life lowers the global score of the HBCHTS questionnaire (decreases compliance) by an average of 0.20 points. Detailed data are presented in The coexistence of the FS may have a detrimental effect on the course of the disease and, additionally, the level of treatment compliance , 30.In our study, FS affected 65.62% of the group studied. FS influenced the level of treatment compliance, cooperation during the study, and the global score on the Hill-Bone questionnaire. It also adversely affected the questionnaire subscales: “reduced sodium intake”, “appointment keeping”, and “antihypertensive medication taking”. There are no studies on the effect of FS on perseverance in the treatment process. However, the Medicaid study emphasized that only 20% of hypertensive patients over 65 comply with the treatment regimen, which might result from the aging processes of the body, including FS .Concurrent frailty and cognitive impairment in older patients are associated with a worse perception of health, increased number of comorbidities, and social isolation of the patient . The coiThere are a few studies which measure the association between the components of the geriatric syndrome and adherence to treatment. Papers that discuss associations between frailty and adherence are based on populations with diseases rather than hypertension , 34. TheOther significant issues in older patients include polypharmacy, increased risk of falls, and cognitive impairment. Antihypertensive treatment of older patients in line with the European Society of Hypertension (ESH) and European Society of Cardiology (ESC) guidelines  largely Identifying the causes of nonadherence to pharmaceutical treatments is a very important factor in planning therapeutic interventions aimed at increasing control, preventing complications, and improving long-term outcomes and any adverse effects of treatment. Precise identification of contributors to low medication adherence is crucial for improving treatment effectiveness and for distinguishing those patients in need of additional supervision in order to decrease the risk of complications from untreated hypertension .There is a one key study limitation that should be discussed. Namely, only a self-reported test identifying FS (TFI tool) was used in the present study. It should be pointed out that some functional tests such as hand grip strength testing with a dynamometer, walk speed assessment using Timed Up and Go test or Gait Speed test, postural control using tensometric platform, and muscle strength testing with an isokinetic device or surface electromyography, should be considered in the future studies as valuable tools for better characterization of frail patients. However, our intention was to focus more on psychological and social factors than physical capacity. The last potential limitation is the fact that the study sample consisted of elderly hypertensive patients from a single outpatient centre. Thus, our findings should be carefully extrapolated to the multicentre or institutional studies.The coexistence of FS has a negative impact on the compliance of older patients with hypertension. Diagnosis of frailty and of the associated difficulties in adhering to treatment may allow for targeting the older patients with a poorer prognosis and at risk of complications from untreated or undertreated hypertension and for planning interventions to improve hypertension control.


The aim of the study was to assess the effects of walking on the blood pressure in sedentary adults with differing degrees of systolic blood pressure (SBP).A total of 529 subjects with SBP above 120 mmHg were enrolled. Blood pressure, body weight, body mass index, waist circumference and walking speed were determined at enrolment and after six months. Walking sessions were supervised by exercise physiologists.p < 0.001), with the greatest reduction (−21.3 mmHg) occurring in subjects with baseline SBP >160 and the smallest reduction (−2.6 mmHg) occurring in subjects with baseline SBP of 120–129 mmHg. Diastolic blood pressure, body weight, body mass index and waist circumference were also significantly reduced following the walking intervention (p < 0.001). These reductions were nearly identical within the various groups.The weekly walking time of the subjects completing the project was uniform and reached 300 minutes by the second month. 56% of participants completed the 6 months intervention  27 had a baseline SBP >160 mm Hg, 35 between 150–159, 70 between 140–149, 89 between 130–139 and 75 between 120–129 mmHg. Following six months of supervised walking, SBP was significantly reduced in all subgroups (In a large group of sedentary adults with varying degrees of SBP, 6 months of supervised walking elicited a marked reduction in systolic blood pressure with the largest reductions in pressure occurring in individuals with higher baseline SBP. Hypertension is the most common, costly, and preventable cardiovascular disease risk factor  and is aThe 2017 AHA guidelines  state thTaking into consideration these guidelines  and the The study was advertised through local newspapers and emails sent to the employees of public organizations active in Ferrara, Italy. Adults and elderly subjects who declared a sedentary lifestyle were considered for the study. During the enrolment phase, face-to-face interviews with potential participants were conducted, during which the purpose and procedures of the study were explained. The Human Studies Committee of the University of Ferrara, number 22-13, approved the study. After obtaining an institutionally approved informed consent, in accordance with the Helsinki declaration, 529 subjects  were enrolled over a 1-year period.None of the patients enrolled presented with comorbidities that interfered with the exercise program of this study.Arterial blood pressure was determined in the seated position after three minutes of rest, using a validated automatic sphygmomanometer (Omron M3) and averaging the values of three successive determinations taken with two-minute intervals between each assessment. The instrument was calibrated each week. No physical activity was performed <3 hours prior to this evaluation. Subjects with a systolic blood pressure (SBP) >140 mmHg were admitted into the study upon authorization of their personal physician. Hypertensive therapies prescribed by family physicians were maintained and not modified during the intervention period. Height and weight were measured and body mass index (BMI) calculated accordingly. Waist circumference was measured using standard procedures .Walking speed was derived from the time taken to walk 100 m on a flat course , at an iInitially, subjects began with a minimum of 15 to 30 minutes of daily walking and were encouraged to walk as frequently as possible with one of the walking groups using individualized walking speed organized within the project. The walking groups were guided and supervised by exercise physiologists. Walking sessions were performed outdoors, always on flat ground.Walking groups were active twice a day, from Monday through Friday, in addition to one walking session on Saturday morning. Based on the walking speed measured at enrolment, the participants were initially assigned to walking groups of “slow” (up to 4 km/h), “medium” (4–5 km/h) or “fast” speeds (above 5 km/h). The participants walked five to six days a week, mainly within the walking groups. Walking speed and walking time were increased progressively. The increments of walking speed and duration were not forced but chosen spontaneously by the participants. The daily walking duration for each group increased to 50–70 minutes within two months and was maintained for the following four months. The weekly walking time was uniform and reached 300 minutes by the second month.To motivate subjects and enhance compliance, a booklet on the importance of regular physical activity was distributed with suggestions on walking duration and intensity. To increase the sense of belonging to the project the participants were invited to monthly meetings on topics regarding the advantages of habitual physical activity and a healthy lifestyle.Systolic and diastolic blood pressure, height, weight, BMI, waist circumference and walking speed were re-determined after six months.The assessed variables  are expressed as mean ± standard deviation.The Kolmogorov–Smirnov test was used to assess the normal distribution of all data.post hoc tests. The influence of age, weight, BMI, waist circumference and walking speed on SBP was analyzed by multivariate analysis. Differences were considered to be significant at the P < 0.05 level.Gaussian Curves were calculated to express the distribution of systolic pressure values at enrolment and after six months of walking in seven groups stratified by of different levels of baseline SBP. Differences between values measured before and at the end of the program were analyzed using paired samples Student’s t-tests. ANOVA analysis were used to compare the Δ change of the systolic blood pressure between sub-groups and to verify differences in body weight at baseline between each of the five group considered. The Bonferroni method was used for A total of 296  subjects with baseline SBP above 120 mmHg completed the six month walking program.No one experienced an adverse event during the study. The weekly walking time of the subjects completing the project was uniform and reached 300 minutes by the second month.There were 119 subjects taking antihypertensive drugs; fifty-eight had a baseline SBP >140 mmHg; thirty had an SBP value between 130–139 mmHg; fifteen had an SBP between 120–129 mmHg. Anti-hypertension therapies were not modified during the study period.There were 233 dropouts . Most left the project within three months after enrolment for insufficient motivation, difficulties in scheduling, change of address and for other unknown reasons.To analyze specifically the effects of walking on the blood pressure of the 296 subjects with elevated SBP finishing the project they were subdivided into five subgroups with baseline SBP >160 mmHg, between 150–159, between 140–149, between 130–139 and between 120–129 mmHg.The values of systolic and diastolic blood pressure obtained after six month of walking in each of these subgroups are shown in SBP decreased significantly in each of the five subgroups, with lowering of −21.3 mmHg in the group of subjects with baseline values >160, −11.8 in the group 150–159, −7.5 in the group 140–149, −5.3 in the group 130–139 and −2.6 in the group 120–129 mmHg.R2 of 0.98. This relationship was similar and equally significant when the data obtained in males (R2 = 0.97) and in females (R2 = 0.99) were analyzed separately (data not shown).These reductions are also evident when analyzing the Gaussian curves of the SBP at baseline and after six months of walking in the five subgroups considered . The relDiastolic blood pressure was also significantly reduced following six months of walking in all subgroups . The decp = 0.006); in waist circumference which was higher in subgroup 1 relative subgroup 5 (p = 0.01) and for BMI which was higher in subgroup 2 and 3 relative subgroup 5 (p = 0.04). Following 6 months of supervised walking, body weight, body mass index and waist circumference decreased significantly in all subgroups. The reductions of the values of these anthropometric variables are relatively uniform and not correlated with the decrements of SBP  are also evenly distributed among the subgroups and are not significantly related to decreases in SBP. In addition, the changes in SBP cannot be attributed to a therapeutic intervention since, during the six-month project, blood pressure therapy was not modified.As documented by Habitual walking can therefore safely and effectively contribute to the blood pressure lowering in hypertensive subjects without exposing the patients to potential adverse effects of drug therapy.Given the fact that moderate physical activity such as walking effectively lowers blood pressure and is associated with numerous other health benefits, guided walking programs should be included as standard adjunctive therapy for hypertension. Since walking groups are effective and safe, with a good adherence and wide-ranging health benefits, they should adopted as part of public health policy .Previous randomized control studies have shown clearly that in control inactive subjects the variables considered, including systolic blood pressure, are not modified . For thiSix months of supervised walking in sedentary adults with high blood pressure is effective in reducing both systolic and diastolic blood pressures, with effects particularly evident in those with more severe hypertension.10.7717/peerj.5471/supp-1Supplemental Information 1Click here for additional data file.


There is evidence of cognitive impairment in patients with end-stage renal disease in hemodialysis (ESRD-HD). However, few studies have exhaustively analyzed executive functions (EFs) in this population, especially considering the influence of a wide range of clinical variables. This study analyzes performance in different EF components in ESRD-HD patients compared to a group of healthy controls (HCs), in addition to the acute effects of HD and the associations of cognitive performance with clinical variables.EFs were evaluated pre- and post-HD in 43 ESRD-HD patients and 42 HCs, using a battery of tests designed to assess EF domains. Age, schooling, mood and blood pressure were statistically controlled. Associations between performance and clinical factors were computed by correlations and hierarchical multiple regression analyses.The performance of the ESRD-HD patients was significantly lower than that of HCs in all the EF domains except for planning. Group differences were marginally significant for reasoning. HD produced no acute changes in global performance, with improvements see only in inhibition and working memory. EF scores were positively associated with total number of months previously transplanted, body mass index (BMI), dry weight, and levels of hemoglobin, albumin, ferritin, calcium, phosphorus, sodium, urea, and creatinine.Global EF functioning was lower in ESRD-HD patients than in HCs. No major acute HD-related EF changes were detected. These findings underline the importance of an adequate nutritional status for maintaining executive functioning in ESRD-HD patients. A range of disorders related to neuronal function have been observed in patients with end-stage renal disease (ESRD), including cognitive problems , 2. NeurEFs are involved in the generation, supervision, regulation, execution, and readjustment of behaviors needed to achieve complex objectives, especially those requiring a novel and creative approach , 6. EFs Research on possible acute changes in EFs produced by HD is available. Schneider et al.  reportedUsing a large battery of tests to cover all EF components, the objectives of the study were: (a) to compare EFs between ESRD-HD patients and healthy controls (HCs), controlling for potentially influential sociodemographic and emotional variables; (b) to compare EFs before and after HD in ESRD-HD patients; and (c) to evaluate the associations between clinical variables and executive performance.The study hypotheses were: (a) ESRD-HD patients would perform worse than HCs in all EF domains, (b) EFs scores would increase after HD in comparison to pre-HD levels, and (c) EFs scores would be associated with clinical and biochemical variables.x2 = 0.87, p = 0.35), age  or years of education  were observed between transplanted and non transplanted patients.The study included 43 patients who were receiving HD treatment (ESRD-HD) and 42 HCs. Seventeen patients were previously transplanted and seven were previously under peritoneal dialysis. All participants spoke Spanish as a first language. Inclusion criteria for the ESRD-HD group were: (1) receipt of HD for ≥ 3 months prior to the study; (2) receipt of three 4h HD sessions/week; (3) absence of any previous psychiatric diagnosis; (4) no history of traumatic brain injury or disorders affecting the CNS; and (5) absence of severe ophthalmic or auditory disease. HCs were recruited by using local advertising and a “snowball” approach, applying the same inclusion criteria as for the ESRD-HD group with the exception of criteria 1 and 2. Groups were matched for sex, age, and years of education . AdditioThe tests included in this study are part of a broader neuropsychological protocol that includes evaluations of basic cognitive processes in ESRD-HD. The EF dimensions evaluated and instruments used were as follows:-Update, i.e., the updating and monitoring of working memory contents. The tests for this domain were: (1) Fluency- Controlled Oral Word Association Test (COWAT) ) (Bodystat®1500 monitoring unit) and seven blood pressure readings (3M Tensocare B100 arm blood pressure monitor) were taken during the pre-HD evaluation.Patients data were gathered from hospital records Tables  and 2. THospital Anxiety and Depression Scale (HADS) was used to evaluate anxiety and depression. Given the positive association between anxiety and depression severity (r = .61 in our study), and in order to reduce the number of variables in the regression analysis and keep alpha inflation at minimum, anxiety and depression scores were aggregated in to a global mood score.Finally, because negative emotional states can affect cognitive performance, The Spanish version  of the HPatients scheduled for HD were recruited from five hemodialysis centers in the provinces of Jaén and Granada (in Spain) and were individually evaluated in two sessions, before and after HD. All participants signed an informed consent form, which was approved by the Ethics Committee of the Jaén Hospital Complex. Evaluations were conducted in participants’ homes after ensuring adequate conditions for the assessment. Participants consumed no food, caffeine, alcohol, or tobacco during the tests. The pre-HD evaluation (before the HD session) was carried out in the hours before HD treatment, i.e., around 56 h after the last HD. The post-HD evaluation (after the HD session) was performed around 20 h after HD treatment, i.e., around 48 h after the pre-HD evaluation . The two2 of the predicted change in performance associated with each block.Multivariate analysis of variance (MANOVA) was used to analyze between-group differences during the first assessment . Age, years of education, mood and systolic blood pressure  = 2.79, p = 0.005, versus HC group.In these analyses, the Group factor  was significant for fluency ; BMI was positively associated with working memory ; dry weight was positively associated with working memory ; hemoglobin was positively associated with fluency ; albumin was positively associated with working memory ; ferritin was positively associated with lower inhibition ; calcium was positively associated with working memory ; phosphorus was positively associated with working memory ; sodium was positively associated with working memory  and decision-making ; urea was positively associated with working memory , and reasoning ; and creatinine was positively associated with working memory .Sodium was positively associated with (1) semantic FAS  and (2) Arithmetic . In the latter case, dry weight was included in a second model with and showed positive associations . Calcium was positively associated with Letters and numbers ; BMI was included in a second model and showed negative associations , and hematocrit was included in a third model and showed positive associations . Urea was positively associated with Similarities  and ferritin was positively associated with lower inhibition in 5DT .The following significant regression models were obtained after controlling for the effects of socio-demographic variables and mood: This study explored EFs in ESRD-HD patients by using a comprehensive test battery covering the domains of updating , inhibitory control, cognitive flexibility, planning and decision-making. Patients performed worse than HCs in terms of fluency, working memory, inhibitory control, cognitive flexibility, and decision-making. These results are in line with previous reports. Regarding verbal fluency, Harciarek et al.  found a The second objective of our study was to establish the acute effects of HD. Both of our groups showed improvement in several EF indexes between the first and second assessments, attributable to learning processes (experience and familiarization gained in the first round of the tests). Regarding group differences in pre-post evaluations, ESRD-HD patients showed a greater post-HD improvement in inhibition (5DT) and working memory (Arithmetic) in comparison to HCs. The study hypothesis was therefore not completely fulfilled, as no differential global improvement was observed after HD in the ESRD group. These results are in partial agreement with the findings of Schneider et al. , who repThe third objective was to analyze associations between EF performance and clinical and biochemical variables . DecisioWith respect to body composition parameters, BMI and dry weight showed a positive association with working memory (Arithmetic). Radić et al.  observedWith regard to the relationships between biochemical variables and EF indexes, we highlight the association of nutritional status and inflammatory markers with working memory, inhibition, reasoning, and decision-making. Albumin was positively associated with working memory (Letters and numbers), confirming previous findings  on the rUrea was positively associated with working memory indexes (Arithmetic) and reasoning (Similarities) in this study. An association between increased urea and EF improvement was also reported by Griva et al.  in ESRD Other biochemical markers commonly related to neuropsychological performance are hematocrit and hemoglobin. In this investigation, hematocrit was associated with working memory (Letters and numbers), in line with previous findings . HemogloA major strength of the present study was the exhaustive evaluation of EF components, which have generally been analyzed in only a partial manner in previous investigations. Several authors have focused on the evaluation of executive indexes such as working memory, verbal fluency, cognitive flexibility, or inhibitory control , 8, 13, In summary, the results of this study reveal a lower global EF performance by ESRD-HD patients than by matched HCs participants in terms of fluency, working memory, inhibitory control, cognitive flexibility, and decision-making. No differences were observed in planning. Comparisons of performance before and after HD showed no global improvement, with only partial gains for inhibition (5DT) and working memory (Arithmetic). With respect to the influence of clinical factors, we highlight the improved performance by patients with a history of transplantation. Many of the associations detected underscore the importance of good nutritional status for achieving good executive functioning.


Moreover, the correlation study in each group showed that the decrease of both t3 and h5 was also related to arterial stiffness (P<0.05). In terms of echocardiographic parameters, the height of dicrotic wave indicated by h5 was the most relevant pulse wave variable. For the health control, h5 was negatively associated with interventricular septal thickness (VST) and left ventricular posterior wall thickness (PWT) (P<0.05), while for the hypertension population and those with target-organ damage to heart, increase of h5 might be associated with decrease of ejection fraction (EF) and increase of all the remaining echocardiographic parameters especially for left ventricular end-systolic diameter (LVDs) and Left ventricular end-diastolic diameter (LVDd) (P<0.05). In conclusion, we found radial artery pulse wave variables were in association with the arterial stiffness and echocardiographic changes in hypertension, which would provide an experimental basis for cardiovascular pathophysiological mechanism of radial artery pulse wave variables.This study aims at exploring the cardiovascular pathophysiological mechanism of TCM  pulse by detecting the correlation between radial artery pulse wave variables and pulse wave velocity/echocardiographic parameters. Two hundred Chinese subjects were enrolled in this study, which were grouped into health control group, hypertension group, and hypertensive heart disease group. Physical data obtained in this study contained TCM pulse images at “Guan” position of the left hand, pulse wave velocity, and echocardiographic parameters. Linear and stepwise regression analysis was performed to assess the association of radial artery pulse wave variables with pulse wave velocity and echocardiographic parameters in the total population and in each different group. After adjusting for related confounding factors, decrease of t Hypertension, as a primary global metabolic risk factor, accounts for 19% of global deaths . The prePulse palpation or pulse diagnosis is one of the most important diagnostic tools in traditional Chinese medicine (TCM) and other related oriental medicine systems. The traditional pulse diagnosis depends mainly on the subjective judgement of the TCM practitioners, which largely hinders the development of TCM pulse diagnosis by its subjectivity and fuzziness. Thereby, considerable researches have been carried out recently to measure radial pulse objectively and automatically by means of modern techniques, such as varied pulse waveform acquisition platforms –8, pulse1) of hypertension group were both higher than those of the healthy group when calibrated in Cheok by automatic pulse analyzer with array piezoresistive sensor [By describing the pulse state of radial artery, TCM pulse diagnosis is actually a direct reflection of the cardiovascular condition. Because hypertension is a major risk factor in the cardiovascular diseases, therefore a number of studies have explored the correlation between hypertension and TCM pulse diagnosis. It was reported that the mean height of main peak (Mm) and the height of main peak  and echocardiography were used, respectively, as a marker of arterial stiffness and cardiac function. The purpose of this study was to investigate whether radial artery pulse wave variables are present in association with the arterial stiffness and cardiac function in hypertension, so as to provide an experimental basis for cardiovascular pathophysiological mechanism of radial artery pulse wave variables in TCM.200 Chinese subjects were enrolled in the study from April 2016 to March 2018, and they were all from the First People's Hospital of Taicang affiliated to Suzhou University.⩾140mmHg or diastolic blood pressure ⩾90mmHg, while hypertensive heart disease group included those hypertensive patients with confirmed diagnosis of cardiac remodeling or dysfunction [For current study, in order to diminish the impact of age on the cardiovascular condition, 159 subjects aged between 45 and 75 years were recruited from the overall participants . Inclusifunction , such as⩾30 Kg/m2; ⑦ pregnant and lactating women; ⑧ history of smoking.Exclusion criteria contained ① patients with hypertrophic cardiomyopathy, cardiac amyloidosis, and other causes of left ventricular hypertrophy; ② patients with congenital heart disease, valvular disease, pulmonary heart disease, pericardial effusion, and pleural effusion; ③ history or symptoms of chronic metabolic diseases such as diabetes mellitus, dyslipidemia; ④ history of pulmonary, hepatic, or renal disease; ⑤ history of varied malignancy disease, endocrine system disease, infectious diseases, and mental disorders; ⑥ obesity patients whose BMI The Medical Ethics Committee of the First People's Hospital of Taicang affiliated to Suzhou University approved the study, and written informed consent was obtained from all included subjects according to the Declaration of Helsinki.Patient metadata were collected . Physical examinations included blood pressure, pulse pressure, body mass index (BMI), brachial-ankle pulse wave velocity (ba-PWV), ankle-brachial index (ABI), and echocardiographic parameters. Ba-PWV is widely acknowledged as the gold standard of arterial stiffness measurements , while Ah1, h4, h5, t1, t3, t4, t5, h3/h1, h4/h1, w/t were calculated using the software included in the DDMX-100 type pulse measurement device.Radial artery pulse images were recorded using a DDMX-100 type pulse measurement device which is developed by Shanghai University of Traditional Chinese Medicine see . The who1: height of the main wave, namely, the height from the peak of the main wave to the baseline of the pulse chart.  h3: height of the tidal wave, namely, the height from the peak of the tidal wave to the baseline of the pulse chart.  h4: height of the dicrotic notch, namely, the height from the valley bottom of the dicrotic notch to the baseline of the pulse chart.  h5: height of the dicrotic wave, namely, the height from the peak of the dicrotic wave to the baseline parallel line at the valley bottom of the dicrotic notch.  h1: time distance between the starting point of pulse chart and the main wave peak, which corresponds to the rapid ejection period of the left ventricle.  t3: time distance between the starting point of pulse chart and the tidal wave peak.  t4: time distance between the starting point of pulse chart and dicrotic notch, which corresponds to the systole period of the left ventricle.  t5: time distance between dicrotic notch and the ending point of pulse chart, which corresponds to the diastolic period of the left ventricle.  t  t: time distance between the starting point and the ending point.  w: width of main wave in its 1/3 height position.3/h1: the ratio of h3 to h1.  h4/h1: the ratio of h4 to h1.  h  w/t: the ratio of w to t.As the most commonly used pulse wave form analysis in TCM , the cla2 test was used, and Bonferroni correction was used to adjust P value for the multiple comparisons.If not otherwise stated, data are presented with mean±SD. In the continuous data, we used ANOVA multiple comparison test or T-test to compare differences among those three groups or between two groups for the normally distributed data, while Kruskal-Wallis ANOVA or a Mann–Whitney U test was for nonnormally distributed data and a Dunn-Bonferroni test for post hoc pairwise comparisons. In the categorical data, Pearson xTo identify the association between radial pulse variables and arterial stiffness/related echocardiographic parameters, linear and stepwise regression analysis was performed using different models. Model 1 adjusted for age, sex, BMI, blood pressure, and pulse pressure, model 2 included model 1 and adjusted additionally for duration time of hypertension, history of taking antihypertensive drug, and the controlling condition of blood pressure. Model 3 included model 2 and adjusted additionally for arterial stiffness (PWV and ABI), which was only used to detect the association between pulse variables and related echocardiographic parameters.For statistical analysis, P values are two sided and subject to a global significance level of 0.05, and they would be conducted in the IBM SPSS 21.0 .The baseline characteristics of 159 participants are shown in 5 value of the three groups was statistically different (p<0.05). Besides, compared with health control group and the hypertension heart disease group, the hypertension group had the lowest h5 value. Moreover, we could see that h1 value might be the second obviously changed variables among those three groups (p=0.081), while more samples should be needed in the future to detect this difference.As for the radial artery pulse wave variables, only h1 value , t5 value , h1 value , and h3/h1 value . ABI was independently associated with h4 value . Besides, after additional adjustment for duration time of hypertension, history of taking antihypertensive drugs, and the controlling condition of blood pressure (model 2), baPWV was still independently associated with t1 value , t5 value , h1 value , and h3/h1 value , so did ABI with h4 value . The above results suggested that a higher baPWV was independently correlated with shorter t1 and t5 value but higher h1 and h3/h1 value, while ABI was positively associated with h4 value independent of the above adjusted risk factors.The association between radial artery pulse wave variables and arterial stiffness in the total studied population is shown in 3 value . In the hypertension group, baPWV was independently associated with h1 value . In the hypertensive heart disease group, t3 value , t5 value , and h5 value  were the independent factors for baPWV, while for ABI, it was only associated with t3 value  and h4 value  in the hypertensive heart disease group. The above results demonstrated that the premature appearance of tidal wave was a sign for a higher baPWV in the healthy old population. Besides, it also indicated that a higher main wave was associated with a higher baPWV in the subjects with hypertension. Moreover, premature appearance of tidal wave, the shortening of the diastolic period of the left ventricle, and the lowering of the dicrotic wave were all related with a higher baPWV in the hypertension subjects with target organ-damage to heart.The association between radial artery pulse variables and arterial stiffness in each different group is shown in 5 value was the only radial artery pulse variable which independently associated with AAO , AODd , VST , PWT , LVDs , and LVDd , while t1 , h5 , h4/h1 , and w/t  were the independent factors which affected the EF value (P<0.05). However, no correlation was found between radial artery pulse variables and LAD.The association between radial artery pulse variables and echocardiographic parameters in the total studied population is shown in 5 value was still the most relevant factor which is associated with almost all the echocardiographic parameters especially for LVDs  and LVDd . In addition, LVDs were additionally associated with t4 value . However, for the EF value, h4 was the only independent factor. Therefore, those results indicated that, independent of the above adjusted risk factors, h5 and t4 were positively correlated with echocardiographic parameters including AAO, AODd, VST, PWT, LAD, LVDs, and LVDd; however, h4 value was positively associated with EF.Besides, after additional adjustment for duration time of hypertension, history of taking antihypertensive drug, the controlling condition of blood pressure (model 2), and extra adjustment for baPWV and ABI (model 3), h4 was independently associated with AAO  and AODD . Besides, h5, t1, and w/t were all negatively associated with VST and PWT. No correlation was found for radial artery pulse wave variables with LAD, LVDs, LVDd, and EF. In the hypertension group, h1 was independently associated with PWT , w/t was independently associated with LAD , h5 was, respectively, related to LVDs , LVDd , and EF , and h4/h1 was independently associated with LVDs . In the hypertensive heart disease group, t1 was independently associated with AODd  and LVDd , h5 was independently related to LVDs , h1  was independent factors for LVDd, and t5 was independently associated with EF . The above results indicated that, independent of the above adjusted risk factors, h4, h5, t1, and w/t value were negatively related to AAO, AODD, VST, and PWT in the healthy population, while in the hypertension population, the augmentation of h1, h5, and w/t and decrease of h4/h1 were hints for a higher PWT, LAD, LVDs, and LVDd and a lower EF. Moreover, in the population with hypertensive heart disease, the shortening of t1 and t5 and the increase of h1 and h5 suggested the increase of AODD, LVDs, and LVDd and the decrease of EF.The association between radial artery pulse variables and echocardiographic parameters in each different group is shown in Pulse condition is a state of pulse throbbing which described the feeling of a finger's palpation. For the blood vessels of human run through the whole body to connect both the internal organs and the external skins, it often provides comprehensive information on the visceral functions, qi and blood, Yin and Yang, which can be used for diagnostic purposes . Pulse d5 value, followed by h1 value. This suggests that the decrease in dicrotic wave and increase in main wave can be detected before the cardiac remodelling and dysfunction. This is partly in line with the previous researches which reported a lower dicrotic wave and a higher main wave in the hypertension group compared with the health control [By observing the three groups , our dat control , 17, 32.3/h1, might be associated with arterial stiffness. Besides, a lower dicrotic notch might be associated with abnormal patency of peripheral occlusive arterial disease. In previous subjective studies, it revealed that the superficial, strong, and fast pulse images were related to higher PWV. By application of objectified pulse diagram parameters, similar results are obtained from our study [3 and h5 value was also independently related to increase of baPWV under the same cardiac condition. In one word, arterial stiffness was suggested by increase of the main wave (h1) and the ratio between h3 and h1 (h3/h1), the premature appearance of the tidal wave (t3), the shortening of rapid ejection time (t1), and diastolic time of left ventricle (t5) as well as decrease of the dicrotic wave (h5).The stepwise regression analysis in association between radial artery pulse variables and arterial stiffness in the total studied population showed that shortening both in the rapid ejection period and in the diastolic period of the left ventricle, as well as ascending of the main wave and hur study , 20, whi5 was the most relevant factor which associated with all the echocardiographic parameters except for the EF value, especially for its associations with LVDs and LVDd. This result was partly in line with the previous research which reported that a larger systolic and diastolic left ventricular dimensions, lower EF, and poorer thickening properties of the left ventricular posterior wall had been observed in subjects whose dicrotic wave was greater than 20% of the main wave via carotid pulse tracing than those who not [4 was the only independent factor. Through the correlation study in each different group, we found that the decrease of h4 value was also independently related with increase of AAO (diameter of ascending aorta) and AODd (aorta sinus department diameter) in the healthy population. Besides increase of h1 was independently associated with increase of PWT  in hypertension population and LVDd (left ventricular end-diastolic diameter) in population with hypertensive heart disease. Decrease of t1 was independently related with the increase of VST and PWT in healthy population and the increase of AODd and LVDd in population with hypertensive heart disease. At last, t5 was positively related with EF in population with hypertensive heart disease.In the total studied population, the stepwise regression analysis in association between radial artery pulse variables and echocardiographic parameters showed that the increase of h who not . However1, t5 and increase of h1, h3/h1 were statistically associated with arterial stiffness in the total population without regard to the cardiac factors and blood pressure. However, decrease of t3 and h5 was also hints for arterial stiffness when the cardiac function and blood pressure were under the same condition. In terms of echocardiographic parameters, our data showed that the height of dicrotic wave indicated by h5 was the most relevant pulse variable. The increase of h5 was associated with the decrease of EF but the increase of all the remaining echocardiographic parameters especially for LVDs and LVDd. The normal dicrotic wave has been generally ascribed to a reflected wave from the recoil of the blood column against the closed aortic valve [Based on the above results, in the radial artery pulse variables, decrease of tic valve , 35. Theic valve . It was ic valve , 33. Howic valve , 37. In To our knowledge, the current study is the first quantitative study to define the exact associations between radial artery pulse wave variables and cardiovascular conditions  in hypertension. This study would provide an experimental basis for cardiovascular pathophysiological mechanism of radial artery pulse wave variables.Several limitations merit discussion. Firstly, the study sample was limited to the patients diagnosed only with systematic hypertension and/or hypertensive heart disease at the age of 45-75 years. A more large-scale study should be carried out in the future to include more cardiovascular risk factors like age, BMI, glucose, lipid, etc. Secondly, as this was a cross-sectional study, we only investigate the history of taking antihypertensive drugs rather than the concrete type of the current antihypertensive drugs. Further longitudinal studies should be conducted to determine whether these changes of radial artery pulse waves evolve in the clinical outcomes of the hypertension as well as the impact of different concrete type of the current antihypertensive drugs on the radial pulse wave changes. Thirdly, this study is conducted by the objective radial artery pulse variables at “Guan” position; a subjective pulse palpation performed by TCM experts should be conducted in the future so as to get a thorough understanding of the pulse changes in hypertension.1, t3, t5, h5 and the increase of h1, h3/h1 might suggest the arterial stiffness. In addition, a higher h5 was the most relevant factor which affected structural echocardiographic variables.In this study, we found radial artery pulse wave variables in association with the arterial stiffness and echocardiographic changes. For all the time-domain variables of wrist pulse, the decrease of t


To evaluate the effectiveness and outcomes of endovascular treatment of TRAS with PTA. We searched our prospectively collected database looking at cases of TRAS between January 2005-December 2011. CCT was the gold-standart for diagnosis of TRAS. Parameters analysed comprised technical aspects, arterial blood pressure variation, and renal function. A minimum follow-up of 24 months was considered. Of the 2221 renal transplants performed in the selected period, 22 (0.9%) patients were identified with TRAS. Fourteen (63.6%) were male and mean age was 377±14.8years (12-69). Kidney graft was from deceased donnors in 20 (80%) cases. On doppler evaluation, mean blood flow speed after transplantation, at TRAS diagnosis and after TAP was 210.6±99.5, 417±122.7 and 182.5±81.6mL/sec, respectively (p<0.001). For SBP and DBP, there was a significant difference between between pre-intervention and all post-treatment time points (p<0.001). After 1 month of the procedure, there was stabilization of the Cr level with a significant difference between mean Cr levels along time (p<0.001). After a mean follow-up of 16±4.2 (3-24) months, overall success rate was 100%. Endovascular treatment with PTA/stenting is a safe and effective option for managing TRAS, ensuring the functionality of the graft and normalization of blood pressure and renal function. Renal transplantation remains the gold-standart treatment for patients with chronic renal failure, not only for a medical stand-point but also for an economic and social perspective. Indications include: end-stage renal disease (ESRD), dyalitic patients and in a preenptive matter.The most common vascular complication in transplanted kidneys is transplant renal artery stenosis (TRAS), with a reported incidence of 1% in selected cohorts. However, literature incidence of TRAS is heterogeneous and usually higher, affecting almost 25% of patients according to some series , 7.Percutaneous transluminal angioplasty (PTA) is considered the less invasive approach for initial management of TRAS with proved efficacy . The purAfter Institutional Ethical Approval, a retrospective search on our prospectively collected database was performed searching for cases of TRAS between January 2005 and December 2011. TRAS was suspected if patient had refractory hypertension and transplant graft dysfunction, or when imaging exams were strongly suggestive of the disease. Initial evaluation was performed with doppler ultrassound and confirmed with contrasted computed tomography (CCT) with arterial phase reconstruction. Only cases confirmed by CCT were considered to have definitive diagnosis of TRAS. Of the 2221 renal transplants performed at our Institution in the selected period, 22 (0.9%) patients were identified with TRAS and all cases were treated with PTA.® stent  was positioned and primary stent placement was performed under roadmap technique. Arteriography showed ideal stent positioning without residual stenosis or complications. An Exoseal® closure device  was used for hemostasis.Initial angiography was performed to evaluate stenosis under ipsilateral common femoral artery approach with a 6-French guiding catheter using a nonionic isosmolar contrast medium. After a intravenous bolus of 5000UI of heparin a 0.014 inches guidewire was used to cross the stenosis and was positioned into a distal renal branch. A 6 x 15mm metallic balloon-expandable Palmaz BlueAnalysed parameters comprised technical aspects, arterial blood pressure variation-systolic and dyastolic; need for antihypertensive drugs; and renal function-serum creatinine (Cr) variation. Blood pressure measurements considered the month before PTA, 2 days, 1 week, 1 month, 6 months, 1 and 2 years after the intervention. Cr values were obtained one week before intervention, 1 day, 3 days, 1 week, 1 month, 6 months, 1 and 2 years after PTA. Blood flow speed at doppler ultrassound evaluation was also obtained after transplantation, at TRAS diagnosis, and after angioplasty.A subgroup analysis was performed to seek for differences regarding the above-mentioned parameters between groups divided by specific cause of TRAS and donnor characteristics. A minimum follow-up of 24 months was considered for all cases. Final success of PTA was considered if the procedure underwent uneventfull and if there was improvement of renal function paralell to blood pressure normalization.Data was analyzed with SPSS V.20 . Results were expressed in mean±standard variation and range, or absolute number and frequencies. The Chi-Square or Fisher Exact Test were used to compare categorical variales. To compare measurements for each parameter between individuals the Levene test was used. One-Way Analysis of Variance (ANOVA) with repeated measures was used to compare continuous variables among different time periods for each patient. ANOVA with fixed factor was used to compare continuous variables among groups. Post-Hoc test was performed with Tukey test. Statistical siginificance was set at p <0.05 and considered a 95% Confidence Interval.In the six-year period analyzed, 22 consecutive patients presented with TRAS after kidney transplantation-TRAS incidence of 0.9%. Of those, 14 (63.6%) were male and 8 (46.4%) female. Mean age was 37.7±14.8 (12-69) years.Kidney graft was from deceased donnors in 20 (80%) cases and from living donors in 5 (20%). All presented with refractory hypertension and/or increased serum creatinine levels. The mean interval time from transplantation to diagnosis was 145 day±111 (In 6 (27.3%) patients the site of renal artery stenosis was at the anastomosis. In 3 (13.6%) cases it was due to kinking and the remaining 13 (59.1%) cases it was distal to the anastomosis.On doppler evaluation, mean blood flow speed after transplantation, at TRAS diagnosis, and after TAP was 210.6±99.5, 417±122.7 and 182.5±81.6mL/sec, respectively (p <0.001). There was a significant difference between mean blood flow speed at time of TRAS diagnosis compared to after transplantation and after angioplasty, these two moments being similar. For each time point, there was no mean blood flow speed difference among patients (p=0.381), showing a homogeneous normalization of the speed after angioplasty. Mean diastolic blood pressure (DBP) showed a mean decrease of 23.4-33.0mmHg from pre-treatment to after intervention. Mean systolic blood pressure (SBP) also presented an average decrease of 11.8 to 17.3mmHg in the same period. After PTA, both showed a relative stabilization .At each time point, there was no statistical significant difference among patients for SBP and DBP (p=0.11). For SBP and DBP, there was a significant difference between mean pressure value along the time period analysed (p <0.001) due to a significant difference between pre-intervention and all post-treatment time points (p <0.001). After the procedure, mean pressure value was similar for all patients at all time points (p non-significant).Finally, when considering the amount of use of antihypertensive drugs, there was no statistically significant reduction in the number of medications used to control the disease.Mean serum Cr level pre-intervention was 4.07±2.82mg/dL, falling to 2.1±1.94 after 2 years of TAP. At each time point, there was no significant mean Cr level between patients.The mean drop of creatinine values from pre-intervention to post-treatment days 1, 3, 7 and 30 was 0.72, 1.16, 1.38 and 2.28mg/dL, respectively. After 1 month of the procedure, there was stabilization of the Cr level . OverallAfter a mean follow-up of 16±4.2 (3-24) months, overall success rate was 100%. No complications neither restenosis occured. Six patients died due to unrelated causes: 3 due to pneumonia, 1 due to vascular cerebral accident, 1 gastric tumor and 1 acute myocardial infarction.Age was found to be significantly different between groups (p=0.018). The kinking cohort (30.5±20.4 years old) was significantly younger than the anastomotic (50.3±10.2 years old) and post-anastomotic groups (56.2±6.2 years old)(p=0.002).There was no difference for SBP between groups (p=0.34). However, DBP was different among cohorts (p=0.036). DBP was significantly lower in the kinking group compared to the anastomosis (p=0.029) but not to the post-anastomotic group (p=0.11).The cohorts were also similar in terms of Cr decrease (p=0.47), blood flow speed at doppler ultrasound (p=0.63), and prevalence of hypertension (p=0.11). Improvement of renal function showed a tendency to be better when due to kinking compared to other sites of stenosis. However this data was not statistically significant, probably due to the small sample size .Comparison regarding the outcomes of renal function, blood pressure behaviour and mean blood flow speed between patients with classical versus expanded donation criteria , was performed. There was no statistically significant difference (p >0.05).TRAS remains the most frequent vascular complication in patients undergoing renal transplantation. It is responsible for 1 to 5% of cases with refractory hypertension following transplantation. The incidence of TRAS is extremely variable; it was reported an incidence of 2.3% in a large series of 2.013 kidney-transplanted patients ; it was Early diagnosis and immediate therapeutic work-up plays an important role in the graft function. The angioplasty of renal artery stenosis has been an excellent therapeutic method in the management of these cases, since it presents few complications with significantly improvement in renal function and blood pressure control. This retrospective evaluation highlights the safety of endovascular management of TRAS and we could succesfully treat all cases without any complication. Furthermore, TAP’s efficiency was symbolized by renal function and graft preservation with significant reduction of mean blood pressure to normal parameters. After a two-year follow-up, no cases of restenosis occurred and these patients are being followed closely for an extended period.TRAS is a serious complication of renal transplantation. There is a higher incidence of TRAS in the first 6 months of transplantation and in elderly transplanted patients. Early appearing stenosis are mainly due to traumatic intimal injury during recovering of the organ or vessel manipulation, kinking of the artery when it is longer than the vein, or technical problems with the vascular suture. Stenosis occurring later, sometimes in terms of years, reflect allograft renal artery hyperplasia or renal and/or iliac atherosclerotic evolution. Late and diffuse stenosis might also reflect endothelial damage related to immune response. In our series, the median time to presentation was 145 days and is consistent with the literature. We found cases of kinking to present in younger patients and with lower dyastolic blood pressure than in patients with anastomotic or post-anastomotic stenosis.We realize the importance of both blood pressure and renal function normalization to improve endurance of the transplanted graft and survival of recipients. We could successfully normalize both parameters in all patients identified with TRAS who were treated with TAP within a 2-year follow-up, which is longer than some recent series -14. Our This investigation has potential draw-backs that cannot be overlooked. It is a retrospective analysis and therefore suscetible to selection and measurement bias. However, our database is collected in a prospective manner and missing data is extremelly rare. Also, the concise group of urologists and nephrologists following those patients together minimize such biases. Another limitation is the small number of patients analyzed. The number of individuals with suspected TRAS is much larger, nevertheless we have a strict criteria to define TRAS which explain the low amount of patients identified with the disease at our Institution. In addition, most differences found in the investigation achieved significance even in this relatively short series. A larger prospective multi-institutional study could provide a better insight into the subgroup analysis.Endovascular treatment with PTA/stenting is a safe and effective option for managing TRAS as it preserves vascular permeability in short and medium term, ensuring the functionality of the graft and normalization of blood pressure and renal function. In addition, patients with TRAS due to kinking showed a tendency of better results in terms of renal function improvement.


Systolic blood pressure rise among T2DM patients was main risk factor for cardiovascular disease. Objective of this study was to identify predictors of isolated systolic hypertension among T2DM patients at Jimma University Specialized Hospital, 2016. We conducted cross sectional study using simple random sampling and interviewer administered questionnaire. Isolated systolic hypertension is SBP ≥ 140 mmHg and < 90 mmHg. Data entered and analyzed using Epi Data and SPSS respectively. Predictor factor was declared at p < 0.05.A total of 315 T2DM took part. Prevalence of ISH was 27.6% [95% CI ]. One hundred sixty and two (51.4%) patients were males with mean age of 54.1 from 22 to 87 years. Male sex , unemployment , age of 47–55 , single , ≤ Grade 8  and income (ETB) 501–800 , 801–1500  and > 1500  were significant factors of ISH. The health sector has to establish preventive strategies for ISH among T2DM patients by giving special attention to predictor factors.The online version of this article (10.1186/s13104-019-4550-3) contains supplementary material, which is available to authorized users. Hypertension is the common comorbidity of diabetes mellitus (DM) . It is pDecreasing of SBP by 10 mmHg lead to 12% reductions of diabetes complications , 10. SBPWe conducted the study at Jimma University Specialized Hospital (JUSH), Jimma, 352 km away from Addis Ababa. We found 1853 T2DM patients (source population) in medical records at JUSH immediately before starting data collection of which 850 patients were accessible during data collection.Study design: Institution-based cross-sectional study design was employed.Study period: It was conducted from April 01 to July 30, 2016.Sample size was calculated using Raosoft sample size calculator  assumingAll T2DM patients aged ≥ 20 years who were present during study period were included whereas those T2DM patients who were severely ill and pregnant women were excluded from the study.Dependent variable: Isolated systolic hypertension.Independent variables: Age, sex, residence, marital status, lifetime khat chewing, lifetime cigarette smoking, lifetime alcohol drink, income, educational level, treatment options for diabetes, BMI, duration of DM, Fasting plasma glucose, occupation,Isolated systolic hypertension (ISH): SBP ≥ 140 mmHg and DBP < 90 mmHg , 26.Hypertension (HTN): SBP and/or DBP of 140/90 mmHg or greater. The 2007 ESH/ESC recommended two distinct BP targets; 140/90 in low moderate risk hypertensive and 130/80 mmHg in high-risk hypertensive .Isolated diastolic hypertension (IDH): DBP ≥ 90 mmHg and SBP < 140 mmHg.Mean arterial pressure (MAP): The sum of DBP and one-third of the pulse pressure. MAP ranges 70–106.7 mmHg for average adults.Pulse pressure (PP): The difference between systolic and diastolic pressure which ranges from 30 to 50 mmHg in average adults.Fasting plasma glucose (FPG) level: Plasma glucose level when expressed in mg/dl of blood which is measured by taking blood sample from a person who was not taking anything orally for at least 8-h prior to taking the blood sample.2, 18.5–24.9 kg/m2, and > 24.9 kg/m2 is considered as underweight, normoweight and overweight respectively.Body mass index: A person with BMI of < 18.5 kg/mRural residence Settling in country side outside of big cities or towns in Ethiopia are referred as rural residents whereas those living in big cities (like Jimma town) were urban residents  with a mean of 124.4 ± 18.95 mmHg. The overall comorbid hypertension was 41% with mean systolic to a diastolic blood pressure ratio of 1.62 ± (1.56)  prevalence of ISH. The high prevalence of ISH in type 2 diabetes mellitus patients might be related with increased vascular resistance via remodeling of blood vessels following hyperglycemia , though .7, 32.5%In the final model significantly associated factors of ISH among T2DM patients were male sex, older age, employment status, lower educational level, monthly income, and marital status.The odds of ISH among T2DM male patients was 2.4 times higher than females. This is similar to a study in South Africa  and BengParticipants with age of 47–55 years were 2.6 times more likely to get ISH than aged 22–46 years. It is in line with previous study , 40. TheIn this study ISH was major public health problem. Being male, single, older age, lower education level and income were significant predictors. The findings of this study indicated health sector stakeholders to establish preventive strategies for ISH among T2DM patients by giving more attention to above mentioned predictor factors.The study cannot show cause-effect relationship. Social desirability and recall bias were also possible limitations.Additional file 1. English version questionnaire to assess predictors of isolated systolic hypertension among type 2 DM patients.


The reliability of blood pressure (BP) measurement in hospitalized patients is a topic of debate and the therapeutic implication of the routinely collected BP profiles is probably overestimated. When measurements are performed in elderly patients, further potential sources of misinterpretation occur. We conducted a subanalysis of a previous study including 79 over 80-year-old hypertensive patients, hospitalized in an internal medicine ward. Five modalities of BP evaluations  were analyzed, considering agreement and accuracy.κ 0.563 and bias 0.6, LoA -20.4 to 21.5 mmHg; κ 0.412). The patients' sensitivity and specificity in predicting hypertensive systolic D24hBPM were 84.8% and 69.7%, respectively. The mean (SD) age of the patients was 86.9±4.9 years (50% women). Patients' self-measurements of both systolic and diastolic BP (SBP and DBP) did not differ significantly from daytime 24-hour monitoring (D24hBPM) . Conversely, SBP and DBP registered by nurses did significantly differ . SBP and DBP measured by patients also showed the better concordance, with lowest biases, and narrowest limits of agreements (LoA) and for SBP higher Kappa statistic values (bias 1.5, LoA -28.9 to 31.9; In elderly hospitalized patients an alternative to 24hBPM, self-measurements by patients offer the better agreement and reliability in detecting hypertensive values. The reliability of blood pressure (BP) measurement in hospitalized patients is a topic of debate and the clinical implication of the routinely collected BP profiles, outside the intensive care units, is not well defined , 2. SeveFurther critical points should also be considered in the evaluation of BP profiles in hospitalized patients: the frequent lack of standardized operational protocols to measure BP and the related inconstant quality of the BP measurements performed and the potential lack of accuracy of some of the BP measuring devices –11. FurtIn patients over 70 years old, it has been shown that more than 90% of the patients were successful at monitoring BP at home . It has Furthermore, BP profiles obtained by self-measurements better correlate with the presence of hypertension target organ damage and with the related cardiovascular risk, compared to office and automated ambulatory monitoring –22. The Compared with the large amount of data referring to the out-patient setting, at present, studies exploring the reliability and the best method to assess BP in elderly hospitalized patients are not available. However, on one hand, the elderly population is the most prevalent in the hospital wards, and on the other hand during the hospital stay the home drug therapy is often reassessed and readapted on the basis of the in-hospital evaluation . Hence, To contribute in filling the knowledge gap, in the present study we set out to investigate the overall agreement and the clinical accuracy of 5 different types of BP measurement modalities in very old hospitalized patients.The present study is the result of a subanalysis of a previous cross-sectional study conducted at the internal medicine service of the teaching hospital “La Carità” in Locarno, Switzerland, from June 2014 to March 2015, in elderly hospitalized patients. The study was approved by the Swiss Ethics Committee and performed in accordance with the Declaration of Helsinki. All study participants provided signed informed consent. Only over 75-year-old patients hospitalized in the internal medicine service, able to understand and sign the informed consent and to perform self-BP measurement, with an automated device operating an arm cuff, were enrolled.From a sample population of 108 participants, data from 79 hypertensive, over 80-year-old patients were included in this analysis. Eight patients less than 80 years old and twenty-one not affected by hypertension were excluded  BP measurement by staff nurses and (ii) by staff physicians, (iii) self BP measurements by patients, (iv) noninvasive continuous finger beat-to-beat BP monitoring, and (v) 24-h BP monitoring (24hBPM).Blood pressure measurements performed by physicians and nurses and self-measurements by the patients were taken with validated automatic oscillometric devices  on the nondominant arm. Preliminarily, a circumference measurement of the arm was performed, to determine the size of the cuff to be applied . BP measurements were performed daytime and at the occasion of every visit, BP was collected thrice . BP measurements taken during the first two days of hospitalization were not used for the statistical analyses.For the self-BP measurements, all participants were empowered through a short training with a resident physician, and a standardized procedure was applied. Patients were instructed to rest at least 5 minutes before starting the BP readings, avoiding activities which could influence BP  in the previous 30 minutes. Patients were also instructed to wear the cuff on the nondominant arm resting on a table at the heart level, and to measure BP, with uncrossed legs, in the sitting position. BP values were registered in a dedicated logbook.Blood pressure was also evaluated using a noninvasive finger monitor (Finometer®). The device collects a beat-to-beat signal using a small finger cuff applied to the fourth finger of the nondominant hand. The calculated BP value is calibrated for every individual patient at the beginning of the measurements, using a traditional arm cuff incorporated in the device. Following a standard protocol, BP values were recorded 5 times: at 30 seconds and at 1, 2, 4, and 6 minutes. Finally, 24-hour BP monitoring (24hBPM) was performed with a Mobil-O-Graph® device . The cuff was fixed to the nondominant arm and the device was set to obtain automatic readings every 30 minutes during the day (06:00–22:00) and every hour at night (22:00–06:00).Continuous and categorical variables were expressed as mean (±SD) and percentages, respectively. To test the agreement between daytime 24hBPM (taken as reference) and each BP measurement method under analysis, individual comparisons were performed. Mean differences and standard errors were compared using a parametric method. Bland & Altman plots (plots of the differences between measurements against the mean), biases, limits of agreement (LoA), and rank correlations for each method were graphically and/or numerically shown.2 between BP values obtained with the different chosen methods and daytime 24hBMP were also represented.Scatter plots depicting correlations, linear regression, and rκ) was also performed .To analyse the diagnostic agreement between the methods under study we calculated the sensitivity, the specificity, and the negative and positive predictive value, in identifying patients with SBP and/or DBP values above the thresholds. A statistical analysis for assessing the agreement between two clinical evaluation methods  were considered significant.Statistical analyses were performed using Stata® Statistical Software: Release 15 (STATA Corp LP) and SPSS® 20 .2 and the arterial stiffness 12.9 ± 1.2 m/sec. 56.3% of the population were dyslipidemic, 25% were smokers, and 46.3% had a previous cardiovascular event.Patients' self-measurements of both systolic (SBP) and diastolic (DBP) BP did not differ significantly from D24hBPM . Conversely, SBP and DBP registered by nurses did significantly differ  .Overall agreement for SBP and DBP comparing the different methods with the D24hBPM are illustrated using scatter plots in the top panels and Bland & Altman plots in the bottom panels of Figures The highest concordance, with lowest biases and narrowest limits of agreement, was found for SBP and DBP measured by patients compared with D24hBPM  .Self-BP measurements also presented a high rank correlation (r=0.645 for SBP and 0.540 for DBP) , with a Systolic and diastolic BP readings made by nurses exceeded the mean D24hBPM with, respectively, a bias of 7.3 (LoA -17.9 to 32.6) and 4.7 mmHg (LoA -14.0 to 23.4).The difference between readings by physicians and 24hBPM, decreased as the blood pressure increased.SBP measured by physicians and daytime 24hBPM presented high rank correlation (r=0.642) with a cut-off point showing that physicians are sensitive in detecting high blood pressure, but poorly specific . PhysiciSystolic and diastolic BP measurements made by finger beat-to-beat on average exceeded mean D24hBPM with, respectively, a bias of 22.2 (LoA -20.3 to 64.9 mmHg) and 11.5 (-19.2 to 42.24) mmHg.>135mm Hg) all methods showed a specificity > 80% and a sensitivity > 60% , and showed the lowest rate of false positive and false negative   in predicting hypertensive daytime 24hBPM values. Moreover, self-systolic measurements by patients presented the better agreement estimated by K statistic with a ctively) . Diastolctively) .In detecting combined high 24-hBPM SBP and DBP the finger beat-to-beat method showed the better values in terms of sensitivity (98.5%) and false positive rate (25.0%). Overall, Finometer® performed better in correctly classifying patients with high SBP and DBP (89.8%). This effect was mainly due to the capacity of Finometer® to detect 100% of the cases of high DBP.An agreement analysis between BP measurement methods was also performed in the subgroup of patients with diabetes (26 out of 79). Results showed a similar trend, with the best agreement, for both SBP and DBP, between patients' self-BP measurements and 24hBPM . However the small sample size did not allow definitively concluding that the pattern concordance of the two subpopulations (diabetics vs. nondiabetics) was the same.The correct way of interpreting blood pressure measurements in hospitalized patients outside the intensive care setting is still a matter of debate. Furthermore, concerns exist when evaluation of BP is performed in elderly patients due mainly to a higher prevalence of pathological arterial wall changes with increased arterial stiffness, masked hypertension, extreme BP variability, and decompensated baroreceptor function –28. In tOur findings boost the evidence that, also in the hospital setting, in the subgroup of over 80-year-old patients, the self-measurement of BP represents a reliable alternative to a 24-hour BP monitoring.The high quality concordance with lower bias and limits of agreements, compared with physician and nurse measurements, also considering the previous data from the literature , 26, sugOur study also corroborates the widely accepted concept that measurements of BP performed by nurses and physicians in the hospital setting are inaccurate if compared with the results of a daytime 24-hour monitoring . The larThe message is not new but interesting if seen in the context of the study. Only a few previous analyses focused in fact on blood pressure behaviour in the subgroup of over 80-year-old patients . The feaHowever, we have to address some limitations of our study. The present evaluation is a subanalysis of a previous cross-sectional study and the agreement assessment in hypertensive over 80-year-old patients was not the objective of the initial investigation. Moreover, the sample size was small and the cutoff points of systolic and diastolic blood pressure to define hypertensive values in elderly are still widely debated. For the statistical analysis, as defined by previous recommendations for hypertensive patients, we chose, irrespective of age, 140/90 and 135/85 mmHg as the upper limit, for clinical readings  and 24hBPM, respectively [In conclusion, in our study, in over 80-year-old in-hospital patients, using the daytime 24-hour monitoring as standard, self-blood pressure measurement was the most accurate assessment method, compared with the alternative modalities tested. Blood pressure readings performed not only by nurses but also by physicians significantly over-/underestimate the true pressure profile exposing patients to inadequate and potentially dangerous therapeutic interventions. Individual blood pressure values are instantaneous expressions of a complex hemodynamic context and they cannot be interpreted without an extensive knowledge of the patient and of the underling mechanisms.


P < 0.0001). These associations remained after adjustment for age, gender, smoking, systolic blood pressure, diastolic blood pressure, dyslipidemia, diabetes duration, Hba1c, and cardiovascular disease (P < 0.0001). C4CV is a novel independent predictor of cardiovascular mortality, macrovascular events, and microvascular events in patients with T2DM.This investigation explored the hypothesis that whether the coefficient of variation of the fourth harmonic amplitude of the radial pulse wave (C4CV) predicts the risk of macrovascular and microvascular events in patients with type 2 diabetes mellitus (T2DM). Radial pulse wave and brachial blood pressure were measured at baseline in 2324 patients with T2DM and C4CV was calculated using the Fourier series method. Macrovascular and microvascular events during follow‐up were determined by medical records. We plotted the Kaplan–Meier curve and performed a Cox proportional hazard model and a log‐rank test to estimate the effectiveness of C4CV as a risk predictor. We divided patients into quartile groups based on C4CV . Compared with patients with C4CV < 4.3%, patients with C4CV> 11.4% had a double incidence of macrovascular events  and microvascular events , and the incidence of cardiovascular death was three times . The Cox regression analysis demonstrated that the risk of both macrovascular and microvascular outcomes increases with the increase in quartile level of C4CV value ( Harmonic analysis of arterial pressure pulse provides insightful hemodynamic information into the condition of the ventricular‐arterial system through the resonance effects  and 954 women (41%). The study was conducted in accordance with the Helsinki Declaration and Good Clinical Practice Guidelines. All participants signed a written informed consent form approved by the Taipei City Hospital Institutional Review Board (IRB number: ISRCTN14306167). Patients received an average of 1.8 ± 0.5 years of follow‐up. Patient demographics, baseline medical conditions, and disease prevalence are assessed by medical records and confirmed by drug use or a medical examination (Table avg) and the variation coefficient of four harmonic amplitude (C4CV) are defined by the following equation:The RPWT2DM collaborative project is an ongoing prospective observational study focusing on the relationship between arterial pulse waves and cardiovascular outcomes in T2DM patients. This sub‐study further focused on C4CV, a risk indicator firstly proposed by Wang et al.  is the kth discrete sampled data point in the mth pulse signal. L is the total number of data points in mx (k), and M is the total number of pulses in one measurement. We divided the enrolled patients into quartile groups based on C4CV value .where After completing the radial pulse wave measurement, blood pressure and heart rate were measured by an automatic blood pressure monitor . This blood pressure measurement is assisted by a trained operator and instructions, and there are no doctors and nurses to avoid the white coat effect.All subjects were involved in the diabetes management program and visited the study hospital every 4–6 months, conducting a clinical assessment of cardiovascular risk based on risk factors and cardiovascular events. The clinical assessment determined all the important vital status, function and activity limitation of subjects, and record all outpatient cardiovascular events. We documented all new occurrences of macrovascular and microvascular events after the baseline radial pulse wave measurement during the follow‐up period. Date of death was verified and the cause of death was confirmed by death certificates and medical record. These clinical outcomes were extracted by the IT department of the research hospital using the diabetes management project database and verified by independent monitors.The primary interest outcomes were the composite endpoints of macrovascular events, consisting of MACE , coronary artery disease, and severe peripheral artery disease. The endpoint of coronary artery disease was defined as a new diagnosis of single coronary artery stenosis (≥70%), multiple coronary stenoses (≥50%), and ischemic myocardium (≥10%) for further cardiac examination. Definition of nonfatal myocardial infarction, hospitalization for heart failure, and diagnosis of coronary artery stenosis was detailed in previous studies  was used for all statistical analyses.Patients were classified into four groups based on the quartile of C4CV value , with the lowest quartile (C4CV < 4.3%) serving as a reference group. Survival curves for the four C4CV groups were plotted using the Kaplan–Meier method. In Figure Table P < 0.0001), and its hazard ratio (HR) is 2.13 . After adjustment for age, gender, smoking, systolic blood pressure, diastolic blood pressure, dyslipidemia, diabetes duration, Hba1c, and cardiovascular disease, C4CV remained significantly associated with composite endpoints of macrovascular disease (P < 0.0001).Table P < 0.0001). Compared with the lowest C4CV quartile, the HRs of MACE were 1.30 , 1.34 , and 2.31  for the second, third, and fourth quartile of C4CV, respectively .We took further steps to analyze the incidence and HR of MACE, jointly and separately. Figure P < 0.001 and P < 0.05, respectively. The Cox proportional hazard model demonstrated that the C4CV quartile was independently associated with coronary artery disease and peripheral arterial disease after adjustment for age, gender, smoking, systolic blood pressure, diastolic blood pressure, dyslipidemia, diabetes duration, EGFR, Hba1c, and cardiovascular disease history . The Cox proportional hazard model further demonstrated that quartile level of C4CV independently predicted  the composite endpoint of microvascular events after adjusting for age, gender, smoking, systolic blood pressure, diastolic blood pressure, dyslipidemia, diabetes duration, EGFR, Hba1c, and cardiovascular disease history.The secondary survey was whether the quartile C4CV predicts a new occurrence of microvascular complications. Figure When we observed each of the microvascular diseases in Figure P < 0.001 for age and EGFR using the t test; P < 0.001 for the gender ratio using the Mann–Whitney U test). Therefore, we build a multivariate Cox proportional hazard model to adjust those confounders  as well as the traditional risk factors including, smoking, systolic blood pressure, diastolic blood pressure, dyslipidemia, diabetes duration, Hba1c, and cardiovascular disease history. The results confirmed that the quartile level of C4CV is independently associated with the risk of macrovascular events  and microvascular events . The results also demonstrated that the quartile level of C4CV was independently associated with the risk of major adverse kidney events . This suggested that hemodynamic status has an additional impact on the risk of future adverse kidney events, independent of current renal function indicators such as EGFR.These data demonstrate that C4CV is associated with macrovascular events, microvascular events, and cardiovascular mortality in diabetic populations, independent of the traditional risk factors described above. Compared with patients with the lowest C4CV quartile, patients with the highest C4CV quartile had a two‐ to threefold increase in the risk of MACE, coronary artery disease, major adverse kidney events, macroalbuminuria, and cardiovascular death, and a more than 70% increased risk of severe peripheral arterial disease and retinopathy. These significant results manifested that the C4CV quartile provides independent predictive value for cardiovascular complications except for polyneuropathy, in patients with T2DM. The first quartile (<4.3%) and the fourth quartile (>11.4%) of C4CV were significantly different in age, gender ratio, and EGFR . In addition, we used a logistic regression to confirm the correlation between the ankle–brachial index < 0.9 and the two harmonic risk markers (quartile C1 and C4CV). The results showed that quartile C1 was associated with ankle–brachial index < 0.9 (P = 0.005), whereas quartile C4CV was not associated with ankle–brachial index < 0.9 . Those result suggests that C1 and C4CV may reflect cardiovascular risk for different reasons and mechanisms.The C4CV will be increased by about 20% in dying rat after a fatal dose of urethane injection  and microvascular diseases (41%) during an average of 1.8 years of follow‐up. The results suggest that C4CV is a powerful independent predictor of most cardiovascular complications except for polyneuropathy, in patients with T2DM, both with and without an established cardiovascular disease. Because the radial pulse wave measurement and harmonic analysis are simple, noninvasive, and relatively inexpensive, C4CV may become a first‐run check technique for assessing cardiovascular risk in routine clinical practice of T2DM.The authors declare that they have no competitive interests.