Multivariate linear regression analysis showed that plasma angiopoietin-2 was independently associated with ACR (P = 0.025). Furthermore, plasma angiopoietin-2 was positively correlated with high sensitive C-reactive protein . In conclusion, plasma angiopoietin-2 was associated with albuminuria and markers of systemic microinflammation in CKD patients. Although previous evidence has shown that angiopoietin-2 destabilizes vasculature and induces inflammation in different scenarios, further study will be required to delineate the role of angiopoietin-2 in albuminuria and microinflammation in CKD patients.Although cardiovascular disease (CVD) is the leading cause of mortality in patients with chronic kidney disease (CKD), the pathophysiology is not thoroughly understood. Given that elevated albuminuria or circulating angiopoietin-2 associates with CVD and mortality in CKD patients, we were intrigued by the relationship between albuminuria and angiopoietin-2. A total of 416 patients with CKD stages 3 to 5 were stratified by urine albumin-creatinine ratio as normoalbuminuria (<30 mg/g), microalbuminuria (30–300 mg/g), or macroalbuminuria (>300 mg/g). The levels of plasma angiopoietin-2 and vascular endothelial growth factor (VEGF) increased, and soluble Tie-2 decreased in the subgroups of albuminuria; whereas angiopoietin-1 did not change. Linear regression showed a positive correlation between urine albumin-creatinine ratio (ACR) and plasma angiopoietin-2 (correlation coefficient  It is well established that chronic kidney disease (CKD) is an independent risk factor of cardiovascular disease (CVD). Patients with CKD are more likely to die of CVD than to enter dialysis. High prevalence of traditional Framingham risk factors in CKD patients undoubtedly leads to high cardiovascular events. Nevertheless, the non-traditional risk factors more precisely elucidate the CKD-related elements.Albuminuria is one of the manifestations in renal glomerular disease. Moreover, it is also indicative of endothelial damage and vascular disease in diverse populations. Evidence has shown that albuminuria is an independent predictor of cardiovascular events in both CKD and non-CKD patients Angiopoietin-1 (Ang-1) and angiopoietin-2 (Ang-2) are ligands of the Tie-2 receptor, the second class of vascular specific receptor tyrosine kinases in vascular development. The Ang/Tie-2 system regulates the quiescent and activated endothelial phenotype in a unique and nonredundant fashion Given that elevated albuminuria and circulating Ang-2 predict CVD and mortality in CKD, we were intrigued by the relationship between albuminuria and Ang-2. In this cross-sectional study, we aimed to define the relationship between plasma Ang-2 levels and albuminuria in patients with CKD stage 3 to 5.A cross-sectional study was performed in a single tertiary medical center in Taiwan from December 2006 to December 2007. Patients aged more than 18 years old from the outpatient clinic with CKD were eligible for inclusion. CKD was defined by either kidney damage or GFR criteria for at least 3 months Patients were classified as hypertensive if systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, or with antihypertensive drugs use. Diabetes was defined by history and blood glucose values (using the American Diabetes Association criteria), oral hypoglycemic medication, or insulin use. The clinical definition of dyslipidemia was fasting total cholesterol ≥200 mg/dL, low-density lipoprotein ≥130 mg/dL, triglyceride ≥200 mg/dL, or lipid-lowering medication.Fasting blood samples were collected in the morning. Blood samples were taken by antecubital venopuncture in the sitting position after resting for more than 5 minutes. The blood samples were collected into EDTA vacutainers and placed on ice immediately. Within 30 minutes of collection, samples were centrifuged at 3000 rpm (1000 g) and 4°C for 15 minutes. After overnight fasting, a random morning urine sample was collected for measurement of creatinine and albumin. The additional first-void specimens were collected after 3 months to confirm the presence of albuminuria. Plasma and urine were kept frozen in aliquots. Complete blood cell count and all biochemical analyses were performed in the Department of Laboratory Medicine, National Taiwan University Hospital.Plasma Ang-1, Ang-2, VEGF and soluble Tie-2 (sTie-2) were measured in duplicate using commercial enzyme-linked immunosorbent assays (R&D System) according to the instructions of the manufacturer. The sensitivities of Ang-1, Ang-2, VEGF, and sTie-2 assays were 1.36, 1.20, 1.61, and 1.00 pg/mL, respectively. Intraassay coefficients of variation of Ang-1, Ang-2, VEGF, and sTie-2 were 2.1%, 1.3%, 1.6%, and 0.8%, respectively. Interassay coefficients of variance of Ang-1, Ang-2, VEGF, and sTie-2 were 1.8%, 2.0%, 2.1%, and 9.3%, respectively.Since the continuous baseline variables, including angiotrophic growth factors, were not normally distributed, differences between these variables among albuminuric status were analyzed using Kruskall-Wallis test. Differences in categorical variables were compared using the chi square test. To examine the correlations between Ang-2 and albumin, uric acid, high sensitive C-reactive protein (hsCRP) and ACR, Ang-2 was log-transformed. Pearson correlation coefficients were computed.The Shapiro-Wilk test was used to test normality. Logarithmic transformation was made for variables when needed. A linear regression model was used to assess the relationship between Ang-2 and albuminuria. We first computed the univariate regression analysis and then generated several multivariable models. First, we adjusted for age and gender in model 1. Second, we further adjusted for all traditional and nontraditional risk factors for albuminuria, including diabetes, hypertension, dyslipidemia, mean brachial systolic blood pressure, eGFR levels, calcium phosphate product, hemoglobin, hsCRP, and medications in use. Estimated glomerular filtration rate was treated as a continuous variable. Medications included angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), statins, calcium channel blocker, β-blocker, pentoxifylline. Each of them was treated as a categorical variable. Finally, we used the stepwise regression method to select variables. All statistical analyses were performed with STATA, version 9 .P<0.0001). Likewise, anemia is more severe in the microalbuminuria and macroalbuminuria group . Elevated uric acid and decreased albumin level were evident in patients with macroalbuminuria (P = 0.001 and P<0.0001) but not microalbuminuria group. Inflammatory biomarkers, including hsCRP and ferritin, did not vary with albuminuria.Total 416 participants with CKD stage 3 to 5  were analyzed . We straP = 0.355, P<0.0001, r = 0.301, 95% CI 0.211–0.386, P<0.0001, P = 0.001, P = 0.011, Although there was no difference in the plasma levels of Ang-1 in the subgroups of albuminuria . The endogenous Ang-2 antagonist, sTie-2, was positively correlated with eGFR . Additional analyses of Ang-1 and VEGF only revealed weak association with eGFR .We further analyzed the relationship between angiotrophic growth factors and eGFR. Linear regression analysis revealed an inverse correlation between Ang-2 levels and eGFR . On the contrary, the levels of serum albumin and hemoglobin showed an inverse correlation with Ang-2 . Among all patients, there were 10.8% with albumin <4 g/dL and 39.1% with hemoglobin <11 g/dL.Since Ang-2 sensitizes endothelial cells and has a crucial role in the induction of inflammation P<0.001). After multivariate adjustment, Ang-2 still revealed independent association with ACR (P = 0.026). Age, diabetes, mean systolic blood pressure, eGFR and medication in use were further selected in the stepwise regression analysis. We confirmed the independent association between plasma levels of Ang-2 and ACR .To delineate the association between Ang-2 and ACR, linear regression analyses adjusted for potential confounding factors was performed . ACR wasThis is the first study that demonstrates the association of plasma Ang-2 with albuminuria and microinflammation in patients with CKD stages 3 to 5. Among the angiogenic growth factors, only Ang-2 shows the positive correlation with albuminuria and hsCRP. We also report inverse correlation between eGFR and plasma Ang-2 levels in moderate to severe CKD patients.We demonstrated the independent association of plasma Ang-2 with albuminuria in CKD patients. The magnitude of albuminuria is associated with not only increased risk of CVD in general population, but also mortality and ESRD in diverse CKD populations We also found the positive correlation between plasma Ang-2 and inflammatory markers in our CKD patients. CKD is recognized as a disease with persistent and low-grade inflammation. Altered cytokine milieu and acute-phase protein, including interleukin-6, TNF-α, and CRP may directly mediate the initiation and progression of CKD complications The mechanism linking endothelial dysfunction, albuminuria and CVD is that endothelial dysfunction leads to increased vascular permeability and glomerular albumin leakage There were several limitations in this cross-sectional study. We could only demonstrated the association between Ang-2 and symbolized markers (of microinflammation and vascular injury). In proposing that Ang-2 connects albuminuria to cardiovascular event, we need to investigate the relationship between albuminuria and Ang-2 in early-stage CKD and control group with endothelial dysfunction (such as hypertension or diabetes mellitus). Prospective studies based on Ang-2 stratification are necessary to study the renal and cardiovascular prognosis in CKD. Besides, the mechanisms attributable to increased systemic Ang-2 are not clearly recognized. A delicate animal model is necessary to investigate the exact origin and the causal relationship between Ang-2 and albuminuria in CKD.In conclusion, plasma Ang-2 was associated with albuminuria and microinflammation in patients with CKD stage 3 to 5. Ang-2 might be a novel non-traditional cardiovascular risk factor in CKD patients. We need further study to identify its role in translating the systemic cardiovascular effect of albuminuria.


Fibulin-1 is one of a few extracellular matrix proteins present in blood in high concentrations. We aimed to define the relationship between plasma fibulin-1 levels and risk markers of cardiovascular disease.Plasma fibulin-1 was determined in subjects with chronic kidney disease  and 60 age-matched control subjects. Among kidney disease patients serological biomarkers related to cardiovascular disease  were measured. Arterial applanation tonometry was used to determine central hemodynamic and arterial stiffness indices.We observed a positive correlation of fibulin-1 levels with age , glycated hemoglobin , creatinine , and fibrinogen . Glomerular filtration rate and fibulin-1 were inversely correlated . There was a positive correlation between fibulin-1 and central pulse pressure  and central augmentation pressure . In a multivariable regression model, diabetes, creatinine, fibrinogen and central augmentation pressure were independent predictors of plasma fibulin-1.Increased plasma fibulin-1 levels were associated with diabetes and impaired kidney function. Furthermore, fibulin-1 levels were associated with hemodynamic cardiovascular risk markers. Fibulin-1 is a candidate in the pathogenesis of cardiovascular disease observed in chronic kidney disease and diabetes. The extracellular matrix protein fibulin-1 is emerging as a new factor in cardiovascular disease. The plasma concentration of fibulin-1 is a predictor of all cause and cardiovascular mortality in patients with diabetes mellitus [Fibulin-1 belongs to a family of extracellular matrix (ECM) proteins with functional associations with elastic fibers and basement membranes. Fibulin-1 interacts with a number of ECM molecules, but whether it serves a structural role has not yet been established . FibulinFibulin-1 mRNA expression is increased in a model of cardiomyopathy , and fibSeveral studies link fibulin-1 to atherosclerosis and thrombosis, including studies showing that it binds fibrinogen, mediates platelet adhesion, is a component of newly formed fibrin-containing thrombi and that it accumulates in human atherosclerotic lesions -10.Based on these findings fibulin-1 may be involved in the development or progression of cardiovascular disease. We tested the hypothesis that plasma fibulin-1 levels are associated with cardiovascular risk markers in patients with chronic kidney disease and diabetes mellitus.Chronic kidney disease (CKD) patients were recruited from the outpatient population of the Department of Nephrology, Odense University Hospital, Odense, Denmark. Written informed consent was obtained from each patient. The protocol was in accordance with the ethical standards of the Declaration of Helsinki and was approved by the regional ethics committee (reference number: S-20090061). Fifty-seven measurements were performed in 32 patients; 16 patients with CKD stage 1 – 5 without hemodialysis therapy and 16 patients with hemodialysis therapy. In 25 of the study participants two measurements per patient were performed with an interval of 2 month. Population characteristics are described in Table 2 for more than 3 months. Estimated GFR was calculated according to the Modification of Diet in Renal Disease formula [CKD was defined by structural or functional abnormalities of the kidney with or without decreased glomerular filtration rate (GFR) or estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m formula .Hemodialysis (HD) patients were routinely dialyzed for 4 to 5 hours, three times weekly. Dialyses were performed using standardized techniques with bicarbonate-based dialysates and controlled ultrafiltration rate. In HD patients, the dialysis dose was calculated as the amount of plasma cleared of urea divided by the urea distribution volume (Kt/V). Diabetes was defined using criteria of the American Diabetes Association or by a history of or current treatment for diabetes mellitus.2, range 24.7 to 30.7; smoking, 21 participants, 35%). Control samples were analyzed in the same time frame and with the same pre-analytical conditions as the study samples. The DanRisk study population has been described previously [Control samples for fibulin-1 determination were obtained from 60 age- and sex-matched subjects without kidney disease and without diabetes from the DanRisk study population for the sole purpose of fibulin-1 concentration comparison , median 27.1 kg/meviously .Examinations and blood samplings were performed between 7 and 10 am. Examinations and blood sampling in HD patients were performed before HD sessions. Analyses were performed at the laboratories of the participating departments according to current laboratory standards.Plasma samples were obtained from EDTA-anticoagulated blood and stored at −80°C. An ELISA for the determination of fibulin-1 concentration was performed as described by our group previously . Plasma Plasma samples for C-reactive protein (CRP), fibrinogen, and interleukin-6 (IL6) were stored at −80°C. Fibrinogen and CRP were determined with a nephelometric method . A commercial ELISA was used to measure concentrations of IL6 . The inter-assay coefficients of variation were: < 10% for fibrinogen, < 6% for CRP, < 7% for IL6.1C) was determined using high-performance liquid chromatography as fraction of total hemoglobin A0. Analyses were performed on a Tosoh G7 automatic analyzer .Glycated hemoglobin (HbABlood pressure (BP) was measured after at least 10 minutes of supine resting in a quiet room prior to blood sampling. The measurements were performed with an automated device .® system  [aortic), diastolic aortic BP (DBPaortic), and aortic pulse pressure (PPaortic).For pulse wave analysis an applanation tonometer  was applied to the radial artery. The recorded radial pressure waveforms and a corresponding brachial BP can be used to generate the ascending aortic pressure waveform. For this purpose a validated transfer function is used by the SphygmoCorstralia) . We analaortic) was derived from CAP expressed as percentage of the central pulse pressure. Since the AIx depends on heart rate we also analyzed the AIx normalized to a heart rate of 75 beats per minute (AIx@75aortic). Aortic pulse wave velocity (PWVaortic) was assessed as a direct measure of arterial stiffness and determined between a carotid artery and femoral artery recording site [The effect of pulse wave reflection on the incident central pulse wave was evaluated using central augmentation pressure (CAP), which was determined from the difference between the first and the second aortic systolic pressure wave peaks. Aortic augmentation index . Categorical variables are reported as numbers and percentages. Non-parametric bivariate correlation analysis (Spearman) was performed. Multiple linear regression analysis with backward selection was used to judge variables of significance for the prediction of plasma fibulin-1 concentration.Analyses were performed with GraphPad prism software  and SPSS software . All statistical tests were two-sided and p-values less than 0.05 were considered to indicate statistical significance.2), 7 patients with CKD stage 3 (eGFR 30–59 ml/min/1.73 m2), 5 patients with CKD stage 4 (eGFR 15–29 ml/min/1.73 m2), 1 patient with CKD stage 5 without hemodialysis therapy (eGFR less than 15 ml/min/1.73 m2). The remaining 16 patients were on chronic hemodialysis treatment; their median dialysis vintage was 42 (13–89) months. The clinical and biochemical variables are given in Table The fibulin-1 study group contained 32 patients: 3 patients with CKD 2 . Compared to control subjects, patients with chronic kidney disease showed higher fibulin-1 levels (p < 0.001). Furthermore, we observed significantly increased fibulin-1 concentrations in patients with chronic kidney disease plus diabetes mellitus  compared to patients with chronic kidney disease without diabetes mellitus .Figure No differences in plasma fibulin-1 concentrations were observed between males and females  or smokers and non-smokers .1C concentration. Fibulin-1 levels correlated with markers of kidney function and uremia  with fibulin-1 levels increasing with deteriorating kidney function/increasing uremia. In hemodialysis patients, fibulin-1 concentrations were not correlated with dialysis dose  or dialysis vintage .Next we analyzed bivariate correlations between plasma fibulin-1 concentration and clinical and biochemical variables Table . We obseAs indicated in Table aortic) and central augmentation pressure (CAP), while a negative correlation existed with heart rate. Markers of arterial stiffness were also investigated. No association was observed between plasma fibulin-1 and central pulse wave velocity. Since the extent of pulse wave augmentation is also heart rate dependent we used aortic augmentation index and heart rate normalized AIx (AIx @75aortic). We did not observe a significant association of plasma fibulin-1 concentrations with AIx@75aortic.We also evaluated the degree to which plasma fibulin-1 levels were associated with hemodynamic variables and established markers of arterial stiffness. Several key variables of central hemodynamics showed significant associations with plasma fibulin-1 levels Table . A positMultivariable regression analysis was performed to assess the independent contributions of different variables to plasma fibulin-1 concentration. According to the results of the bivariate correlation analysis age, presence of diabetes, creatinine, and fibrinogen as a marker of inflammation and coagulation was taken into account. To avoid multicollinearity between the hemodynamic variables, CAP was chosen for the analyses. The results are presented in Table In the present study we show a positive association between plasma fibulin-1 concentration and several cardiovascular risk markers in patients with CKD. Our findings are in accordance with findings from earlier experimental and clinical studies which suggested links between fibulin-1, cardiovascular disease and diabetes ,9,16,17.In the present study, plasma fibulin-1 concentration was found to increase with age in the study population. This is in agreement with our data previously published [Correlations were also observed between markers of deteriorating kidney function and increasing plasma fibulin-1 concentrations, with creatinine being an independent predictor of plasma fibulin-1 concentration. These findings are in accordance with findings from a multiplex proteomic study showing that plasma fibulin-1 could be a marker of renal impairment .We also found an independent association between fibulin-1 and fibrinogen, a positive acute phase protein whose blood levels are increased in CKD. Fibrin clot characteristics in CKD differ from non-CKD patients in close correlation to inflammatory level rather than to the extent of uremia . Not onl1C values. The presence of diabetes was an independent predictor of elevated plasma fibulin-1 levels.Our previous studies demonstrated elevated plasma concentrations of fibulin-1 in diabetic patients [The mechanism underlying the increase of plasma fibulin-1 is not known. In patients with diabetes we showed that it exists also in those patients without microalbuminuria hence without signs of initial kidney damage ,21. One An important dimension of the present study was the analysis of central hemodynamics and vascular stiffness in relation to plasma fibulin-1 concentrations. We found a correlation with aortic AIx and central augmentation pressure (CAP). CAP was retained as independent variable in the multivariable analysis. When we performed analyses of arterial stiffness markers we did not find a correlation of plasma fibulin-1 concentrations to aortic PWV and heart rate normalized aortic AIx. Thus, plasma fibulin-1 seems to be unrelated to arterial changes that result in changes of aortic PWV. Also, increased arterial stiffness that results in an increased heart rate normalized aortic AIx  was unreSeveral potential new biomarkers for cardiovascular diseases in diabetes have appeared during recent years. These biomarkers are associated with dysfunctions in different disease pathways and consequently display both, similarities and discrepancies in their clinical appearance.While it was shown that plasma fibulin-1 was able to predict all-cause mortality in patients with diabetes ,25. ElevThe exact role of fibulin-1 in cardiovascular disease may be complex since it is associated with pathologies in both, arterial and heart tissue. In diabetes an accumulation of fibulin-1 in the arterial wall and in plasma has been described. Plasma fibulin-1 correlated significantly with left atrial volume index and plasma N-terminal pro-B-type natriuretic peptide .With respect to the above described results from our study and from previously presented investigations we find it reasonable to speculate that in clinical conditions with increased plasma fibulin-1 such as diabetes or chronic kidney disease plasma fibulin-1 may be involved in disease pathways which contribute to thrombotic and cardiovascular complications. Furthermore, plasma fibulin-1 displays a potential as cardiovascular biomarker which awaits further studies.In summary, we demonstrate an increase in plasma fibulin-1 concentration in association with diabetes and impaired kidney function. A positive association exists between plasma fibulin-1 and fibrinogen levels. Also, an increase of central augmentation pressure and augmentation index resulting in higher left ventricular systolic loading is associated with higher fibulin-1 plasma concentrations. These associations of plasma fibulin-1 are compatible with the idea that fibulin-1 may have a role in the complex pathogenesis of cardiovascular disease.1C: Glycated hemoglobin; HD: Hemodialysis; IL6: Interleukin-6; Kt/V: Dialysis dose; PP: Pulse pressure; SBP: Systolic blood pressure; VSMC: Vascular smooth muscle cells.ACE: Angiotensin converting enzyme; AIx: Augmentation index; AIx@75: AIx normalized to a heart rate of 75 beats per minute; AT: Angiotensin; BMI: Body mass index; BP: Blood pressure; CAP: Central augmentation pressure; CKD: Chronic kidney disease; CRP: C-reactive protein; DBP: Diastolic blood pressure; ECM: Extracellular matrix; GFR/eGFR: Glomerular filtration rate/estimated glomerular filtration rate; HbAThe authors declare that they have no competing interests.PM and LMR designed research; AS, PM, EMB, JJS, MN, ACPD, HM, WSA, and LMR conducted research; AS, PM, JJS, MN, ACPD, HM, WSA, and LMR wrote the paper; AS had primary responsibility for final content. All authors read, critically revised and approved the final manuscript.


Objective. To observe the relationship between changes in renin-angiotensin-aldosterone system (RAAS) activity and blood plasma glucose after administration of hydrochlorothiazide (HCTZ) for one year in patients with hypertension. Methods. 108 hypertensive patients were given 12.5 mg HCTZ per day for one year. RAAS activity, plasma glucose levels, and other biochemical parameters, as well as plasma oxidized low density lipoprotein (oxLDL) levels, were measured and analyzed at baseline, six weeks, and one year after treatment. Results. After one year of treatment, the reduction in plasma glucose observed between the elevated plasma renin activity (PRA) group (−0.26 ± 0.26 mmol/L) and the nonelevated PRA group (−1.36 ± 0.23 mmol/L) was statistically significant (P < 0.05). The decrease of plasma glucose in the elevated Ang II group (−0.17 ± 0.18 mmol/L) compared to the nonelevated Ang II group (−1.07 ± 0.21 mmol/L) was statistically significant (P < 0.05). The proportion of patients with elevated plasma glucose in the elevated Ang II group (40.5%) was significantly higher than those in the nonelevated Ang II group (16.3%) (P < 0.05). The relative oxLDL level was not affected by the treatment. Conclusions. Changes in RAAS activity were correlated with changes in plasma glucose levels after one year of HCTZ therapy. The renin-angiotensin-aldosterone system (RAAS) is composed of a series of hormones and corresponding enzymes. By controlling the blood volume and peripheral resistance, RAAS helps maintain the balance between human blood pressure, water and electrolytes, and thus homeostasis. Currently, the levels of plasma renin activity (PRA), angiotensin II (Ang II), and aldosterone (ALD) have become the key indicators for diagnosis, treatment, and clinical research about both primary and secondary types of hypertension. Research has demonstrated that RAAS activation not only was an important mechanism for the development of hypertension, but also could modulate insulin resistance . PatientFrom November 2007 to October 2008, 108 patients diagnosed with primary hypertension in Liangshan First People's Hospital in China were recruited. Inclusion criteria are (1) older than 18 years, either sex; (2) Han ethnicity; (3) diagnosis of hypertension based on World Health Organization and the International Union of Hypertension (WHO/ISH) diagnosis and grading standards issued in 1999: mild to moderate hypertension refers to those who had 3 consecutive systolic blood pressures of 140 to 179 mmHg (1 mmHg = 133.32 Pa) and/or diastolic blood pressures of 90 to 109 mmHg in the sitting position measured on different days. Exclusion criteria are (1) secondary hypertension; (2) severe renal and hepatic dysfunction; (3) severe valvular heart disease, cardiomyopathy, and unstable angina or undergoing coronary artery bypass surgery in 6 months; (4) gout or diabetes mellitus; (5) never taken antihypertensive medications. The ethics committee at each participating center approved the study. All eligible subjects participated voluntarily and written informed consent was obtained from all patients.All 108 patients were given 12.5 mg HCTZ  by mouth once daily for one year and the follow-up interval was one month. Dosage was increased to 25 mg in patients with inadequate blood pressure control. A variety of biochemical indicators were tested at baseline, six weeks and one year after beginning treatment. General information that was collected or calculated included gender, age, height, weight, body mass index (BMI), and previous medical history. Standard program was used to calculate height and body mass index.Blood pressure was measured while the patient was seated after at least 5 min and had not smoked for 15 min before each measurement. Calibrated mercury sphygmomanometer was used to measure blood pressure. Two weeks before drug administration, three measurements were taken and the mean pressure levels were considered as the baseline pressure. All measurements were standardized: the same time (8:00 a.m. to 9:00 a.m.), arm, sphygmomanometers, and doctor.+), triglyceride (TG), total cholesterol (CHO), high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), and very low density lipoprotein cholesterol (VLDL-C). The measurement was performed in the biochemistry laboratory of Sichuan Provincial People's Hospital using automated biochemical analyzer (OLYMPUS AU5400). The blood drawings were conducted at the time of enrollment for baseline, six weeks, and one year after beginning HCTZ treatment.Patients avoided vigorous activity and maintained normal eating habits for 3 days prior to blood draws. Blood samples were drawn at 8 am after overnight fasting to measure laboratory biochemical parameters, including blood urea nitrogen (BUN), creatinine (Cr), plasma glucose (GLU), blood potassium (KSandwich enzyme-linked immunosorbent assay (ELISA) was used to measure the plasma level of oxLDL as previously described . Goat anFor the RAAS activity determinations, venous blood was taken from a vein in the antecubital fossa in the presence of the anticoagulant heparin. Serum angiotensin converting enzyme (ACE) levels and ALD levels were measured in the dual-points ending-point determination method. Diagnostic kits were purchased from Beijing Shizhen Zhongtuo Biotechnology Co., Ltd., or provided by Northern Biotechnology Research Institute. PRA and Ang II levels were measured by radioimmunoassay in venous blood after adding enzyme inhibitors (included in the kit). Diagnostic kits were also provided by Northern Biotechnology Research Institute. All measurements were performed according to the manufacturers' protocols.t-test was used to compare the values at baseline and those after one year of treatment. Levels of plasma GLU and blood K+ in different RAAS groups were compared with Two-Sample Comparison t-test. Chi-square test and multivariate linear regression analysis were used for multifactorial variables. P < 0.05 was considered as statistically significant.SPSS 13.0 software was used to establish and analyze the database. Numeric variable data is expressed as mean ± standard deviation. Paired 2 ± 3.4 kg/m2. After treatment with HCTZ for one year, GLU, CHO, LDL-C, PRA, and Ang II levels in all patients were significantly decreased and HDL-C levels were increased significantly. However, there were no significant changes in other indexes  completed this study during their one-year drug administration and followups. The average age was 57.0 ± 8.1 years, and mean BMI was 27.2 kg/m indexes .According to the changes in RAAS activity after one year of medication, patients were divided into elevated and nonelevated RAAS groups. Glucose concentrations and changes were compared between these two groups .P > 0.05) between the GLU concentrations of patients with elevated PRA and Ang II levels and those in the nonelevated patient groups (P < 0.05) than those in the nonelevated patient groups. The reductions of GLU concentration in patients with elevated ACE and ALD concentration were lower than those in nonelevated patients; however, the differences were not statistically significant (P > 0.05).There were no statistically significant differences  proportion of patients with a higher GLU in the Ang II elevated group compared with those in the Ang II nonelevated group. According to changes in RAAS and GLU levels after 1 year of medication, patients were divided into either elevated or nonelevated groups. The proportions of patients with both elevated RAAS activity and GLU concentrations were determined. Results are shown in +, into the linear regression equation. The results showed that after adjustment for other factors, the serum Ang II levels were independently associated with GLU level after taking HCTZ for one year . Our results also provided other evidence to confirm that changes in RAAS activity were positively correlated with change in GLU concentration: the higher the RAAS activity, the higher the GLU concentration. These results also suggest that when providing treatment to diabetic patients with hypertension, in order to achieve the desired therapeutic effects, lowering both the GLU concentration and RAAS activity should be considered simultaneously. Our study showed that there was less reduction in GLU concentrations in patients with elevated Ang II, and the proportions of patients with elevated GLU were higher than those in patients in whom Ang II was not elevated. Multivariate analysis showed that changes in Ang II concentrations were positively correlated with changes in GLU concentrations; that is, there was a statistically significantly smaller decrease in GLU concentrations in patients who had a smaller reduction in Ang II after taking HCTZ for one year (+ concentrations (data not shown) after administering HCTZ for one year, while previous publications showed that the influence of thiazide diuretics on glucose metabolism was related to reductions in blood K+ concentration. We think that the reasons for this inconsistency may include that (1) thiazide diuretics may exert their effects on glucose metabolism through mechanisms unrelated to RAAS activity; (2) effects of diuretics are dosage-related, and the dosage of HCTZ in this study was 12.5 mg daily, a relatively low dosage. This dosage may not have been high enough to influence blood K+ concentration; (3) a differential response to HCTZ between the domestic population and patients from other countries could not be ruled out.We did not observe a relationship between RAAS activity and blood KWe did not observe significant effect on plasma oxLDL level before and after one-year HCTZ treatment. Although the trend indicates a slight reduction of oxLDL, this may be due to the more consciousness of the patients during the treatment towards the more healthy diet.There was a correlation between changes in blood Ang II levels and changes in blood GLU concentrations in patients with hypertension after one year of hydrochlorothiazide administration. This result suggests that, when treating patients with hypertension with thiazide diuretics, attention must also be paid to controlling RAAS activity to avoid the negative impact of the drug on GLU metabolism. As there was a one-year follow-up period in this study, longer-term follow-up may be necessary to confirm this conclusion. (i) RAAS is one of the main mechanisms through which the body regulates water and salt metabolism. Its activation not only plays an important role in the pathogenesis of hypertension , but als(ii) Excessive RAAS activity, acting synergistically with microcirculatory changes, can affect pancreas, the major insulin secreting organs, and insulin sensitivity  and impaWhat is known about this topic is the following.(i) We found a positive correlation between changes in blood Ang II levels and changes in blood GLU concentrations in patients with hypertension after one year of hydrochlorothiazide administration. When treating patients with hypertension with thiazide diuretics, attention must also be paid to controlling RAAS activity to avoid the negative impact of the drug on GLU metabolism.What this study adds is the following.


Autosomal dominant polycystic kidney disease is a lifelong progressive disorder. However, how age, blood pressure, and stage of chronic kidney disease (CKD) affect the rate of kidney function deterioration is not clearly understood.In this long-term observational case study up to 13.9 years (median observation period for slope was 3.3 years), serum creatinine was serially measured in 255 mostly adult patients. The glomerular filtration rate was estimated (eGFR) using a modified Modification of Diet in Renal Disease Study method. The total kidney volume (TKV) has been measured in 86 patients at one center since 2006.P < 0.0001), but the annual rate of decline of eGFR did not correlate with age or initially measured eGFR. In patients with CKD stage 1, eGFR declined at a rate which was not significantly different from other advanced CKD stages. Hypertensive patients had lower eGFR and larger TKV than normotensive patients at a young adult age. The slopes of regression lines of eGFR and TKV in relation to age were not different between high and normal blood pressure groups.As age increased, eGFR declined significantly  contains supplementary material, which is available to authorized users. P = 0.2). Even if the glomerular filtration rate (GFR) is maintained near normal at a young adult age, ADPKD patients already have decreased effective renal plasma flow and an increased filtration fraction [Progressive deterioration of renal function and enlargement of renal cysts are two hallmarks of autosomal dominant polycystic kidney disease (ADPKD). It is widely recognized that during the renal compensation period, renal function decreases slowly but subsequently decreases at a relatively faster rate , 2. In afraction . A recenfraction . As a reCurrently, potential therapeutic interventions are being developed for ADPKD –11. The It is not known how the declining rate differs between CKD stage 1 patients through to CKD stage 3 patients with ADPKD. It is important to delineate the characteristics of the natural course of disease progression in ADPKD when therapeutic intervention becomes feasible.2) was calculated using the following formula: eGFR  = 194 × Cr−1.094 × Age−0.287, and eGFR  = eGFR  × 0.739. This equation is a Japanese coefficient for the modified Isotope Dilution Mass Spectrometry-Modification of Diet in Renal disease (IDMS-MDRD) Study [2/year) and 1/Cr (dl/mg/year) were calculated when creatinine was measured for at least two points with an interval longer than 12 months. Slopes were calculated using linear regression analysis in each patient. The staging of kidney function is based on the K/DOQI Clinical Practice Guidelines on CKD [Two hundred and fifty-five patients with ADPKD participated in an observation study at Kyorin University, Teikyo University and Hokkaido University from 1995 to 2009. The patients fulfilled Ravine’s diagnostic criteria. The study was an observational case study measuring serum creatinine at least once a year and monitoring blood pressure. Serum creatinine was measured enzymatically. The estimated glomerular filtration rate  Study . The slos on CKD .Since 2006, total kidney volume (TKV) has been measured at Kyorin University Hospital in routine clinical practice by high-resolution magnetic resonance imaging using volumetric measurement of cross-sectional imaging, as described in the report from the Consortium for Radiologic Imaging Studies in Polycystic Kidney Disease (CRISP) , 14, 15.In the present study, hypertension is defined as high blood pressure requiring the use of anti-hypertensive agents. In the three hospitals where the study was conducted, blood pressure >130/85 was commonly treated by renin−antiotensin system blockers to achieve the target blood pressure.For evaluation of the relationship between eGFR and TKV, data were analyzed when eGFR and TKV were measured within 1 month. As eGFR and TKV were measured several times in one patient, initial measurement data were used to examine age-related changes of eGFR and TKV. This protocol was approved by an institutional review board, and the study was conducted in accordance with the guidelines of the Declaration of Helsinki. All participants gave written informed consent to use their clinical data for medical research.P < 0.05 was considered to indicate statistical significance. P values for differences between CKD stages were obtained using ANOVA or the Kruskal–Wallis test. Correlations between two variables were examined by linear regression analysis. The correlation coefficient (r) was obtained by the Spearman rank-order correlation coefficient. The relations of two linear regression lines between normotensive and hypertensive groups were compared by F test. Student’s t test was used to calculate the P value between two age groups.Analyses were performed with Microsoft Excel 2003, SAS 9.1 for Windows. Parametric variables are expressed as the mean ± standard deviation. Two-sided Pertinent data in groups according to the measured parameters are shown in Table P < 0.0001).Initially measured eGFR in relation to age is shown in Fig. The change in eGFR per year (eGFR slope) was plotted against age and initially measured eGFR in 196 patients Fig. a, b. TheP < 0.0001). Slopes of eGFR and 1/Cr were not statistically different among CKD stages, and even younger patients with relatively preserved kidney function in stage 1 had similar slopes of eGFR and 1/Cr to patients in advanced stages. The percent ratio of the decline in eGFR and 1/Cr in relation to the initially measured values progressively increased as the CKD stage advanced (P < 0.0001).In Table 1/Cr was plotted against age in 106 patients who had been followed for more than 3 years Fig. . SimilarThe effects of age on the eGFR and TKV slopes are examined in Table y-intercepts, since there was a significant difference  in the y-intercept of the two regression lines under the null hypothesis that the y-intercept of the two lines was equal. There was no significant difference  in the slope of the two lines under the null hypothesis that the slope of the two lines was equal.The initially measured eGFRs and log-transformed TKV are plotted against age in normotensive and hypertensive patients in Fig. Table ADPKD is the most common hereditary kidney disease. The disease is characterized by the formation of numerous kidney cysts and their development, leading to kidney enlargement and failure, reaching end-stage renal failure in up to about 50% by age 70 .Polycystic kidney disease animal model studies suggested that earlier intervention resulted in more effective prevention of disease progression , 18. The2/year. In 46 patients with mean TKV >1500 ml, the TKV slope was 86.8 ± 161.6 ml/year (5.6 ± 8.8%/year) (Table P = 0.005), whereas the slopes of GFR did not differ significantly among subgroups with different initial ages (P = 0.20); there was no significant interaction between TKV and age (P = 0.95) [P = 0.154). In addition, there was no significant relationship between age and eGFR slope  . In the The MDRD equation for estimating GFR is widely used –10 but iIn 5 of 36 patients followed for more than 5 years, renal disease progression accelerated during observation Fig. . This ac2, the eGFR slope was negative, as shown in Fig. In relatively younger adult (29.9 ± 11.4 years) patients whose renal function was retained (CKD stage 1 in Table 2) in the present study and GFR measured by iothalamate clearance (117 ± 32 ml/min) were not statistically different. The present study shows a negative eGFR slope and the study [A recent study which examined the detailed renal functions of young ADPKD patients showed abnormal kidney function even in the younger generation . In a quhe study  showed dInitially measured eGFR in relation to age in hypertensive patients was lower than that in normotensive patients, and the present results indicated that differences in eGFR between the two groups had already occurred before age 36 Fig. . HyperteThe potential limitations of this study include retrospective analysis, use of eGFR and 1/Cr, as well as an ethnically homogenous patient population in Japan, and hence it may not be applicable to other ethnicities.In conclusion, eGFR starts to decline in young adult patients with apparently normal eGFR. After adolescence, the declining rate of eGFR is relatively constant and does not relate to age or GFR. Hypertensive patients had lower eGFR and larger TKV than normotensive patients at young adult age. After adolescence, eGFR declined at a similar rate between normotensive and hypertensive groups. A long-term longitudinal study starting in childhood is necessary to more thoroughly understand the characteristics of disease progression in ADPKD.1/Creatinine is plotted against age in all 255 patients (JPEG 87 kb)Below is the link to the electronic supplementary material.


This study is aimed to evaluate the clinical significance of heart rate turbulence (HRT) parameters in predicting the prognosis in patients with chronic heart failure (CHF).From June 2011 to December 2012, a total of 104 CHF patients and 30 healthy controls were enrolled in this study. We obtained a 24-hour Holter ECG recording to assess the HRT parameters, included turbulence onset (TO), turbulence slope (TS), standard deviation of N-N intervals (SDNN), and resting heart rate (RHR). The relationships between HRT parameters and the prognosis of CHF patients were determined.1/2 rate than those with NYHA grade II/III. There were statistical differences in TS, LVEF, SDNN and RHR between the non-deteriorating group and the non-survivor group. Significant differences in TS among the three groups were also found. Furthermore, CHF patients in the non-survivor group had lower levels of TS than those in the deteriorating group. Correlation analyses indicated that TO negatively correlate with SDNN, while TS positively correlated with SDNN and left ventricular ejection fraction (LVEF). We also observed negative correlations between TS and left ventricular end-diastolic cavity dimension (LVEDD), RHR, homocysteine (Hcy) and C-reactive protein (CRP). Multivariate Cox regression analysis further confirmed that LVEF (≤30%), HRT2, SDNN and RHR were independent risk factors which can indicate poor prognosis in CHF patients.The assessment follow-up period lasted until January 31, 2013. The overall mortality of CHF patients was 9.6% (10/104). Our results revealed that CHF patients had higher levels of TO than those of healthy subjects, but the TS levels of CHF patients were lower than that of the control group. CHF patients with NYHA grade IV had higher HRTOur findings indicate that HRT may have good clinical predictive value in patients with CHF. Thus, quantifying HRT parameters could be a useful tool for predicting mortality in CHF patients. Chronic heart failure (CHF), one of the most common forms of heart failure, is a pathophysiological state in which an abnormality of cardiac function is responsible for the failure of the heart to pump blood at a rate necessary to deliver nutrients to metabolizing tissues . Despitein vitro stimulation, and cannot reflect the instantaneous malignant arrhythmias. [Clinically, the currently accepted prognostic indicators for CHF mainly consist of heart rate variability (HRV) and LVEF, which may both have some limitations to their own extents . HRV, asythmias. . As for ythmias. ,12. TherHeart rate turbulence (HRT), modulated by the baroreceptor reflex, is a physiological biphasic response of the sinus node to premature ventricular contractions, which involves a short initial acceleration followed by a deceleration of the sinus rhythm due to the baroreflex.  There arThe Ethics Committee of the First Affiliated Hospital of Harbin Medical University approved the study design. All patients gave informed consent in written to undergo diagnostic and therapeutic procedure at the time of hospitalization.The study was performed in patients diagnosed of CHF when admitted to the First Affiliated Hospital of Harbin Medical University from June 2011 to December 2012. Patients enrolled in this study must satisfy all of the following criteria: (1) all patients in the study had to meet the diagnostic criteria for CHF as specified by the 1995 World Health Organization/International Society and Federation Cardiology (WHO/ISFC); [In our present study, 104 CHF patients  were enrolled with a mean age of 61.0 ± 10.0 years . According to the NYHA classification, these patients were divided into grade II , grade III  and grade IV  groups. There were 37 patients  with ischemic heart disease and 67 patients  with nonischemic heart disease. In addition, 30 healthy controls  with a mean age of 58.0 ± 9.0 years  were enrolled in the control group after detailed medical examination, which includes medical history taking, physical examination, chest X-ray, echocardiography, Holter monitoring and blood biochemical examination.0 group with TO < 0 and TS > 2.5 ms/normal-to-normal interval ; HRT1 group with either TO ≥ 0 or TS = 2.5 ms/RR ; HRT2 group with TO ≥ 0 and TS ≤ 2.5 ms/RR  [All patients were managed under a uniform and standard assay method. HRT of CHF patients were quantified by TO and TS acquired through the 24-hour 3-lead Holter digital recordings  according to a previously published method . HRT wasbnormal) . For thebnormal) .Two-dimensional and Doppler echocardiographic examinations were performed with a HP5500 ultrasound system . In the parasternal long-axis view, M-mode echocardiograms were made of left ventricle from the left hemithorax in short-axis.The median duration of the entire study follow-up was 10.5 ± 8.3 months . All events recorded in the study were adjudicated blindly by an ad-hoc committee on the basis of pre-agreed definitions and procedures. Follow-up information was collected for all patients through outpatient service and phone calls. The end point was prospectively defined as the composite of heart failure and cardiac mortality.The assessment follow-up period lasted until January 31, 2013. Finally, the overall mortality of CHF patients was 9.6% (10/104). There were 32 CHF patients  exhibiting a deterioration of cardiac function and 62 patients showing no significant deterioration.2 or Fisher’s exact test for dichotomous parameters. Correlation between autonomic markers was assessed with Spearman correlation coefficient. Survival curves were estimated with the Kaplan-Meier method and compared by the log-rank test. Independent predictors of death were identified with multivariate Cox proportional hazards model and expressed as hazard ratio (HR) with 95% confidence interval (CI). A P value of less than 0.10 was considered statistically significant and all tests were two-sided. All analyses were performed using the SPSS 18.0 software .Data were expressed as mean ± standard deviation (mean ± SD) unless otherwise specified and qualitative data are presented as percentages. Comparative analyses between the groups were performed with the Student’s t-test for continuous variables and ΧP < 0.001), but the TS levels of CHF patients were lower than that of the control group . There was a significant difference in the rate of HRT1/2 between CHF patients and healthy controls . Furthermore, CHF patients with NYHA grade IV had higher HRT1/2 rate than those with NYHA grade II/III  , but no associations were found between TO and other factors . TS positively correlated with SDNN  and LVEF . However, there were negative associations between TS and LVEDD , RHR , Hcy  and CRP . We also observed no correlations with TS to age and TC levels (both P > 0.05). Correlations of TO and TS with relevance factors are shown in Table Correlation analyses indicated that TO negatively correlated with SDNN . Furthermore, CHF patients in the non-survivor group had lower levels of TS than those in the deteriorating group (P < 0.001).Our results suggested that there were statistical differences in TS, LVEF, SDNN and RHR between the non-deteriorating group and the non-survivor group    , LVEF ≤30%), SDNN (≤100 ms), RHR (≥75 bpm), HRT5) Table . Multiva, LVEF , HRT2, SDNN and RHR were independent risk factors for poor prognosis of CHF patients. Among these risk factors, HRT2  was the strongest predictor of CHF with a high hazard risk of 5.12 after CHF and remained highly significant after adjustment for LVEF and other clinical risk factors. The combination of abnormal TO and TS may result in tachycardia which would cause decreased heart efficiency in increased myocardial oxygen consumption, decreased myocardial perfusion during myocardial relaxation and diastolic, thereby leading to myocardial injury and aggravating or worsening heart failure [Generally, HRT is described as the acceleration and subsequent deceleration of sinus rate . Abnorma studies . In addi studies . Consist studies . Univari failure . NeverthOur findings indicated that HRT may have good clinical predictive values in patients with CHF. Thus, quantifying HRT parameters could be useful tool in predicting mortality in CHF patients. However, due to the limitations mentioned above, further detailed studies with larger sample size and longer follow-up periods are still required to confirm our results.The authors have declared no competing interests among themselves.YDC carried out the experiments and drafted the manuscript. WSJ, GS and FW analyzed the data. XHY, SL and QW contributed the material and the analysis tools. YDC and QXF participated in the design of the study and performed the statistical analysis. QXF conceived the study, and participated in its design and coordination and helped draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2261/14/50/prepub


Rostafuroxin lowered blood pressure (BP) in some animal models and in humans.The Ouabain and Adducin for Specific Intervention on Sodium in Hypertension (OASIS-HT) Trial was a phase-2 dose-finding study of rostafuroxin, a digitoxygenin derivative, which selectively antagonizes the effects of endogenous ouabain (EO) on NaOASIS-HT consisted of 5 concurrently running double-blind cross-over studies. After 4 weeks without treatment, 435 patients with uncomplicated systolic hypertension (140-169 mm Hg) were randomized to rostafuroxin  or matching placebo, each treatment period lasting 5 weeks. The primary endpoint was the reduction in systolic office BP. Among the secondary endpoints were diastolic office BP, 24-h ambulatory BP, plasma EO concentration and renin activity, 24-h urinary sodium and aldosterone excretion, and safety. ANOVA considered treatment sequence (fixed effect), subjects nested within sequence (random), period (fixed), and treatment (fixed).P = 0.90) on 0.15 mg/d rostafuroxin to 2.72 mm Hg (P = 0.04) on 0.05 mg/d. In the 5 dosage arms combined, the treatment effects averaged 1.30 mm Hg (P = 0.03) for systolic office BP; 0.70 mm Hg (P = 0.08) for diastolic office BP; 0.36 mm Hg (P = 0.49) for 24-h systolic BP; and 0.05 mm Hg (P = 0.88) for 24-h diastolic BP. In the 2 treatment groups combined, systolic (-1.36 mm Hg) and diastolic (-0.97 mm Hg) office BPs decreased from week 5 to 10 (P for period effect ≤0.028), but carry-over effects were not significant (P ≥ 0.11). All other endpoints were not different on rostafuroxin and placebo. Minor side-effects occurred with similarly low frequency on rostafuroxin and placebo.Among 410 analyzable patients , the differences in the primary endpoint (rostafuroxin minus placebo) ranged from -0.18 mm Hg :  A computerized procedure generating random numbers was used for randomization. Centers opted whether they would use blocks of study medication for 4 or 6 patients. At the end of the run-in period, the study manager at the coordinating office  checked all entry and exclusion criteria and after stratification for center randomized eligible patients to one of 5 doses of rostafuroxin Figure . The firDuring the run-in period, the investigators informed patients on the life style changes to be implemented, including cessation of smoking, moderation of excessive alcohol intake, regular physical activity, weight reduction in overweight patients, and a reduction of dietary sodium intake to 120-160 mmol/d. A 24-h urinary sodium excretion at the end of the run-in period exceeding 200 mmol was an exclusion criterion. After randomization, in a cross-over design, patients took one of the 5 doses or rostafuroxin or matching placebo for 5 weeks and during the next 5 weeks switched to the alternative study medication. Short visits were scheduled 2 weeks after the initiation of each course of double-blind medication and visits with an extensive evaluation took place 3 weeks later at the end of each double-blind treatment period.Uncontrolled hypertension was a blood pressure of at least 180 mm Hg systolic or 110 mm Hg diastolic on office measurement, confirmed within one week after the initial measurement. Patients with uncontrolled hypertension during the first treatment period were immediately withdrawn. Orthostatic hypotension was a drop in systolic blood pressure by at least 40 mm Hg on standing up from a sitting position. Patients experiencing orthostatic hypertension during the first treatment period were crossed over to the second treatment period. Patients with uncontrolled hypertension or orthostatic hypotension during the second treatment period proceeded immediately to the end-of-study evaluation.Patients took their study medication around 8 AM before breakfast. Clinic visits were scheduled within 8 hours of drug intake. Depending on local conditions, each center standardized the time interval between the intake of the study medication and the measurement of the clinic blood pressure. On the days before the end-of-period visits 5 and 7 Figure , the patAt the screening visit, the investigator determined the appropriate cuff size for each patient. If arm circumference was less than 32 cm, a standard cuff with a bladder of 12 × 22 cm was applied. For arms with larger circumference, cuffs had a bladder size of 15 × 31 cm. If at the screening visit, the differences in systolic and diastolic blood pressures between both arms were less than 10 mm Hg, all blood pressure readings throughout the trial were obtained at the non-dominant arm. Otherwise, the arm giving the highest blood pressure readings was used.705IT recorder . The average of the last 3 readings was used to determine eligibility and for statistical analysis. Immediately after the 5 blood pressure measurements with the patient in the sitting position, the observer obtained 2 blood pressure readings while the patient was standing. These 2 standing measurements were averaged to determine the occurrence of orthostatic hypotension. Throughout the trial, each patient was followed up using the same Omron 705IT device applied to the same arm by means of equally sized cuffs. To detect irregularities, the quality of the blood pressure readings was monitored during the study with respect to digit and number preference [At each visit, after the patients had rested for 5 minutes in the sitting position, the observer measured the office blood pressure 5 times consecutively at the brachial artery, using the validated oscillometric Omron eference .At the end of the run-in period as well as at the end of the 2 double-blind treatment periods, patients underwent 24-h ambulatory blood pressure monitoring. Validated oscillometric SpaceLabs 90207 recorders . At baseline and at the end of each treatment period, patients also underwent a standard 12-lead ECG recording.The primary efficacy measure was the sitting systolic blood pressure measured at the office. With significance set at 5% and power at 90%, approximately 440 patients, 88 in each crossover arm, had to be randomized to detect within each arm of the trial a blood pressure difference of 8 mm Hg between rostafuroxin and placebo, assuming a standard deviation of 15 mm Hg and a drop-out rate of 10%.Statistical analyses were performed according to the intention-to-treat principle with SAS software, version 9.2 . The analysis set included all patients who had at least one evaluation available for each of the 2 cross-over periods. In case of missing data, the last observation within each period was carried forward. Patients who withdrew from the study during the first treatment period because of uncontrolled hypertension contributed to the statistical analysis with the last blood pressure for the first period; for the second period they were assigned the average blood pressure on the treatment, which they should have taken during the second period.Measurements with a skewed distribution were normalized by a logarithmic transformation. Sodium and potassium excretions were standardized to 24 hours. The effects of rostafuroxin on blood pressure and other measurements were evaluated using analysis of variance with the treatment sequence (fixed effect), subjects nested within sequence (random effect), period (fixed effect) and treatment (fixed effect) entered as covariables. Measurements obtained at the end of each treatment period were used as dependent variables. Analyses were performed in each dosage arm separately and in all dosage arms combined. The hypothesis of no sequence effect in the ANOVA model was tested to check for carry-over effects. In sensitivity analyses, we analyzed the blood pressure changes from baseline to week 5, using Student's t-test for paired and unpaired observations. We also adjusted the ANOVA for 24-h urinary sodium excretion and did a separate analysis in patients whose 24-h urinary sodium excretion was less than 200 mmol at both weeks 5 and 10.Of the 642 screened patients, 435 (67.8%) met the entry criteria and were randomized. Twenty-five patients were not included in the analysis because they prematurely terminated the trial in the first treatment period  on average by 5.3 ± 12.0 mm Hg and 2.9 ± 8.1 mm Hg from baseline to week 5  and 1.5 ± 6.6 mm Hg (P ≤ 0.0001), respectively. However, in each of the 5 dosage arms, blood pressures were similar on rostafuroxin as compared to placebo (Tables P = 0.90) on 0.15 mg/d rostafuroxin to 2.72 mm Hg  on 0.05 mg/d (Table P = 0.03) for the systolic office blood pressure; 0.70 mm Hg  for the diastolic office blood pressure; 0.36 mm Hg  for the systolic 24-h blood pressure; and 0.05 mm Hg  for the diastolic 24-h blood pressure. Similar results were obtained when the day- and night-time blood pressures were analyzed separately. No significant (P ≥ 0.11) carry-over effect was detected in any of the dosage arms for any of the blood pressure endpoints. In the 2 treatment groups combined, the conventional systolic (-1.36 ± 12.4 mm Hg) and diastolic (-0.97 ± 8.3 mm Hg) blood pressures decreased slightly from week 5 to week 10, leading to a significant period effect (P = 0.028 and P = 0.018 respectively).The conventional systolic and diastolic blood pressures decreased  in daytime (115.0 ± 50.1 μmol/min and 50.3 ± 31.5 μmol/min) than nighttime urine collections (90.7 ± 52.3 μmol/min and 30.8 ± 26.1 μmol/min). Both the daytime  and nighttime  sodium excretion rates, but not the potassium excretion rates, increased significantly from baseline to week 5, but thereafter remained unchanged (P ≥ 0.11).At baseline urinary volume averaged 1502 ± 574 mL/24 h and the urinary sodium and potassium excretion 152.8 ± 55.7 mmol/24 h and 62.7 ± 35.2 mmol/24 h, respectively. The sodium and potassium excretion rates were greater (P = 0.071) for the 24-h sodium excretion and -0.2 μmol/min  for the 24-h potassium excretion (Table P ≥ 0.55).The 24-h, day- and nighttime excretion rates of sodium and potassium were similar on placebo and active treatment in all 5 dosage arms. The between-treatment differences in the 5 dosage arms combined averaged -5.1 μmol/min , 1.00 pmol/L  and 0.99  for plasma ouabain, plasma renin activity and the 24-h urinary aldosterone excretion, respectively , 0.58 ng/mL/h , and 26.3 nmol/24 h , respectively. These hormones did not change during follow-up and were similar on placebo and rostafuroxin in each of the 5 dosage arms (Table P = 0.14). Table P ≥ 0.10) and none were different on placebo and rostafuroxin (P ≥ 0.18) with one exception. Hemoglobin was slightly lower on rostafuroxin than placebo .Among the 435 randomized patients, a total of 96 adverse events were reported on active treatment and 56 on placebo treatment. These events occurred in 64 and 50 patients, respectively  and all were similar on placebo and rostafuroxin (P ≥ 0.083).At baseline, heart rate averaged 76.2 ± 11.5 beats/min on conventional measurement (sitting) and 74.5 ± 8.5 beats/min on 24-h ambulatory measurement. The baseline values of the ECG intervals were 157.0 ± 24.9 msec, 85.3 ± 11.6 msec and 381.2 ± 40.8 msec, and 401.7 ± 52.5 msec for PR, QRS, QT and QTThere was a significant period effect with a slight, but significant reduction in the conventional blood pressure from week 5 until week 10 (see above). We therefore did an additional analysis including only blood pressures at baseline and at 5 weeks, according to a parallel-group design based on the first randomization Figure . The resP = 0.03) for systolic office blood pressure and 0.68  for diastolic office blood pressure. Furthermore, in the 199 patients with 24-h urinary sodium excretion below 200 mmol at baseline and at 5 and 10 weeks, the corresponding estimates were 0.88 mm Hg systolic  and -0.39 mm Hg diastolic . Finally, analyses of the office blood pressure  was 1.32 mm Hg  linearly increased with the orally administered dose.In placebo-controlled phase-1 studies in healthy male volunteers , who received rostafuroxin in a daily dose ranging from 1 to 10 mg for up to 7 days, no clinically significant adverse effects occurred ,6,19. InP = 0.039), 5.0 mm Hg (P = 0.007), and 5.0 mm Hg (P = 0.014), respectively. In a second study with double-blind design . Compar P = 0.01, respect P = 0.01, respect P = 0.01, respect P = 0.01, respectP = 0.034) in all patients on rostafuroxin and by 2.72 mm Hg (P = 0.044) in those randomized to 0.05 mg/d. Several mechanisms might explain these negative findings. First, the large drop in blood pressure between baseline and the end of the first double-blind period  and subsequently increased to 170.2 ± 74.4 mmol/24 h  at 5 weeks and to 174.8 ± 73.8 mmol/24 h  at 10 weeks. A 24-h urinary sodium excretion below 200 mmol was a positive selection criterion at the end of the run-in period [Finally, of the 410 analyzed patents, 193 (47.1%) had been previously treated for hypertension. Antihypertensive treatment potentially conceals the effects of mutated adducin and ouabain on blood pressure. A 4-week period was probably insufficient to wash-out all effects of prior treatment. However, for reasons of recruitment, it proved impossible to limit the recruitment to never-treated patients, as we did before . For etha priori and representing 23% of the patients randomized in OASIS-HT showed a significant decrease in blood pressure. Based on these preliminary pharmacogenomic results, we are now starting a more focused phase-2 trial comparing the effects of rostafuroxin and losartan in hypertensive patients with a specific genetic profile (EudraCT Number 2010-022073-34).Rostafuroxin did not reduce blood pressure at any dose. Important secondary objectives of the OASIS-HT trial were to investigate the dependence of the blood pressure lowering activity of rostafuroxin on genetic variation in the enzymes involved in the synthesis and breakdown of ouabain and on polymorphisms in the adducin cytoskeleton proteins. The results of these analyses are beyond the scope of this report and will be reported elsewhere. In short, the pharmacogenomic study revealed that carriers of a genetic profile stated http://www.kuleuven.be/lrd/about/mission.html). Giuseppe Bianchi is an advisor to the Prassis Research Institute , which is affiliated with Sigma-Tau. Antonella Bachieri and Giovanni Valentini are employees of Sigma-Tau and Patrizia Ferrari is an employee of the Prassis Research Institute.The Studies Coordinating Centre  received financial support from Sigma-Tau for the scientific coordination of the OASIS-HT trial within the legal framework of Leuven Research and Development ; The Czech Republic―R Cifková (Prague), J Filipovský (Pilsen), J Peleška, J Widimský Jr (Prague), M Souček, J Vítovec (Brno), J Špinar (Brno), V Stanek J Widimský Sr (Prague); France―A Fournier (Amiens); Germany―E Brand, SM Brand-Herrmann (Münster); Ireland―J. Barton, C. Kelly ; Italy ―G Basso (Schio), E Casiglia, V Tikhonoff (Padua), G Colangeli (Castelfranco), E Degli Esposti (Ravenna), N Glorioso (Sassari), P Manunta (Milan), M Timio (Foligno); The Netherlands―PW de Leeuw (Maastricht), M Krekels (Sittard); Poland―M Dłuzniewski (Warsaw), T Grodzicki (Krakow), A Januszewicz (Warsaw), K Kawecka-Jaszcz, A Olszanecka, K Stolarz-Skrzypek, M Klocek (Krakow), K Narkiewicz, B Wyrzykowski (Gdansk), W Piwowarska (Krakow), A Tykarski (Poznan); The Russian Federation―Y Nikitin (Novosibirsk), V. Milyagin (Smolensk), S. Nedogoda (Volgograd); Slovenia―J Brugljan, R Acceto (Ljubljana); Spain―P Armario (Barcelona), C Calvo-Gomez (Santiago de Compostela), JA Division-Garrote , A Coca-Payeras (Barcelona), F Hernández-Menárgez (Murcia), M Luque-Otero (Madrid), M Pascual-Izuel (Sagunto), A Pose-Reino (Santiago de Compostela), J Redón ; Switzerland―M Burnier.Scientific Coordinators―J A Staessen, G Bianchi; National Coordinators―R Acceto (Slovenia), G Bianchi , E Brand (Germany), M Burnier (Switzerland), H Celis (Belgium); J Filipovský (Czech Republic), A Fournier (France), K Kawecka-Jaszcz (Poland), G McInnes (United Kingdom), Y Nikitin (Russian Federation), ET O'Brien (Ireland), J Redón (Spain); Studies Coordinating Office―T Kuznetsova, Y Jin, T Richart, JA Staessen, L Thijs ; Logistic Coordination―A Bacchieri, G Valentini .


Self-monitoring of hypertension with self-titration of antihypertensives (self-management) results in lower systolic blood pressure for at least one year. However, few people in high risk groups have been evaluated to date and previous work suggests a smaller effect size in these groups. This trial therefore aims to assess the added value of self-management in high risk groups over and above usual care.The targets and self-management for the control of blood pressure in stroke and at risk groups (TASMIN-SR) trial will be a pragmatic primary care based, unblinded, randomised controlled trial of self-management of blood pressure (BP) compared to usual care. Eligible patients will have a history of stroke, coronary heart disease, diabetes or chronic kidney disease and will be recruited from primary care. Participants will be individually randomised to either usual care or self-management. The primary outcome of the trial will be difference in office SBP between intervention and control groups at 12 months adjusted for baseline SBP and covariates. 540 patients will be sufficient to detect a difference in SBP between self-management and usual care of 5 mmHg with 90% power. Secondary outcomes will include self-efficacy, lifestyle behaviours, health-related quality of life and adverse events. An economic analysis will consider both within trial costs and a model extrapolating the results thereafter. A qualitative analysis will gain insights into patients’ views, experiences and decision making processes.The results of the trial will be directly applicable to primary care in the UK. If successful, self-management of blood pressure in people with stroke and other high risk conditions would be applicable to many hundreds of thousands of individuals in the UK and beyond.ISRCTN87171227 The potential benefit from optimal blood pressure (BP) lowering in patients at high cardiovascular risk following stroke or TIA, coronary heart disease or with diabetes or CKD is large. The PROGRESS trial demonstrated that blood pressure lowering is beneficial in reducing risk of stroke amongst both hypertensive and non-hypertensive individuals with a history of stroke or TIA ,2. For pGuidelines for the various at risk groups vary in terms of recommendations for blood pressure lowering. The National Clinical Guideline for stroke  and the Data from national and international surveys suggest that blood pressure control is sub-optimal . Novel iSelf-management can encompass a wide range of behaviours in addition to medication titration and monitoring of symptoms, such as an individual’s ability to manage physical, psychosocial and lifestyle behaviours related to chronic illness . Self-efTherefore, the aim of this trial is to determine whether the benefits from blood pressure lowering observed in the TASMINH2 trial will also be observed in a population of people at high cardiovascular risk without using telemetry and to assess further the mechanism behind any change in blood pressure observed. The TASMIN-SR trial sets out to investigate whether self-management is effective and cost effective in people with stroke and other high risk conditions.The primary aim of TASMIN-SR is to compare self-management with usual care in the control of hypertension in patients with stroke and other at-risk conditions.The trial has four main research questions:1. Does self-management of blood pressure result in better control of blood pressure in people with stroke and other at-risk conditions compared to usual care?2. Is self-management of blood pressure in people with stroke and other at-risk conditions achievable in routine practice and is it acceptable to patients?3. What is the relationship between self-management of blood pressure, self-efficacy, lifestyle behaviours, patients’ attitude to health and health care and use of other self-care strategies in people with stroke and other at-risk conditions?4. Is self-management of blood pressure in people with stroke and other at-risk conditions cost effective?The primary outcome of the trial will be the difference in office systolic blood pressure (mmHg) at 12-month follow-up between intervention and control adjusted for baseline blood pressure and co-variates. Secondary outcomes  will include:–  Difference in office SBP at 6-month follow-up between intervention and control–  Difference in office DBP at 6 and 12-month follow-up between intervention and control–  Percentage time in target BP range–  Difference in pulse rate–  Difference in self-management self-efficacy–  Difference in lifestyle behaviours–  Difference in health-related quality of life–  Difference in BP measurement preference–  Difference in anxiety–  Difference in attitudes to health and healthcare–  Difference in use of other self-management strategies–  Reasons for non-participation–  Adverse events (including cardiovascular events and death)–  In addition there will be a qualitative analysis and health economic modelling.TASMIN-SR is a pragmatic, primary care based, unblinded, randomised controlled trial  of self-management of BP consisting of self-monitoring with self-titration of anti-hypertensive medication in people with stroke and other at-risk conditions.Ethical approval has been obtained from North West – Greater Manchester East ethics committee (reference: 10/H1013/60). Site specific R&D approval will be obtained from the relevant Primary Care Trusts.Usual care will consist of the participant seeing their General Practitioner (GP) and/or nurse for routine BP measurement and/or adjustment of medication at the discretion of the health professional.Self-management will consist of self-monitoring of BP with self-titration of medication following a predetermined 3-step plan, dependant on the self-monitored BP readings.Participants will be trained to self-monitor BP using an automated sphygmomanometer. Patients will self-monitor BP for the first week of each month of the study, and will take measurements in the morning. Two seated BP readings will be taken, with a five-minute rest period between them. The second of these readings will be used to determine if medication requires altering. Participants will be provided with a guideline that contains simple colour coded instructions. Very high or very low readings that persist when a third reading is taken five minutes after the second reading will require the participant to contact their practice for advice and potentially will need checking. Four or more above target readings in two consecutive weeks of measurement will require a change in medication. Readings within target range will simply require further monitoring the following month.Blood pressure targets will be based on The British Hypertension Society guidelines  and JoinParticipants will complete a simple form each month to record their daily BP readings and colour coding. These forms will be used to determine any action that is required at the end of the measurement week, including whether a medication change is required. The form will be printed on three-part non-carbon copy paper to allow one copy to be kept by the patient, one returned to the research team, and one posted to the GP should a medication change be required. Reply paid envelopes will be provided for this purpose. At follow-up, data from participants’ BP machines will be uploaded onto a database so that the research team has an electronic copy.Each intervention patient will be given an individually tailored three-step management plan through which to adjust medication according to measured BP. Each step will represent a single medication change  that will be made following two consecutive months of raised readings. Medication choice will remain at the discretion of the GP who will be provided with an algorithm summarising the national clinical guidelines for advice on hypertension. If patients use all three steps of their management plan they will return to their GP and an additional two-step plan will be devised. This will not be until at least eight months into the trial, assuming no very high or very low readings, so a three-step plan should be sufficient. Any additional monitoring  will be the responsibility, and at the discretion, of the GP.Included with the letter of invitation to take part in the trial, will be a form for people to voluntarily return should they wish to decline the invitation. This will ask for basic demographic details as well as their reasons for wishing to decline.The study population will comprise people with stroke/TIA, diabetes, CKD3, CABG, MI or angina, with poorly controlled hypertension managed in primary care. Eligibility criteria will be age above 35, have had a diagnosis of stroke/TIA, diabetes, CKD3, MI, angina, or CABG, and clinic blood pressure greater than 130/80. Exclusion criteria will be inability to self-monitor (such as dementia or score of >10 on the short orientation memory concentration test), postural hypotension (systolic BP drop > 20 mmHg), prescribed more than three anti-hypertensive medications, taking part in a current BP study or previously having taken part in TASMINH2 [Eligible patients will be identified from general practices via the UK Primary Care Research Network. Trained practice nurses will identify potentially eligible patients by searching practice-based registers for patients having a Read Code of stroke/TIA, diabetes, CKD3, Angina, CABG, or MI and whose last systolic BP measurement was greater than 145 mmHg  GPs wiParticipants who withdraw will not be replaced, but asked if they are prepared to continue to attend follow-up clinics.Patients will be randomised to either usual care or self-management using an internet based system with telephone backup. Minimisation will be used to take into account practice, gender, age, high risk group  and baseline BP.nd and 3rd reading will comprise the primary outcome. Patients will then be randomised to either usual care or self-management. All patients will be given a diary to assess daily lifestyle behaviours and self-management self-efficacy which they will be asked to complete everyday for one week starting the first Monday of the month after their baseline appointment. Patients randomised to usual care will be asked to book an appointment for a routine blood pressure check and medication review with the study GP. Patients randomised to self-management will be asked to make an appointment with the research team for a training session on how to monitor their BP. Participants will be asked to practice at home for a week before returning for a second training session covering the self-titration aspect of the intervention. If necessary, a third training session will be offered for additional support. Following successful completion of the training, patients will be asked to make an appointment with the study GP at their practice for a routine BP check and to devise a three step titration plan for any potential medication changes. Patients who are unable to complete all aspects of the training will be given the option to self-monitor without self-titration of medications.At baseline, all patients will attend a clinic at which the study will be explained, informed consent gained, height, weight, and BP measurements taken, and questionnaires regarding demographics, past medical history, BP measurement method preference, use of self-management strategies, attitudes to health and healthcare completed, and baseline economic data collected Table . MeasurePatients will be asked to attend two follow-up clinics at 6- and 12-months post-randomisation. Each clinic will be timetabled for no more than one hour, during which patients will have their BP and weight measured by the research team and will be asked to complete a questionnaire similar to the one completed at baseline. At the 12 month follow up, participants will also be given a blank postcard and asked to write a few sentences about their experience of the trial. Additionally, the research team will check that patients in the intervention arm are using the blood pressure monitors correctly. Flow through the trial is summarised in Figure A sample size of 243 people per group is required for 90% power assuming a standard deviation of 17 mmHg and a difference of at least 5 mmHg between intervention and control groups. This represents a clinically significant decrease in BP and is in line with the reduction observed in TASMINH2 and would result in around 20% reduction in stroke risk and 10% coronary heart disease risk. Based on the follow-up in TASMINH and TASMINH2 self-monitoring trials, a 10% drop out rate during follow-up is assumed, meaning a sample of 270 per group will need to be randomised, a total of 540 patients altogether. Should the drop-out rate be higher than TASMINH2, for instance 20%, the study would have more than 85% power.Patients will be recruited over an eight month period. Based on practice-based pilot searches, it is estimated that in a practice with an average size of 6000 patients, 2.5% will be eligible for invitation. Previous experience from the TASMINH2 trial suggests that approximately 30% of invited patients will attend baseline clinics, and of these 50% will be eligible . A minimThe primary analysis will include all available participants, i.e. all of those with complete data from follow-up, and will be performed at the end of the trial after all data has been collected. A mixed model analysis will be used to examine differences between intervention and control systolic BP at twelve months, adjusting for practice (as a random effect), baseline BP, gender, and high risk group. Planned sub group analyses will be of older vs younger (65 as threshold), males vs females, better controlled at baseline vs worse controlled at baseline (threshold 145 systolic), the different risk groups and deprivation. Sensitivity analyses will examine the potential effect of missing data. These will include multiple imputation, replacement of missing data by the most recent previous data or by the mean of the series. Any deviation from the original statistical plan will be described in the final report and publications.The economic analysis will be in two parts. The first part is a cost-effectiveness analysis conducted alongside the randomised clinical trial . An economic evaluation will compare the strategy of self-management of blood pressure in at-risk patients to the strategy of usual care. Primary outcome will be expressed in terms of the cost per additional 1 mm Hg reduction in office SBP from baseline to 12 months. Use of utility-based outcomes (EQ-5D) will allow a secondary outcome to be the cost per quality-adjusted life year (QALY) gained over the same 12 months period. The results for both outcomes will be expressed in terms of incremental cost-effectiveness ratios (ICERs). NHS resource use will include hospital and GP consultations, medications, referrals, equipment and training. Intervention costs, including equipment and training, will be collected by the research team. All other resource use data will be collected from practice computer systems by the research team at follow up visits. Cost data will be derived from sources such as the British National Formulary (BNF), the National Schedule for Reference Costs and the Unit Costs of Health and Social Care (PSSRU) .The second part will be a model-based cost-effectiveness analysis, building on the trial-based analysis and using published data on long-term outcomes and costs. The model will estimate the long-term cost-effectiveness of self-management of blood pressure in people with stroke and other at- risk conditions in terms of cost per QALY gained. The model type and structure will be informed by reviewing modelling studies which consider outcomes after stroke and other at-risk conditions. Experts within the team will advise on the final structure of the model. Costs to be included in the model will be for self-management , hospital stays, readmissions and long-term care for stroke and other cardiovascular outcomes related to level of disability and discharge destination. Resource use will be determined from the trial and estimates from the literature. Unit costs will be collected from published sources  . OutcomeThis part of the study aims to gain insight into patients’ decision making processes regarding whether to seek professional advice, whether to make a medication change, or any concerns they may have.Each month, on an open-comment section of the BP measurement record, intervention patients will be asked to write down their description of any action they took, whether it followed protocol or not, their decision making process, and their thoughts and feelings associated with the decision making. Similarly, the postcards participants will be given at the end of the study provide a further opportunity for open comment about the trial. This approach is useful for capturing aspects of a patient’s experience of a study or an intervention which may otherwise not be documented . The opeThe results of the trial will be directly applicable to primary care in the UK. If successful, self-management of blood pressure in people with stroke and other high risk conditions would be applicable to many hundreds of thousands of individuals in the UK and beyond.It is anticipated that the potential risks of this study are low and similar to those associated with usual care. Particular issues are potential increased anxiety when patients find excessively high or low blood pressure readings, or as a result of self-titration. The patient guideline will advise contact with the supervising physician or nurse for a blood pressure check and further management if required. Training of participants will cover repeated measurements in the case of high or low readings and a helpline will be available should participants or clinical staff require advice over and above that provided in the guideline. The study GP will have control over prescription of all medications within the study, and will make changes to prescriptions as required. Participants will be advised to attend their GPs should they experience an adverse event thought to be due to their participation in the trial.RJM has received equipment for research purposes from Omron and Lloyds Healthcare. FDRH has received limited research support in terms of blood pressure devices from Microlife and BpTRU. All other authors declare that they have no conflicts of interest.RJM conceived the study and in collaboration with JM, SB and FDRH gained the funding. The protocol was developed by the trial investigators group comprising all the authors. The first draft of this paper was written by CO with RM and subsequently edited and approved by all co-authors. All authors read and approved the final manuscript.This is the protocol for a randomised controlled trial comparing self-management of blood pressure (BP) with usual care in people with previous stroke, coronary heart disease, diabetes or chronic kidney disease.The primary research question is: does self-management of blood pressure result in better control of blood pressure in people with stroke and other at-risk conditions compared to usual care?The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2261/13/21/prepub


To assess acute effects of bevacizumab (anti-VEGF therapy) on cerebral microvessels and systemic cardiovascular regulation.20 consecutive patients with colorectal cancer  received bevacizumab intravenously (5 mg/kg) uncoupled of chemotherapy. Prior to and within the first 24 hours after bevacizumab infusion, patients were investigated for retinal endothelial function. A series of a triple 24-hour ambulatory blood pressure measurement was conducted. Retinal endothelial function was determined as flicker light-induced vasodilation. The integrity of baroreflex arc and autonomic cardiovascular control was examined by stimulatory manoeuvres.Bevacizumab therapy significantly reduced the vasodilatory capacity of retinal arterioles in response to flicker light. A slight decrease in diastolic pressure and heart rate was observed after bevacizumab infusion but this was unrelated to changes in retinal function. The pressure response upon nitroglycerin was largely preserved after bevacizumab infusion. The proportion of patients with abnormal nocturnal blood pressure regulation increased under anti-angiogenic therapy. Autonomic blood pressure control was not affected by bevacizumab treatment.Bevacizumab acutely impairs microvascular function independent of blood pressure changes. Imaging of the retinal microcirculation seems a valuable tool for monitoring pharmacodynamic effects of bevacizumab.NCT00740168NCT ID:  Vascular endothelial growth factor (VEGF) is a key mediator of physiological and pathological angiogenesis. As all solid tumors are dependent on pathological angiogenesis, anti-VEGF therapy has been approved in various advanced and metastatic cancer types ,2.The rationale for treating cancer patients with angiogenesis inhibitors has been on the assumption that unlike in tumor vessels survival and functioning of the normal vasculature is largely independent of VEGF signalling . AlthougHere, we investigated the acute impact of bevacizumab administration on retinal vessel reactivity in relation to acute changes of cardiovascular regulation inclusive blood pressure using the dynamic retinal vessel analysis and evaluation of the autonomic nervous system. We hypothesised that the dynamic retinal vessel analysis represents a useful non-invasive and easy applicable tool to monitor functional microvascular alterations following VEGF inhibition.Patients with histological confirmed metastatic or locally advanced, inoperable colorectal cancer were enrolled into the study. All patients had an indication for treatment with bevacizumab / fluoropyrimidine containing chemotherapy regimens and had not previously received drugs directly targeting the VEGF pathway. Bevacizumab was administered at a dose of 5 mg/kg one day before the start of chemotherapy (day 0). To separate effects, fluoropyrimidine based chemotherapy was started after completion of all functional vascular measurements on day 1 as described below. Patients were evaluated by dynamic retinal vessel analysis, autonomic function tests and 24-hour ambulatory blood pressure monitoring (ABPM) the day before (day -1) and the day after bevacizumab infusion (day 1). ABPM was also applied on the day of bevacizumab treatment (day 0). The protocol was approved by the Ethics Review Board of the Medical Faculty of the Dresden University of Technology. All patients signed a written informed consent before inclusion into the study. The procedures conformed to the principles of the Declaration of Helsinki ® akut Spray, Pohl Boskamp, Hohenlockstedt, Germany) were recorded for five minutes followed by deep metronomic breathing at a rate of six breaths per minute for two minutes. For evaluation of orthostatic reaction, patients were tilted to a 60° upright position for 15 minutes. After 10 minutes of head-up tilting, 400 μg glyceroltrinitrate was repeatedly administered while tilting was continued for another five minutes. During head-up tilting the subsequent decrease in ventricular filling and stroke volume evokes a transient fall in arterial pressure which is counter-regulated by the baroreflex arc with resultant tachycardia  and vasoconstriction (sympathetic activation). This reaction is amplified by the application of vasodilatory agents such as glyceroltrinitrate. Orthostatic hypotension may occur as a result of sympathetic dysfunction which is defined as a reduction in systolic blood pressure of at least 20 mmHg and/or diastolic pressure of at least 10 mmHg within three minutes of upright tilt  years. Overall survival of all patients was 23.5 [15.0 – 31.8] months (median [95% CI]). Patients receiving bevacizumab as first line treatment (n = 9) had an average survival of 27.1 [21.8 – 32.4] months and those receiving the antibody as second line treatment (n = 11) survived on average 21.2 [14.0 – 28.5] months.Static retinal vessel analysis revealed that there was no arteriolar narrowing based on age-normalised reference values of the ARIC (Atherosclerosis Risk in Communities) population. With bevacizumab, no change was observed for arterial diameter, but there was a trend towards a smaller venous diameter  evoked similar decreases in systolic blood pressure before and after bevacizumab infusion during supine  and upright position  Figure a. The niMany efforts have been made to target the VEGF pathway in tackling cancer growth and tumor metastasis. Anti-angiogenic therapies using anti-VEGF antibodies or inhibitors of VEGF receptor 2 are increasingly employed in combination with standard therapy for the treatment of advanced cancer. However, predictive markers of efficacy as well as of toxicity have not yet been established. Imaging studies using diffusion contrast enhanced MRI (DCE-MRI) have documented very early changes in response to treatment with VEGF inhibitors ,25. HoweArterial hypertension is a candidate prognostic biomarker of response to VEGF therapy . One hypThe vasodilatory response of retinal vessels to diffuse luminance flicker stimulation is considered to be endothelium dependent through release of NO . Hence, It is however intriguing that we did not observe any functional change in retinal veins after bevacizumab administration. The lack of effect may be due to a marked regional and segmental heterogeneity in vascular endothelial function . AccordiIn vitro and in vivo studies clearly demonstrated the role of VEGF in maintaining baseline vascular tone by regulating NO synthesis and prostacyclin release [Although elevated blood pressure or hypertension has been the most frequently documented side effect of anti-angiogenic treatment  we did n release . Loss ofWe must acknowledge limitations of our pilot study. The small number of patients precluded us from performing multivariate modeling for analysis of possible interactions, especially co-morbidities, nor from doing correlation analysis of results of functional vascular analysis with outcome data of anti-angiogenic treatment. However, it is important to note that the study design allowed for separating the effect of anti-angiogenic treatment from that of chemotherapy.We demonstrate that the anti-VEGF antibody bevacizumab acutely impairs endothelial function of retinal arteries irrespective of blood pressure changes. Hence, functional imaging of the retinal microcirculation seems a valuable tool to monitor early effects of anti-VEGF treatment. Considering the close relationship between therapeutic and side effects of VEGF blockade, flicker provocation of retinal vessels may be a valid predictor of therapy success and outcome.ABPM: 24-hour ambulatory blood pressure monitoring; DCE-MRI: Diffusion contrast enhanced MRI; HF: High-frequency; LF: Low-frequency; MTRS: Multiple trigonometric regressive spectral analysis; NO: Nitric oxide; VEGF: Vascular endothelial growth factor.The study was supported by the University Hospital Carl Gustav Carus. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Gunnar Folprecht received honoraries for lectures and advisory boards from Roche / Genentech. All other authors have declared that no competing interests exist. Additionally, Focke Ziemssen has received speaker’s fees or consultancy honoraria from Alcon, Alimera, Allergan, Biogen, Bayer, Pfizer and Novartis.MR performed the statistical analysis and drafted the manuscript. RH assisted in the statistical analyses. TZ, FZ and GF designed the trial. TZ, KT, GF participated in the coordination of the trial and revised the manuscript for intellectual content. GE and HR revised the manuscript for intellectual content. All authors revised and approved the final manuscript.