The study aimed to assess the clinical significance of selected single nucleotide polymorphisms (SNPs) in patients with diastolic heart failure (HF): inflammation , fibrosis [Arg25Pro transforming growth factor β (TGF β) rs1800471], endothelial function [-786 T/C nitric oxide synthase (NOS) rs2070744], glucose and lipid metabolism [Pro12Ala peroxisome proliferator activated receptor (PPAR)γ rs1801282], and vitamin D metabolism [cytochrome P450 27B1 (CYP27B1) C-1260A].110 patients with HF with preserved and mid-range ejection fraction (HFpEF and HFmrEF) were recruited. GG homozygotes in 174 G/C of IL6 polymorphism are characterized by higher values of estimated glomerular filtration rate based on the study Modification of Diet in Renal Disease (eGFR MDRD) and C allele in the NOS polymorphism and AA profile in C-1260A of CYP27B1 polymorphism correlated with a lower eGFR (MDRD). In multivariate analysis the CG genotype for 174 G/C of IL-6 and allele A in C-1260A of CYP27B1 are the only SNPs independently associated with worse course of HFpEF and HFmrEF. These data confirm the importance of the selected SNPs in aggravation and complications of hypertension. Hypertension is the most prevalent comorbidity in heart failure (HF) and can lead to different activated pathophysiological mechanisms in heart failure with preserved and mid-range reduced ejection fraction (HFpEF and HFmrEF).Left ventricular (LV) diastolic dysfunction is an increasingly prevalent disease process in hypertensive patients2.Current studies suggest that natriuretic peptides have the potential to improve the establishment of diagnosis of early HFpEF but they still have significant limitations. There are still doubts whether the cut-off points of N-terminal pro brain natriuretic peptide (NT-proBNP) and brain natriuretic peptide (BNP) in diagnosis and monitoring of diastolic HF should be the same for the whole HF spectrum3.In HFpEF, extracardiac comorbidities such as metabolic risk, arterial hypertension, and renal insufficiency drive left ventricular remodeling and dysfunction through systemic inflammation and coronary microvascular endothelial dysfunction. The latter affects left ventricular diastolic dysfunction through macrophage infiltration, resulting in interstitial fibrosis, and through altered paracrine signaling to cardiomyocytes, which become hypertrophied and stiff because of low nitric oxide and cyclic guanosine monophosphate. Systemic inflammation also affects other organs such as lungs, skeletal muscle, and kidneys, leading, respectively, to pulmonary hypertension, muscle weakness, and sodium retention4. In this study we assessed the clinical significance of the single nucleotide polymorphisms reflecting different pathophysiological pathways in diastolic HF as complications of hypertension: inflammation , fibrosis [Arg25Pro transforming growth factor β (TGF β) TGFβ rs1800471], endothelial function . Our polymorphisms selection we was based on careful analysis of literature in the context of diastolic HF potential patomechanisms and pathogenetic mechanisms4.The new therapies should be targeted towards specific HF phenotypes, instead of the ‘one-size-fits-all’ approach, which has not been successful in clinical HFpEF. Unless the structural and biological determinants of the failing heart are deeply understood, it will be impossible to differentiate HFpEF patients appropriately, identify subtle myocardial abnormalities, and finally reverse abnormal cardiac function. The identification of specific structural cardiac HFpEF phenotypes may represent one way to differentiate subgroups of HFpEF patients with specific therapeutic targets. The use of selective biomarkers in diastolic HF may help to distinguish pathophysiological mechanisms of HFpEF and HFmrEF. Because of phenotypic diversity in HFpEF and HFmrEF, personalized therapeutic strategies are proposedThe patients’ characteristics are presented in Tables There were no significant changes between HF patients with and without the G allele. GG homozygotes in 174 G/C of IL6 polymorphism are characterized by higher values of estimated glomerular filtration rate based on the study Modification of Diet in Renal Disease (eGFR MDRD) (ml/min/1.73 m²)] and systolic mitral annular velocity (S). There were higher eGFR (p = 0.01) and higher S (p = 0.03) for GG genotype in hypertensive patients with HF –Table HF patients with the A allele in TNF-308 G/A rs1800629 polymorphism had lower systolic blood pressure and higher incidence of paroxysmal atrial fibrillation –Table There were no differences between patients with HF with and without the G allele in PPAR gamma polymorphism.Patients with HF and CC profile of TGF beta polymorphism had higher LV mass and a higher level of TNF alpha in plasma –Table Patients with the C allele in NOS polymorphism had a higher class according to the New York Heart Association (NYHA) classification (p = 0.04), lower blood pressure p = 0.03), a higher level of cystatin C (p = 0.02), lower eGFR MDRD (p = 0.02), and lower left ventricular ejection fraction (LVEF) (p = 0.007) compared to patients without the C allele -Table , a highePatients with AA profile in C-1260A of CYP27B1 polymorphism had lower values of eGFR (MDRD) (p = 0.02) and higher levels of uric acid (p = 0.03) compared to the CA and CC profile. There were no significant differences according to CC vs non-CC profile in CYP 27 polymorphism –Table Logistic regression analysis was used to identify the risk factors for a worse HF course based on NYHA classification scale, which is useful in assessing the stage of HF based on how much the patient is limited during physical activity.Variables significant in univariate comparisons (p < 0.05) ) further impaired endothelium-dependent vasodilation. In addition to its well-recognized role in the regulation of vascular tone, nitric oxide modulates sympathetic and parasympathetic nervous system activities. Abnormalities of both autonomic control and nitric oxide synthase activity are known to occur in patients with congestive HF22. Recently, a polymorphism of the promoter of the endothelial nitric oxide synthase (eNOS) gene has been associated with a reduction of eNOS activity. Patients homozygous for the polymorphism of the eNOS promoter had a greater autonomic imbalance as reflected by significant differences in high- and low-frequency heart rate variability, so this polymorphism may serve as a marker for patients at increased risk for sudden death and more rapid progression of disease23. In the Genetic Risk Assessment of Heart Failure (GROH) substudy of the African-American Heart Failure Trial, in 786 T/C promoter NOS3 polymorphism, the T allele was associated with LVEF (p = 0.01). In HF subjects, NOS3 genotype influences blood pressure and LV remodeling24.The next assessed polymorphism (-786 T/C NOS rs2070744) is involved in endothelial function. This polymorphism located in the promoter region is associated with regulation of NOS3 gene expression level. Carriers of the T allele have lower levels of nitric oxide than CC homozygotesIn our study patients with the C allele in NOS polymorphism had a higher class according to the NYHA classification, lower blood pressure and LVEF and worse parameters of kidney function (cystatin C and eGFR MDRD) compared to patients without the C allele.et al. no significant differences were observed in genotype or allele frequencies between case and control groups for VDR, CYP27B1 or CYP2R1 SNPs, either before or after stratification by the recruitment centre or when restricted to patients with end-stage renal disease25. Patients with gout have lower calcitriol levels that improve when uric acid is lowered. The mechanism of these observations is unknown. In the study of Chen W. et al. hyperuricemia suppresses 1-α-hydroxylase, leading to lower 1,25(OH)2D and higher parathormone in rats, and this is mediated by nuclear factor kappa-light-chain-enhancer of activated B cells (NFκB)26.In our study patients with the AA profile in C-1260A of CYP27B1 polymorphism had lower values of eGFR (MDRD) and higher levels of uric acid compared to CA and CC profiles. Vitamin D and its analogues are reported to have renoprotective effects in chronic kidney disease including diabetic nephropathy (DN). Vitamin D(3) is converted to 1,25(OH)D(3) by CYP2R1 and CYP27B1. The biological action of 1,25(OH)D(3) is mediated via its receptor. In the study by Martin 29. Alterations in the structure of cardiac tissue, particularly fibrous tissue transformation, are considered to be the major cause of cardiac remodeling. The accumulation of extracellular matrix increases myocardial stiffness and consequently impairs contractile behavior of the heart muscle. Regarding the role of TGF beta 1 in HF, the results are not consistent between studies29.TGF-beta 1 is one of three isoforms of the TGF-beta superfamily. Transforming growth factor beta 1 (TGF-beta 1) represents a central regulator of cardiac fibrosiset al. the authors investigated serum levels of TGF-beta 1 in 401 patients with atrial fibrillation and congestive HF. Patients with HF had lower TGF-beta 1 levels than those without (p = 0.0005)30. Similarly, in our previous study patients with hypertension and HF had lower TGF-beta levels than those with only hypertension. In this study we revealed that hypertensive patients with HFpEF and HFmrEF and higher concentrations of TGF beta 1 were characterized by lower classes according to the NYHA classification. The lower levels of TGF beta 1 in patients with more aggravated HF may result from higher consumption of TGF-beta 1 within the impaired myocardium or antifibrotic functions of natriuretic peptides.In the study of Behnes M. 31.This supports experimental data from the literature, in which natriuretic peptides have been shown to suppress adverse structural remodeling in the atria and ventricles. TGF beta 1 is upregulated by Ang II, and induction of TGF beta 1 causes cardiac fibrosis. The interplay between Ang II and TGF beta 1 causes continued activation that may result in chronic hypertension and progressive myocardial fibrosis, leading to HFCurrent HF therapies mainly focus on blocking the detrimental effects of long-term neurohormonal activation and largely ignore the physiological compensatory effect of the natriuretic peptide system and other endogenous vasodilator systems.We hypothesized that a higher level of TGF beta might be present during earlier phases of diastolic HF and that is why it is present in patients with less severe HF symptoms.32. In the patients admitted for decompensated HF in the RICA registry, renal dysfunction was frequently associated with HFpEF. eGFR below normal was strongly associated with all-cause mortality. Further decline of renal function was frequent, especially among diabetic and patients treated with MRA agents33. Also in the study of Ter Maaten et al. impaired renal function was a risk factor for developing HFpEF32. In the study of Primessnig et al. the rat model of chronic kidney disease (CKD) with HFpEF was associated with slowed relaxation of LV cardiomyocytes34.Renal dysfunction is common in patients with HF and is associated with high mortality. This relationship is well established in HF and reduced ejection fraction (HFrEF), but it is not fully understood in HFpEF and HFmrEF. In the new paradigm for HFpEF, proposing a sequence of events leading to myocardial remodeling and dysfunction in HFpEF was recently introduced, involving inflammatory, microvascular, and cardiac components. The kidney might play a key role in this systemic process. Renal impairment causes metabolic and systemic derangements in circulating factors, causing an activated systemic inflammatory state and endothelial dysfunction, which may lead to cardiomyocyte stiffening, hypertrophy, and interstitial fibrosis via cross-talk between the endothelium and cardiomyocyte compartmentset al. prospectively studied 299 patients enrolled in the Northwestern University HFpEF Program35. CKD and reduced eGFR were both associated with worse cardiac mechanical indices including left atrial (LA) reservoir strain, LV longitudinal strain, and right ventricular free wall strain, even after adjusting for potential confounders, including co-morbidities, EF, and volume status35. Reduced eGFR was also associated with worse outcomes 35. Gori et al. studied 217 participants from the PARAMOUNT study with HFpEF who had echocardiography and measures of kidney function36. Renal dysfunction was associated with abnormal LV geometry , lower midwall fractional shortening (MWFS), and higher NT-proBNP36. Compared with patients without renal dysfunction, those with low eGFR and no albuminuria had a higher prevalence of abnormal LV geometry and lower MWFS36. In these studies in HFpEF patients, CKD was independently associated with worse cardiac mechanics, which may explain why HFpEF patients with CKD had worse outcomes36.Unger 37. Serum cystatin C is a novel and stable biomarker not influenced by sex, age, exertion, diet, body mass index, muscle mass or serum creatinine37]. Cystatin C is a small, low-molecular weight protein from the group of cysteine proteinase inhibitors. It is produced by all nucleated cells in the body and secreted into the extracellular space at a steady rate. With low molecular weight and a high isoelectric point, it readily undergoes glomerular filtration. In the proximal tubule it is absorbed and then catabolized, and therefore does not return to the circulation38. Plasma CysC has a significant advantage over other markers clinically used to estimate GFR. Impaired renal function is an independent marker for left ventricular hypertrophy (LVH) and a good predictor of morbidity and mortality in cardiovascular disease. In the study of Li et al. there was a positive correlation between serum cystatin C levels and interventricular septal thickness, posterior wall thickness, and LV weight index, and the serum level of cystatin C was an independent marker for hypertensive LVH38.Cystatin C is a marker of renal function that also predicts cardiovascular outcome. The serum cystatin C level in patients with HFpEF is an independent predictor for all-cause mortality and/or readmission in patients with acute HF, regardless of renal functionet al. examined 4453 subjects aged 65 years or older without HF et baseline from the Cardiovascular Health Study. They compared the association of cystatin C with risk of incident HF with normal ejection fraction (HFnEF) and HF with reduced ejection fraction (HFrEF). During 8 years of follow-up, 167 cases of incident HFnEF and 206 cases of incident HFREF occurred. Increased risk of HFnEF was apparent only in the highest cystatin C quartile , while a linear trend was present for HFrEF 39. In our study worse kidney function assessed with both eGFR and cystatin C was independently associated with worse course of HF with preserved and moderate reduced EF, which is consistent with the results of the above publications.Moran 2 vitamin D3 , is a nuclear hormone receptor ligand, which is known to have profound effects on calcium and phosphate homeostasis. The heart is particularly noteworthy in that plasma 25(OH) vitamin D3 [25(OH)D3] levels have been shown to correlate inversely with the incidence of a variety of cardiac disorders, including ischemic heart disease and HF. Interventional studies in a variety of cell culture systems and animal models suggest that the liganded VDR can exert antihypertrophic activity in cardiac myocytes in vitro and in vivo40. Cardiac ventricular tissue also expresses 1α-hydroxylase (Cyp27B1), implying that it has the capacity to produce 1,25(OH)2D3, the cognate ligand of the VDR, from circulating 25(OH)D3.Vitamin D or its bioactive metabolite, 1,25 (OH)Low serum levels of 25-hydroxyvitamin D3 are known to be associated with increased mortality, and several studies have reported that vitamin D3 supplementation improves cardiovascular outcomes in patients with chronic kidney disease (CKD).et al. the serum levels of 1,25(OH)2D3 correlated significantly with transmitral to early diastolic mitral annular velocity ratio (E/e’) used as a surrogate marker of diastolic function and the radial augmentation index (rAI) used as an indicator of arterial stiffness and reflects LV afterload 41. Even in hypertensive patients without CKD, it was a useful indicator for LV diastolic dysfunction41. The genetic variation in vitamin D-dependent signaling might be associated with congestive HF in human subjects with hypertension. In the context of hypertension, an SNP in CYP27B1 was associated with congestive HF . Based on the study by Wilke RA, genetic variation in vitamin D biosynthesis is associated with increased risk of HF42. Our results, corresponding with the conclusions of Ito et al. and Wilke et al., show that the A allele in C-1260A of CYP27B1 was an independent predictor of worse course of diastolic HF, confirming the association of vitamin D homeostasis with LV diastolic function in hypertensive patients42.However, the effects of 1,25 dihydroxyvitamin D3  on cardiovascular disease remain unclear. In the study of Ito H. 44.The continued lack of effective therapies to improve outcomes in HFpEF underscores the knowledge gaps regarding the pathophysiology of HF with diastolic dysfunction. The new HFpEF paradigm proposes that comorbidities drive structural and functional remodeling through systemic endothelial inflammation45. Age, increased BMI, diabetes, low ejection fraction, left main stenosis, and genetic variation in the IL-6 promoter were established as significant independent risk factors for the survival of patients with three-vessel disease46.The systemic proinflammatory state triggers a downstream cascade of cardiac microvascular endothelial activation, oxidative stress, and abnormal myocardial cyclic guanosine monophosphate signaling, leading to microvascular rarefaction, chronic ischemia, fibrosis and progression to HF47. These results suggest that, at least in part, the effect of the IL-6 -174G > C polymorphism on coronary heart disease is likely to operate through inflammatory mechanisms, but the genotype effect on diastolic HF is largely unexplained. In our study the -572 G/C genotype of IL-6 may be a genetic marker of diastolic HF47.Compared to those with the GG genotype, men carrying the -174C allele had a relative risk of coronary heart disease of 1.54  and this effect was greatest in smokersThe promise of pharmacogenetics lies in its potential to identify the right drug at the right dose for the right individual. Many cells that play an important role in the cardiovascular system express the vitamin D receptor (VDR) and respond to 1,25-(OH)2D with cell-specific function and gene regulation. These cells include cardiomyocytes, vascular endothelial cells, vascular smooth muscle cells, phagocytes, and cells of the nephron, which produce renin.48. Moreover, these mice presented with overexpression of renin and atrial natriuretic peptide48. Due to the high prevalence of hypovitaminosis D among patients with high cardiovascular risk, vitamin D supplementation therapy may be warranted in this population. The meaning of the allele A in C-1260A of CYP27B1 in active vitamin D deficiency needs further investigations.Vitamin-D deficient patients present a higher risk of cardiovascular disease than the general population. In mice lacking CYP27B1 , in addition to the expected phenotype , development of hypertension and cardiac hypertrophy were also observedThe presence CG genotype for 174 G/C of IL-6 in patients with hypertension may serve as a predictor of diastolic heart failure with inflammatory background and motivate to start with also non-pharmacological therapies reducing inflammation like smoking cessation and regular physical training. The meaning of anti-inflammatory drugs in primary hypertension needs further investigations.49.110 patients with HF recognized based on the ESC guidelines 2012  were consecutively included in the study between January 2014 and October 2015. Based on ESC guidelines 2016 our HF group contains patients with heart failure with preserved and mid-range heart failure (HFpEF and HFmrEF)The exclusion criteria were as follows: unstable hypertension, New York Heart Association (NYHA) class IV HF, evidence of pulmonary hypertension on echocardiography, obstructive or restrictive pulmonary disease, hyperthyroidism and hypothyroidism, pregnancy and lactating, hemodynamically significant acquired heart defects with the exception of mitral and tricuspid incompetence secondary to left and/or right ventricular dilatation, cancer, significant anemia, abuse of alcohol or drugs, chronic inflammatory and other diseases, operation or severe injury during a month prior to blood collection or lack of informed consent to participate in the study. All enrolled patients underwent blinded adjudication by cardiologists experienced in adjudication. Detailed clinical, biomarker and imaging data were collected at the time of enrollment and echocardiograms were performed and interpreted by cardiologists blinded to genetic and biomarkers analysis. Functional polymorphisms were selected from six candidate genes: CYP27B1, NOS3, IL-6, TGF beta, TNF alpha, and PPAR gamma. We also assessed the levels of selected HF biomarkers and performed echocardiographic examinations.50. Systolic and diastolic arterial pressures were measured using a sphygmomanometer and stethoscope.Fasting venous blood samples were drawn in the morning and the obtained serum was frozen at the temperature of −70 °C. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease (MDRD) formulaApproval from the Bioethics Commission of the Medical University of Lodz (No. RNN/496/11/KB) was obtained. All methods in this study were performed in accordance with the guidelines and regulations approved by the Bioethics Commission of the Medical University of Lodz. Written informed consent was obtained from all the patients.In the current study, we isolated DNA from whole blood using a commercial kit (Chemagen). The approximate yields are 30–40 ng DNA/100 μl whole blood. The DNA was stored at 4 °C until required as a template in polymerase chain reaction. The polymorphisms were studied using the RFLP-PCR method. Primers and restriction enzymes are described in Table The samples after PCR reaction were digested by using appropriate enzymes and were subjected to 6% acrylamide gel and stained with ethidium bromide. Fragments for wild type, heterozygous and mutants are presented in Table The concentrations of NT-proBNP, cardiotrophin-1 (CT-1), cystatin C (CysC), tumor necrosis factor alpha (TNF-α), collagen III N-terminal propeptide (PIIINP), syndecan-4, interleukin-1 receptor-like protein 1 (IL1RL1), transforming growth factor beta (TGF-β1) and lipocalin-2/NGAL were determined using the EMax Endpoint ELISA Microplate Reader analyzer . TNF-α was analyzed with the enzyme-linked immunosorbent assay , with 2 polyclonal antibodies directed against TNF-α. Determination of NT-proBNP and CT-1 was performed with reagents of USCN Life Science Inc./Cloud-Clone Corp , using a sandwich ELISA assay according to the manufacturer’s protocol. Measurement of CysC was performed using a sandwich enzyme immunoassay  developed for the quantitative measurement of this marker in human serum. Analysis of the concentration of PIIINP, syndecan-4 and IL1RL1 was performed with a USCN Life Science Inc./Cloud-Clone Corp  kit, using a sandwich ELISA assay according to the manufacturer’s protocol. Measurement of TGF-β1 was performed using a sandwich enzyme immunoassay  designed for the quantitative detection of TGF-β1 levels in cell culture supernatants, human serum, plasma or other body fluids. Determination of lipocalin-2/NGAL was conducted using the BioVendor Human Lipocalin-2/NGAL ELISA sandwich enzyme immunoassay. Analysis of the concentration of galectin-3 (GAL3) was performed with a USCN Life Science Inc./Cloud-Clone Corp  kit, using a sandwich ELISA assay.51. LV volumes and EF were determined by biplane Simpson’s method. The ratio of early (E) filling peak velocity to early diastolic (E’) mitral annular myocardial velocity was calculated as an index of LV filling pressure51.All patients were examined following a standardized protocol using an ALOKA Alpha 10 Premier  with a 3–11 MHz probe. Quantitative echocardiography was used following current guidelinesst and 3rd quartile (Q25-Q75) for numerical variables and the number and percentages for categorical variables. The Shapiro-Wilk test was used to assess the normality of variables distributions.The STATISTICA 10 software package  and SPSS Statistics 21  were used for analysis. All values are presented as the median and 1To examine the relationship between qualitative variables the chi-square test of independence or chi-square test with Yates’ correction and maximum likelihood chi-square test were used. To compare two independent groups, Student’s t-test for continuous variables with normal distribution and the Mann-Whitney U test for non-normally distributed variables were used.To compare more than two independent groups, analysis of variance  or Kruskal-Wallis test  with post hoc multiple comparisons was used.Stepwise logistic regression was used to identify factors significantly associated with the presence of significant symptoms according to the NYHA classification. A value of p < 0.05 was considered significant.The study included a relatively small number of patients, and the findings need to be confirmed in a larger population. The present study was conducted as a prospective, consecutive recruitment of patients with heart failure with preserved and mid-range ejection fraction. There was only one patient with AA profile of NOS3 -786 C/T rs2070744 polymorphism and one patient with AA homozygote in TNF-308 G/A rs1800629.These data confirm the importance of the selected SNPs in aggravation and complications of hypertension. The CG genotype for 174 G/C of IL-6 and allele A in C-1260A of CYP27B1 are SNPs independently associated with worse course of HFpEF and HFmrEF.


We proposed using compression sonography to observe the coaptation and collapse of the radial artery as a surrogate for automated cuff blood pressures (BP). We hypothesize that the pressure required to achieve coaptation and complete collapse of the artery would correlate to the diastolic and systolic BP, respectively. This pilot study was to assess the feasibility of ultrasound-guided radial artery compression (URAC) for BP measurement and compare patient comfort levels during automated cuff with URAC measurements.This was a prospective cohort pilot study with a convenience sampling of 25 adult patients at a single urban emergency department. URAC pressure was measured, followed by cuff manometry on the same arm. A 100mL normal saline bag was connected to the Stryker pressure monitor and placed on the volar wrist. Pressure was applied to the bag with a linear transducer and the radial artery was observed for coaptation of the anterior and posterior walls and complete collapse. Pressures required for coaptation and collapse were recorded from the Stryker display. Patient level of comfort was also documented during the URAC method, with patients reporting either “more,” “same” or “less” comfort in comparison to automated cuffs. We analyzed data using intraclass correlation and paired t-tests. Interrater reliability was calculated using intraclass correlation.The mean cuff systolic BP was 138.6 ± 22.1 mmHg compared to 126.9 ± 19.8 mmHg for the URAC systolic BP (p=0.02). For diastolic BP, there was no significant difference between the cuff BP and the URAC BP . The intraclass correlation (ICC) for systolic BP was 0.48 (p=0.04) and 0.57 (p=0.02) for diastolic BP. The agreement between the two observers was 0.88 for identifying coaptation on ultrasound (diastolic pressure) and was 0.92 for identifying collapse (systolic pressure). Eighty percent (20/25) of subjects found the URAC method more comfortable than the cuff measurement, and the remainder found it the same (5/20).This pilot study showed statistically significant moderate correlation between automated cuff diastolic BP and URAC measurements for vessel coaptation. Additionally, most patients found the URAC method more comfortable than traditional cuff measurements. Compression ultrasonography shows promise as an alternative method of BP measurement, though future studies are needed. Automated cuff devices are the standard method of measuring blood pressure (BP) in the emergency department (ED). When these devices fail to obtain accurate pressures,We propose a new technique to assess intraluminal radial artery pressure using ultrasound-guided radial artery compression (URAC) sonography. It was previously shown that compression ultrasound of the arm can be used by non-vascular sonographers. Thalhammer et. al. successfully measured peripheral venous pressure using compression ultrasound of the cephalic vein and a specialized pressure tranducer.6Our technique is novel in that it uses compression sonography to assess arterial pressures and only uses equipment commonly in place in the ED. We hypothesize that the pressure required to achieve coaptation and then collapse of the radial artery on ultrasound will correlate to the standard automated cuff measurements for diastolic and systolic BP, respectively.Inclusion criteria were any adult patients with a triage automated-cuff pressure reading. Exclusion criteria were toxic-appearing patients, patients with apparent life- or limb-threatening illness or injury, patients meeting triage criteria for emergent care, patients with significantly abnormal triage vital signs , patients unable to give verbal consent, and patients unable to have cuff blood pressures done in either upper extremity.The ultrasound screen and pressure monitor were video recorded and over-read by another investigator who was blinded to the initial URAC measurements.coaptation as the point at which the anterior and posterior walls of the pulsatile radial artery first touched and complete collapse as the point at which the radial artery no longer visibly opened or displayed pulsatility. The pressure reading on the Stryker monitor was recorded at the points of coaptation and complete collapse. The ultrasound screen and Stryker monitor were recorded with a Sony Handycam camcorder, which was reviewed by the principal investigator to independently identify the point of coaptation and complete collapse to assess agreement. The patient’s BP was then measured using a standard automated cuff. Patient level of comfort with the URAC method was also assessed, with patients reporting either “more,” “same” or “less” comfort compared to automated cuffs.Patient was seated in a standard triage chair with an armrest. The radial artery was identified using a Zonare ZS-3 Ultrasound System  and an L10-5 linear ultrasound transducer set to the vascular exam settings. A 100mL bag of normal saline was connected to a Stryker intra-compartmental pressure monitor using standard intravascular tubing and flushed with saline to remove any air . The 100What do we already know about this issue?Venous pressure can successfully be assessed using compression ultrasound of peripheral veins. However, no studies have used compression ultrasound to assess arterial blood pressureWhat was the research question?Is ultrasound-guided radial artery compression (URAC) a feasible method to assess blood pressure?What was the major finding of the study?There is a statistically significant correlation between automated cuff and URAC diastolic blood pressure measurements.How does this improve population health?If found to be an acceptable method of assessing blood pressure, URAC could be a backup method to measure blood pressure and potentially replace invasive methods of assessment in select patients.We performed data analysis using SPSS Statistics version 24.0 . A paired samples t-test was performed for both systolic pressure (URAC vs cuff pressure) and diastolic pressure (URAC vs cuff pressure) to determine any statistically significant differences. We also compared the URAC and cuff pressures using the intraclass correlation coefficient. Interrater reliability between the two observers was calculated using the intraclass correlation coefficient.This study found a statistically significant difference between automated systolic pressure and URAC pressure for artery collapse (p = 0.02), but no statistically significant difference between automated diastolic pressure and URAC coaptation pressure (p = 0.46) . IntraclWe often guide the management of patients in the ED by their BPs. When unable to obtain accurate readings using automated methods, we spend precious time attempting different locations, using standard cuff manometry and occasionally resorting to invasive methods with its inherent risks. For these reasons a simple, non-invasive and reliable method of measuring BP is desirable for when the automated cuff fails.As described by Thalhammer et al., compression sonography using special equipment is capable of accurately measuring venous pressure with peripheral veins.This pilot study found a statistically significant moderate correlation between automated diastolic pressure and URAC measurement for coaptation pressure (p = 0.46). Furthermore, there was a high level agreement between two observers independently identifying the points of coaptation and collapse of the radial artery walls. The results show the URAC method has some promise as a reliable alternative method of BP assessment.Given the focal pressure being applied to the arm with the URAC method, the secondary aim of this study was to compare patient’s comfort level during automated cuff and URAC measurements. Automated BP cuff measurements are commonly uncomfortable for the patient.The authors of this study did not undergo any special training for this procedure but are trained in emergency sonography with fellowship or equivalent training. However, previous studies have shown that vascular compression of the forearm can be successfully performed after brief training,This pilot study has several limitations. It consisted of a small convenience sampling of patients at a single urban ED, which limits its generalizability. As a standard, our study used automated cuff pressures instead of a more accurate invasive BP measurement. Patients with significantly abnormal BPs were excluded. The technique requires the observer to be comfortable with identification of the radial artery on ultrasound, image optimization, and maintaining an adequate image of the vein while applying pressure on the saline bag. For this pilot study we used tools commonly found in most EDs, but not all EDs may have a Stryker or other intra-compartmental pressure monitor available. The system would have to remain partially constructed to be efficient. However, if compression-ultrasound BP assessment is further validated, a simple and integrated device could be developed.Compression ultrasonography shows promise as a method for BP measurement. Further studies are needed and should target comparison of compression sonography measurements to more accurate standards. If proven reliable, compression ultrasonography could serve as a backup method for BP measurement, reduce the need for arterial line placement, and be integrated into workflows for efficient use.


This cross-sectional and comparative study evaluated correlations between hemodynamic measurements, resistance artery function and fish consumption to the content of long chain n-3 polyunsaturated fatty acids in adipose tissue, a long-term marker of seafood intake.Patients with chronic kidney disease have a markedly increased cardiovascular mortality compared with the general population. Long chain n-3 polyunsaturated fatty acids. Information on fish intake was obtained from a dietary questionnaire and compared with adipose tissue n-3 polyunsaturated fatty acids.Seventeen patients with chronic kidney disease stage 5 + 5d and 27 healthy kidney donors were evaluated with hemodynamic measurements before surgery; from these subjects, 11 patients and 11 healthy subjects had vasodilator properties of subcutaneous resistance arteries examined. The measurements were correlated to adipose tissue n-3 polyunsaturated fatty acids in adipose tissue did not differ between patients and controls. n-3 polyunsaturated fatty acid levels in adipose tissue were positively correlated to systemic vascular resistance index;  and negatively correlated to cardiac output index . No correlation was observed between n-3 polyunsaturated fatty acid levels in adipose tissue and vasodilator properties in resistance arteries. n-3 PUFA content in adipose tissue increased with increasing self-reported fish intake.Fish intake and the content of n-3 polyunsaturated fatty acids in hemodynamic properties. However, this is apparently not due to changes in intrinsic properties of the resistance arteries as no correlation was found to n-3 polyunsaturated fatty acids.The correlations found, suggest a role for  Patients with chronic kidney disease (CKD) have a high risk of cardiovascular disease (CVD) compared with the general population and with declining renal function, the risk of CVD increases . In the n-3 polyunsaturated fatty acids (PUFA) might have cardioprotective effects [n-3 PUFA on CVD, although data are not entirely consistent [n-3 PUFA, eicosapentaenoic acid 20:5 (EPA) and docosahexaenoic acid 22:6 (DHA), are primarily found in fatty fish and are also available in fish oil supplements.Long chain  effects , 8, and nsistent –11. The n-3 PUFA supplementation has an effect on arterial stiffness [n-3 PUFA supplementation significantly reduces arterial stiffness when determined as PWV or systemic arterial compliance [n-3 PUFA have also proved an attenuating effect on arterial stiffness [n-3 PUFA supplementation on the vascular endothelial function, evaluated as flow-mediated dilatation of the brachial artery. Thus, n-3 PUFA improved the endothelial function in patients with metabolic syndrome, whereas such an effect could not be documented in healthy adults [Several trials in non-CKD populations have addressed whether tiffness –14, and mpliance . Studiestiffness . Contrady adults , 18. They adults  and are y adults , whereasy adults –24.n-3 PUFA concentration in adipose tissue with arterial stiffness, cardiac output, systemic vascular resistance and endothelium-mediated vasodilatation in resistance arteries. Furthermore self-reported fish intake was compared to n-3 PUFA concentration in adipose tissue.The aim of this explorative cross-sectional and comparative study of patients with CKD stage 5 + 5d and healthy kidney donors was to correlate n-3 PUFA in adipose tissue. Inclusion criteria were age above 18 years and scheduled for either living related-donor renal transplant (14 patients) or insertion of peritoneal dialysis catheter (3 patients) at the Department of Nephrology, Aarhus University Hospital, Denmark, during 1st of November 2010 until the 31st of October 2011. Inclusion ran consecutively and patients were approached when an operation date was scheduled. Exclusion criteria were severe congestive heart failure, persisting cardiac arrhythmias, reduced pulmonary function, leg amputation, severe psychiatric disease and acute infection. Three patients had diabetes mellitus, and 3 had previously documented CVD. Ahead of inclusion nine patients were not on dialysis, while 8 were treated with peritoneal dialysis. Median dialysis vintage was 294 days (range: 100–1154 days). All but one of the patients were treated with one or more antihypertensive drug: ACE-inhibitor (6 patients), angiotensin II receptor antagonist (7 patients), calcium channel antagonist (13 patients), beta-blocker (8 patients), furosemide (15 patients).A total of 18 patients with chronic kidney disease stage 5 + 5d (CKD) and 27 healthy kidney donors were included in the study. One patient was excluded from statistical analysis because of missing values for Patients prepared for living donor transplantation received immunosuppressive therapy 2 days in advance: Prednisolone 20 mg/d, Tacrolimus 0.2 mg/kg/d and Mycophenolat mofetil acid 1.5 g/d.Twenty-seven healthy kidney donors who did not receive any medication served as controls. Control subjects were related to the patients .The day before surgery, the participants’ hemodynamic data were measured along with height, weight and blood pressure. The participants filled out a questionnaire regarding fish intake, and fasting blood samples were drawn on the day of surgery. During surgery, a 2 × 3 cm biopsy from the abdominal wall containing skin, adipose tissue and subcutaneous resistance arteries was removed. Adipose tissue was submerged in liquid nitrogen and stored in a −80 °C freezer prior to analysis of fatty acid composition. Resistance arteries from the biopsy were isolated and mounted for isometric force measurements.6, 0.1%) and nitrous oxide (N20 0.5%) in an O2/N2 mixture. Rebreathing was done in 15 s with a gas volume of 1.8 l and a respiratory breathing rate of 14–18 min−1. Gas was sampled continuously from the mouthpiece and analyzed on-line by the IR gas analyzer. A constant ventilation rate and volume were ensured by synchrony between the graphical tachymeter on the computer screen and the study subject, who was instructed to empty the bag with each breath. The rebreathing software calculated pulmonary blood flow from the rate of uptake of N2O into the blood . The first two or three breaths were excluded from analysis if total lung volume changes measured by SF6 indicated incomplete gas mixing. After correction for system volume changes using SF6 concentration, the first two or three breath were excluded from the analysis due to initial incomplete gas mixing. For the majority of patients without pulmonary arterial-venous shunt (SaO2 ≥ 98%) the measured pulmonary blood flow value was considered equal to CO, whereas for patients with pulmonary shunt, the shunt was calculated and added to CO. The shunt fraction was calculated using the oxygen concentration. The calculations were performed under the assumption that gasses were mixed completely, that equilibration of gasses between alveoli and blood was rapid and that lung blood flow was constant.Seventeen patients with CKD and 27 healthy subjects were part of the hemodynamic study. Blood pressure, pulse rate and cardiac output (CO) were measured with a portable non-invasive device consisting of a three-way respiratory valve with a mouthpiece and a rebreathing bag connected to an infrared photoacuostic gas analyzer, a pulse oxymeter and a device for automatic blood pressure measurement . CO was measured by rebreathing a gas mixture of sulfahexafluoride (SFSystolic blood pressure and diastolic blood pressure were measured using an automatic device connected to the Innocor®. Systemic vascular resistance index (SVRi) was calculated as: /Cardiac output and indexed to body surface. The measurement was performed twice, and the mean value was used for data analysis.Pulse wave velocity (PWV) and augmentation index (AI) were measured in the supine position after 10 min of rest. Carotid–femoral PWV was measured with SphygmoCor® , using the integral software.Augmentation pressure was calculated as the difference between the second and first systolic peaks, and AI was calculated as the augmentation pressure expressed as percentage of pulse pressure. AI was measured for aorta. All of the measurements were made in duplicate by one trained study nurse, and the mean values were used in the subsequent analysis.2 in air to keep pH at 7.4. After mounting, the arteries equilibrated for 20 min before the elastic properties were characterized by stepwise increasing the artery circumference as previously described [In the microvascular study, 11 patients with CKD and 11 healthy subjects were examined; the included patients where those where dissection were successful and viable vessels found. Skin and subcutaneous tissue samples were taken during surgery and immediately placed in a 5 °C physiological salt solution (PSS). In the biopsies, 2 mm long resistance artery segments were dissected for measurement of endothelium-dependent vasodilatation. The artery segments were mounted on two stainless steel wires (40 μm diameter) in organ baths of a 4-channel wire myograph  or in a 2-channel wire myograph  for isometric force measurements. The organ baths contained PSS at 37 °C, continuously bubbled with 5% COescribed . Experim2PO4 1.18, MgSO4 1.17, NaHCO3 25, CaCl2 1.6, EDTA 0.026, glucose 5.5 (mM). Indomethacin was dissolved in ethanol, all other chemicals in distilled water. Chemicals were acquired from Sigma-Aldrich .The composition of PSS: NaCl 119, KCl 4, KHSelf-reported fish intake was obtained using a previously validated dietary questionnaire . A score3/MeOH [Adipose tissue samples were obtained from the abdominal region and stored at −80 °C. Fatty acids were extracted in CHCl3/MeOH , dissolv3/MeOH . Fatty aEstimated glomerular filtration rate (eGFR) was calculated from the 4-point MDRD formula . Asymmett-test or rank-sum when appropriated; gender was compared using Fisher’s exact test. Normality was visual check of quintiles of the individual variables against quintiles of normal distribution and standardized normal probability plot and using Sharpiro-Wilks test. All 3 tests should suggest normality for it to be accepted. Only n-3 PUFA was not normally distributed and had to be logarithmically transformed and normality was confirmed by Sharpiro-Wilks test. Log n-3 PUFA concentrations in adipose tissue had equal median and variance for CKD patients and healthy subjects, and were pooled and divided into three fish intake groups, which were compared using Kruskal-Wallis test. Correlation tests were conducted using linear regression. Comparison of the regression coefficient for healthy subjects and CKD patients was done as described by the Educational Department of UCLA [Data in tables are presented as mean ± standard deviation. Baseline characteristics were compared using Student’s  of UCLA . All stan = 17 vs. healthy subjects 7.1 ± 2.4, n = 27). Content of long chain n-3 PUFA in adipose tissue were comparable between CKD patients and healthy subjects .Baseline statistics are seen in Table n = 15 vs. 7.24 ± 1.46 m/s, n = 25; p < 0.05), augmentation index was lower in CKD patients  while cardiac output index and SVRi did not differ significantly between CKD patients and healthy subjects /m2, n = 16 vs. 32.6 ± 6.9 mmHg/(L/min)/m2, n = 26). Baseline characteristics for the microvascular study group (11 vs. 11) did not differ from the whole group. No difference was seen between dialysis and non-dialysis patients (data not shown).PWV was higher in CKD patients  were divided into three groups according to their fish intake. As shown in Fig. n-3 PUFA content in adipose tissue increased with increasing fish intake and groups were significantly different from each other (p < 0.01).All subjects  and control subjects . No differences in hemodynamic function between CKD and controls were found  .The “total” Ach-induced vasodilatation in the microvasculature was not associated with the content of sue Fig. . Furthern-3 PUFA content in adipose tissue and self-reported fish intake were both similar in CKD patients and controls. In both CKD and healthy subjects, n-3 PUFA levels and SVRi were positively associated, whereas n-3 PUFA and cardiac output index were negatively associated. The content of long chain n-3 PUFA in adipose tissue was not associated with endothelial function in small resistance vessels.n-3 PUFA content in adipose tissue  and fis3 intake  as well controls . In contcontrols  and pericontrols  had simin-3 PUFA levels between CKD patients and controls suggests that uptake, processing and storage of n-3 PUFA in CKD patients are comparable to healthy controls, as described earlier [The duration of HD has also proved important for the general nutritional intake, since both total energy, protein and lipid consumption are negatively correlated with the duration of HD . In the  earlier .n-3 PUFA in adipose tissue and the SVRi was found in both CKD patients and control subjects. An earlier study in healthy adults reported that resting SVR 5 hours after consuming a meal rich in DHA or EPA was the same as in the controls given a meal without DHA or EPA [n-3 PUFA in adipose tissue and cardiac output index in both controls and CKD patients. The aforementioned study [n-3 PUFA acute effects did not find differences in cardiac output at rest or exercise after DHA/EPA/placebo ingestion. Resting cardiac output is reduced in patients with CVD [n-3 PUFA lower the basic metabolic rate [n-3 PUFA and the microvascular endothelial-mediated vasodilator function, this apparently is not due to changes in intrinsic properties of the resistance arteries. Rather the change in resistance may stem from continual in-vivo activation from nerves, paracrine or endocrine processes.A positive correlation between A or EPA . A subseed study  of n-3 Pwith CVD . Howeverwith CVD . Moreovelic rate , which cn-3 PUFA and cardiac index/SVRi. However, associations were not found with PWV or augmentation index. This contradicts an earlier study showing DHA to be inversely associated with PWV in non-diabetic CKD patients [The current study showed associations between patients . PWV is patients , and then-3 PUFA ingestion on mortality or CVD in CKD patients in clinical trials. However, an observational study [n-3 PUFA treatment to be beneficial in secondary prevention of myocardial infarction in chronic HD patients, while no effect was seen on the primary endpoint, a composite of total cardiovascular events and death [n-3 PUFA on hemodynamic function and mortality in CKD patients.It has been difficult to prove an effect of al study  has suggnd death . Longer n-3 PUFA on endothelial function in large arteries [n-3 PUFA in adipose tissue with microvascular function. The endothelial Ach-induced vasodilatation was not correlated to n-3 PUFA in adipose tissue. Furthermore, the individual Ach-induced vasodilator pathways were not associated with long chain n-3 PUFA levels (data not shown). These results are in line with animal studies performed on rat femoral resistance arteries [n-3 PUFA.Although several studies have addressed the effect of arteries , 18, thiarteries  and suggThe study design was cross-sectional and therefore cannot establish causal relationship between variables. Since all healthy kidney donors were related to an CKD kidney recipient, the two groups may tend to have the same fish intake. This could influence measurements of hemodynamic and microvascular properties and potentially mask differences which could have been found in non-related groups. Due to the rather low sample size, a risk of type II error exists. In this type of experiment confounding variables are also a hazard. Due to the size of the study, is has not been possible to adjust for confounders such as smoking, exercise or family history.n-3 PUFA in CKD patients and control subjects. This is in contrast with earlier findings, but might be explained by young age of subject and the short duration of dialysis. Long chain n-3 PUFA were negatively correlated to cardiac output index, which may imply that n-3 PUFA enhance tissue oxygen uptake and lower metabolic rate. This could further explain the observed positive correlation between n-3 PUFA and systemic vascular resistance index although not through intrinsic properties of resistance arteries, as they did not correlate to long chain n-3 PUFA in adipose tissue.In conclusion, this study found similar fish intake and adipose content of long chain


The diagnostic and prognostic implication of exaggerated blood pressure response to exercise has been controversial, with opinions ranging from a benign process to a harbinger of potential cardiovascular morbidity. Nonetheless, lowering of blood pressure and prevention of hypertension is in first instance preferable by lifestyle changes, and many studies have shown the inverse association between physical activity level and the incidence of cardiovascular diseases suggesting low aerobic fitness as a strong predictor for future cardiovascular disease and all-cause mortality in both healthy and cardiovascular disease patients, including those with hypertension.Endothelial function, large artery stiffness and neurohormonal response are surely implicated both in the development of exaggerated blood pressure response to exercise and in the positive effect of physical exercise in the prevention and management of hypertension and cardiovascular disease in general.In their interesting and well documented review published in this issue Kim and Ha broadly described the possible pathophysiologic mechanisms of exaggerated blood pressure response to exercise and its clinical implications: in this regard, a very interesting issue could be represented by the role of exercise training. In fact, there is an the ample evidence in the literature that physical activity could positively affect endothelial function, arterial stiffness, neurohormonal response and finally blood pressure levels both in healthy men and in hypertensive patients and so should be considered a very important element in the prevention and management of cardiovascular disease. The diagnostic and prognostic implication of exaggerated blood pressure response to exercise has been controversial, with opinions ranging from a benign process to a harbinger of potential cardiovascular morbidity . NonetheIn their interesting and well documented review published in this issue Kim and Ha  broadly


Kidney transplantation is the most cost-effective therapy for end-stage renal disease. Post-operative complications account for 15%–17% of all cases and are associated with significant morbidity. Currently 4.8% of post-transplantation patients have returned to dialysis. Our center’s main transplant origin is cadaveric donation. To review surgical complications of kidney transplantation over the past 5 years. This was an observational descriptive study that included all patients from 2011 to 2015. A total of 55 cases were reviewed. Diabetic nephropathy was the etiology in 30.9% of cases. Post-surgical complications occurred in 12.7% of patients with a post-operative mortality of 4%. Graft survival at 1 year was 82.4% with a 91% 1-year patient survival.Early identification and treatment of surgical complications are critical for patient and graft survival. Complications are low but significant. Kidney transplantation is considered the most cost-effective therapy for end-stage renal disease (ESRD). Since the first human kidney transplantation by Joseph Murray in 1954 [Complications of renal transplantation can be classified as pathological or surgical. Pathological complications include rejection, infection, and cardiovascular events, while surgical complications involve vascular and urological complications, lymphocele, wound infection, and herniation.Despite all advances, graft-endangering complications are primarily of vascular etiology. Vascular complications account for 3%–15% of all cases . These iAccording to the United Network of Organ Sharing (UNOS), graft survival at two years is 90%; however, in 5-year surveillance reports, 30% of patients have lost the graft or died with a functioning kidney . The maiKnowledge of the incidence of clinical manifestations and management of surgical complications is necessary for all kidney transplant surgeons. The objective of this study was to report our experience with the epidemiology, peri-operative variables, and surgical complications of kidney transplantations performed over the past five years in our center.An observational descriptive study was conducted between 2011 and 2015 at “Dr. José Eleuterio González” University Hospital. All renal transplant recipients were included. Demographic variables, medical history, laboratory tests, details of the surgical procedure and post-transplantation follow-up at three months and one year were reviewed.Patients with a complete transplantation protocol, including cardiovascular, infectious, psychosocial and urological evaluations were included. All patients underwent panel reactive antibodies (PRA), human leukocyte antigens (HLA), and cross-lymphocyte cytotoxicity tests. All patients signed informed consent and all organ donations were cadaveric.Regarding the surgical technique, after washing the bladder with amikacin and placement of a Foley catheter, we proceeded to place the donated kidney in the right or left iliac fossa using side-to-end anastomosis of the renal artery and vein to the iliac vessels. To perform neoureterostomy we used the antireflux Laedbetter-Politano and the Lich-Gregoir techniques according to the decision of the operating surgeon. Statistical analysis was performed using SPSS v20 .2. The origin of the nephropathy was type 2 diabetes mellitus in 17 (31%); hypertension in 10 (18%); and other pathologies such as nephrolithiasis, glomerular diseases, or idiopathic in the remaining 28 patients. Of the total patients, 48 were on renal replacement therapy for a mean period of 2.18 years with 21 (43%) patients in hemodialysis and 27 (57%) in peritoneal dialysis  men and 24 (43%) women. The mean age of recipients was 49.5 years; the mean body mass index (BMI) was 27 kg/mdialysis .From the transplanted kidneys, 49 (89%) were located in the right iliac fossa and 6 (11%) in the left. Out of the donated specimens, 33 (60%) were right kidneys and 22 (40%) were left.The mean time of cold ischemia was 8.44 hours; it was 4.15 hours for the surgical procedure and 450 mL for approximate total blood loss. Nine (16%) patients had multiple renal arteries (MRA). In the immediate post-operative period, only one patient received more than three units of packed red cells and four patients remained in critical care for more than 48 hours. The mean hospital stay was 12 days. For ureterovesical anastomosis, we performed 47 (85%) Laedbetter-Politano and 7 (12%) Lich-Gregoir procedures. Vascular anastomoses were performed side-to-end and in one case with three renal arteries they were anastomosed together with a cadaveric graft iliac vein.There were 7 (13%) post-surgical and 5 (9%) chronic complications, stratified by etiology . Two  are used for diagnosis . HematomUrological complications are the most common complications in the late period after kidney transplantation, presenting an incidence ranging from 2.5% to 12.5% , lower tHigh immunosuppressing regimens, acute rejection, BK virus, and infection also lead to obstruction. A low-steroid protocol and meticulous surgical technique decreases the incidence  and the In the case of multiple renal arteries (MRA), many centers prefer not to use these kidneys when other suboptimal conditions such as advanced donor age, coexist . The maiSometimes, a small low polar renal artery may be the only irrigation the ureter has, so these vessels cannot be sacrificed during implantation . If thisLymphoceles occur during the dissection process by opening the lymphatics. In most patients, these fluid collections are asymptomatic and are found in ultrasound examination not requiring any invasive treatments. Larger collections may be associated with dilation of the collector system, pain, fever, and declined renal function. In these cases, ultrasound-guided aspiration should be done. Some cases may require insertion of a nephrostomy tube, although we can also open a non-infected lymphocele to peritoneal cavity. Wound infection rate in these patients is high due to the immunosuppression, but it may be managed with antibiotics. Hernia formation requires surgical repair.The four deaths we reported were in patients older than 60 years, with type 2 diabetes mellitus, hypertension, and with renal replacement therapy. One mortality was directly associated with graft failure at three months because of a ureteral injury with posterior urinoma formation. We were not able to establish independent prognostic factors of statistical significance for surgical complications based on complications analyzed.It is recommended that routine and emergency examinations with Doppler ultrasound are done for graft preservation. Surgical complications of kidney transplantation can be minimized with standardization of surgical techniques. Additionally, each organ should be used in its best condition. Early identification and treatment of these complications are critical to patient and graft survival. Thanks to advanced surgical techniques, kidney transplantation continues to be a safe treatment modality.


Background. Comorbidity of chronic obstructive pulmonary disease (COPD) and asthma  is a significant problem in pulmonary practice, whose pathogenetic issues are not clarified yet. Objective. To study the features of the regulation of immune response in patients with comorbid COPD and asthma. Methods. We assessed the levels of CD3+, CD4+, CD8+, CD4+/CD8+, CD19+, CD25+, HLA-DR, total IgE, TNF-α, IL-4, IFN-γ, TXB2, and LTB4 in patients with comorbid COPD and asthma. Results. The study involved 44 people with COPD, 39 people with asthma, and 12 people with comorbid COPD and asthma. The specific features in comorbid COPD and asthma were lymphocytosis, increased absolute count of T-helper cells, increased cytotoxic T-lymphocytes in relative and absolute count, increased relative and absolute numbers of B-lymphocytes, and high levels of total IgE. The elevated levels of TNF-α and IL-4 and inhibition of IFN-γ production were detected. The content of LTB4 was maximal; TXB2 levels were higher than in control group but lower than in COPD and asthma. Conclusion. In comorbid COPD and asthma inflammation increased even during stable period. High levels of eicosanoids, low production of Th1-type cytokines, and active synthesis of opposition IL-4, along with increased IgE, indicate the activation of Th2-type immune response. An important feature of COPD is a progressing pulmonary obstruction concurrent with airway remodeling [Comorbidity of chronic obstructive pulmonary disease (COPD) and asthma  is one of the most important problems in current pulmonary practice, but many pathogenetic, diagnostic, and therapeutic aspects of the problem remain unsolved yet , 2. The phocytes , 8. The modeling . Despitemodeling .Comprehending the mechanisms of ACOS, there must be considered that the stacking of pathogenetic processes and the additional mutual burdening are highly possible. Currently, only the first attempts to solving the issue are taken. The problem of the clinical and laboratory features of the diseases in the pathogenic and applied diagnostic aspects remains unresolved too. All of aforementioned questions raise some difficulties in the practical work even for a well-informed specialist.The aim of the study was to investigate the state of cellular and humoral immunity, the mediators of inflammation in COPD, and asthma and their combination and to establish the features of the regulation of immune response in patients with comorbid course of chronic obstructive pulmonary disease and asthma.The study involved 115 people (60 men and 55 women). The inclusion criteria were stable COPD (GOLD I or II), mild persistent, controlled, and partly controlled asthma, and ACOS.During the screening of employees from a certain company COPD GOLD I was firstly diagnosed in 27 people. 17 people had a stable COPD GOLD II, 39 people mild persistent, controlled, and partly controlled asthma, and 12 people comorbid COPD and asthma. The control group consisted of 20 healthy volunteers (6 men and 14 women), nonsmokers and never smoking before, without allergic anamnesis record. The survey of patients was conducted after signing the informed consent and in accordance with the standards of the Declaration of Helsinki (2008).2). Criteria for COPD diagnosis were respiratory symptoms , presence of risk factors , family history of COPD, postbronchodilator FEV1/FVC < 0.7, postbronchodilator FEV1 ≥ 80% from normal for COPD GOLD I, and 50% ≤ FEV1 < 80% from normal for COPD GOLD II, in accordance with the Global Strategy for Diagnosis, Management, and Prevention of COPD (GOLD 2016) [The diseases were diagnosed by patient medical history, physical examination, measurement of peak expiratory flow (PEF), spirometry with bronchodilator test , and laboratory tests. Respiratory failure was diagnosed by clinical symptoms and the levels of venous oxygen saturation (SaOLD 2016) .Asthma was diagnosed by spirometry tests. Criteria for asthma diagnosis were respiratory symptoms , the presence of allergic reactions and diseases, family history of asthma, normal or >80% from predicted FEV1, postbronchodilator increase in FEV1 > 12% or 200 mL from base level, and average daily PEF variation 3-4% for controlled asthma and 6-7% for partly controlled asthma in accordance with the Global Strategy for Asthma Management and Prevention (GINA 2016) [ACOS was diagnosed in the presence of respiratory symptoms , risk factors , allergic reactions and diseases before the age of 40 years, family history of asthma and COPD, postbronchodilator FEV1/FVC < 0.7, and increase in FEV1 ≥ 15% or 400 mL from base level.The survey with validated questionnaires was conducted to assess the symptoms of the basic disease: for evaluation of dyspnea: modified mMRC questionnaire , to assess asthma control level: ACQ-5 test (Asthma Control Questionnaire), and to evaluate the impact of COPD on a patient's daily life and health status: CAT test (COPD assessment test). The criteria for inclusion in the study were the absence of COPD and asthma exacerbations in last two months. The exclusion criteria were the occupational respiratory diseases, cardiovascular diseases  and their complications, diabetes, thyroid diseases, acute pathological conditions, and exacerbations of chronic diseases. All patients received basic medical treatment depending on the nosology: patients with controlled asthma received beta-agonists with short-term effect according to need; patients with partially controlled asthma, beta-agonists with short-term effect and inhalation corticosteroids ; and patients with COPD, cholinolytics with long-term effect (18 micrograms per day). ACOS was treated by using cholinolytics with long-term effect (18 mg/day) and inhalation corticosteroids/beta-agonists with long-term effect .+, CD4+, CD8+, CD4+/CD8+, CD19+, and CD16+56+) and humoral  immunity. The parameters of cell-mediated immunity were determined by flow cytometry (“BD Multitest 6-Color TBNK” reagent). The total IgE levels in serum were assessed by ELISA (“Xema-Medica” kit). Cytokine profile was evaluated by the levels of pro- and anti-inflammatory cytokines TNF-α, IL-4, and IFN-γ, determined by flow cytometry  via flow cytometer BD FACSCanto II. FCAP 3.0 software was used for data processing . The secretion of oxylipins was assessed by the levels of their stable metabolites—thromboxane B2 (TXB2) and leukotriene B4 (LTB4). For isolation of eicosanoids from serum we used minicolumns , and the levels were determined by quantitative ELISA . Measurement was carried out in 96-well plates via spectrophotometer “Biotek Power Wave” (USA). The data were processed in “Statistica” software, version 6.1 (1203C for Windows).Inflammatory activity was evaluated by the state of cell , most were men—32 people (72.7%). COPD GOLD I was diagnosed for 27 people (61.4%) and COPD GOLD II for 17 people (38.6%). Respiratory failure (I and II degrees) was diagnosed in 25 (56.8%) patients with COPD GOLD I and II. Patients had dyspnea during intensive physical activity. Daily physical activity was performed entirely. SaO2 level ranged from 92 to 94% for respiratory failure of I degree and from 84 to 89% for respiratory failure of II degree. 28 patients with COPD are smoking (63.6%). The smoking index in patients with COPD GOLD I was 24.4 packs/year and in patients with COPD GOLD II 28.6 packs/year. 10 people with COPD (22.7%) had underweight (BMI < 18.5). The assessment of the life quality by CAT showed a minor impact of COPD on life for majority of examinees. However, in patients with COPD GOLD II the impact on life was 1.9 times greater (p < 0.01).The clinical characteristics of study participants are presented in n = 39), most were women—23 people (59%). While verifying the diagnosis, controlled asthma was diagnosed for 15 people (38.5%) and partly controlled asthma for 24 people (61.5%). 13 patients with asthma were smoking (33.3%) and their smoking index was 0.35 packs/year. The majority of patients with asthma had overweight, with BMI 28.9 ± 3.24 kg/m2. The sensitization to indoor, food, and pollen allergens was noted for 32 people (82%) and hereditary load for 9 people (23.1%). ACQ-5 test showed a controlled course of the disease in only 38.5% of patients.Among patients with asthma (n = 12) there were 6 men (50%) and 6 women (50%). All patients in this group have COPD GOLD II and mild persistent and partly controlled asthma. Two people were smoking (16.7%), with smoking index 16.3 packs/year. Body weight in the group of patients with comorbidity mainly corresponded to normal values (BMI 18.5–25); for 3 patients an overweight was identified (BMI 27.6 ± 0.3 kg/m2). The impact of COPD on health for patients with comorbidity was higher. The average value of SAT in group 4 was significantly higher than that in the group of patients with COPD GOLD I, indicating a moderate impact of disease on quality of life. Dyspnea on mMRC scale was the highest in patients with comorbidity compared with patients with COPD (the minimum level of dyspnea was 1 point and maximum 3 points). The level of control in patients with comorbidity by ACQ-5 test was lower by 31.7% compared with patients with asthma (p < 0.01). The sensitization to allergens was noted for 8 people (66.7%), hereditary load was noted for 7 people (58.3%), and asthma episodes before 40 years were noted in 6 patients (50%).Among patients with ACOS  and the absolute levels of CD3+ cells  were increased , was shown. The content of lymphocytes with cytotoxic function (CD3+CD8+) in absolute values was prevalent in COPD patients compared with control group and patients with asthma  that affected the immunoregulatory index (CD4+/CD8+), which was increased to the value of 2.4 standard units . The content of B-lymphocytes (CD19+) in COPD has a tendency to decrease in comparison with control group. Along with the changes in T-cell immunity the immunoregulatory disorders were also revealed in patients with COPD. The levels of the proinflammatory cytokine TNF-α in serum were increased to 48.51 pg/mL and levels of IFN-γ to 78.69 pg/mL (p1-2 = 0.000004). In contrast, the levels of anti-inflammatory cytokine IL-4 were decreased to 43.95 pg/mL in patients with COPD in comparison with other groups . The increase in levels of serum LTB4 was detected up to 18.00 pg/mL (p1-2 = 0.000282) and TXB2 up to 31.36 pg/mL (p1-2 = 0.000004) in comparison with control group. Thus, the activation of the immune T-cells, the inhibition of B-cells, the active endogenous interferon synthesis, and high levels of eicosanoids were specific for patients with COPD. The data suggest that the disorders in the immune system are of the Th1 type of immune response, forming the persistent inflammation.It was revealed that the pronounced changes in the state of cellular immunity are preserved at remission stage of respiratory diseases, in comparison with control group. Comparative analysis of T-cells subpopulations showed that, in group of COPD patients compared with control group, group of patients with asthma and ACOS, the relative  and absolute count  in comparison with COPD group and ACOS group. The results suggest a persistent inflammation in patients with asthma, even without allergen presence. The absolute numbers of CD3+CD4+ cells in asthma patients were not significantly different from control group but were lower than in COPD group and ACOS group . The absolute numbers of cytotoxic T-lymphocytes (CD3+CD8+) were decreased in patients with asthma in comparison with COPD and ACOS groups . The immunoregulatory index (CD4+/CD8+) in patients with asthma did not exceed 2.15 standard units. The levels of B-lymphocytes (CD19+) in patients with asthma were increased in comparison with control group (p1-3 = 0.000010) and COPD patients (p2-3 = 0.000001), indicating the activation of humoral immune system, which is supported by high levels of IgE  and is specific for allergic inflammation.CD3α up to 40.29 pg/mL  and IL-4 to 90.42 pg/mL  were detected, while the levels of IFN-γ were decreased to 26.99 pg/mL . The levels of LTB4 in serum were increased to 50.53 pg/mL  and TXB2 to 34.77 pg/mL .In cytokine profile of asthma patients the high levels of TNF-γ and an increase in levels of vasoactive mediators—eicosanoids  and cytokines —were observed for asthma in clinical remission, indicating the persistence of the inflammatory process due to the activation of Th2-type immune response.The inhibition of T-cell immunity and the production of IFN-p1-4 = 0.000638, p2-4 = 0.000118, and p3-4 = 0.12776), the increase in absolute numbers of T-helper cells , and relative  and absolute  content of cytotoxic T-lymphocytes. The levels of B-lymphocytes were also increased, both in relative  and absolute  count, accompanied by high values of total IgE . Along with the changes in cellular immunity the disorders of cytokine profile were detected in patients with ACOS, presented by increased levels of serum TNF-α (p1-4 = 0.000029) and IL-4  and a moderate inhibition of IFN-γ production . The content of serum LTB4 in patients with ACOS had maximum values up to 86.75 pg/mL . TXB2 levels were higher than in control group (p1-4 = 0.000090) but significantly lower than in patients with COPD (p2-4 = 0.000132) and asthma (p3-4 = 0.000509). Thus, the increased activity of the T- and B-cell components of the immune system, high levels of pro- and anti-inflammatory cytokines, and increased levels of LTB4 were specific for comorbidity.The study of immunological parameters in ACOS patients has shown a slight lymphocytosis , consistent with the work by Rhee .γ), and high synthesis of opposition IL-4, together with the increased production of IgE, indicate an active inclusion of the mechanisms of switching to Th2-helpers in patients with ACOS, requiring further studies.The allergic sensitization in 66.7% of patients, asthma episodes before 40 years in 50% of patients with ACOS syndrome, high levels of eicosanoids in serum, low production of Th1-type cytokines . Presumably this may be explained by the initiation of systemic damage, by the generalization of the basic mechanisms of inflammation, and by loss of protective role of these mechanisms  , 18. To


The fraction of exhaled nitric oxide (FeNO) and blood eosinophils, markers of local and systemic eosinophilic inflammation, respectively, are increased in asthmatic patients. Little is known concerning the relationship between the FeNO levels and blood eosinophils in asthmatics.Twenty severe asthmatics with persistent FeNO elevation (≥40 ppb) and blood eosinophilia (≥3%) despite maintenance therapy including high‐daily‐dose inhaled corticosteroids were analyzed. We investigated the response of FeNO and blood eosinophils to systemic corticosteroids treatment and the change in Asthma Control Questionnaire (ACQ) according to differences in the response of FeNO and blood eosinophils to steroid.r = 0.37, P = 0.11). 50% of the subjects showed both ≥20% reductions in FeNO levels and blood eosinophils. There were significant differences in the ACQ score between the steroid response group and poor response group (P < 0.005). The group in which both FeNO and blood eosinophils were suppressed fulfilled the change in score of ≥0.5 on the ACQ.The changes in blood eosinophils were not correlated with the changes in FeNO levels by systemic steroid treatment (In the patients with severe asthma, responses to systemic corticosteroids were variable in terms of FeNO and blood eosinophils. It was necessary to suppress both persistent eosinophilia and high FeNO for the improvement of asthma control. Asthma is a heterogeneous disease with different phenotypes We have previously assessed the response to high dose systemic corticosteroids in terms of asthma control, lung function, blood eosinophils, and FeNO level in severe asthma patients with persistently high levels of FeNO despite maintenance therapy including high‐daily‐dose inhaled corticosteroids (ICS) Twenty severe asthmatics with persistent FeNO elevations (≥40 ppb) and blood eosinophilia (≥3%) despite maintenance therapy including high‐daily‐dose ICS  were analyzed. All subjects were recruited from Wakayama Medical University Hospital. Long‐acting beta2‐agonist, leukotriene receptor antagonist, and theophylline were used to 20 (100%), 13 65%), and 11 (55%) patients, respectively. ACQ, lung function test, blood eosinophils, and FeNO were assessed before and after 14 days treatment with 0.5 mg/kg oral prednisolone/day. The baseline mean values of the ACQ score, FeNO, and blood eosinophil percentage were 1.8, 60.1 ppb, and 8.2%. The study design and population characteristics have been previously reported in detail %, and 11In evaluating the responses of FeNO and blood eosinophils to systemic corticosteroids treatment, Spearman's correlation analysis was performed. The patients were divided into four groups based on the reduction in FeNO and blood eosinophils by systemic corticosteroid treatment as follows: steroid response (both ≥20% reduction in FeNO levels and blood eosinophils); poor response (FeNO) (<20% reduction in FeNO levels and ≥20% reduction in blood eosinophils); poor response (Eos) (≥20% reduction in FeNO levels and <20% reduction in blood eosinophils); poor response (FeNO and Eos) (both <20% reduction in FeNO levels and blood eosinophils).U‐test. The Kruskal–Wallis test, Mann–Whitney U‐test, and chi‐squared test were used to determine statistically significant differences in the patient characteristics.We evaluated the differences in the ACQ score among the four groups in response to systemic corticosteroids treatment by Kruskal–Wallis test and the differences in the ACQ score between the steroid response group and poor response group by Mann–Whitney r = 0.37, P = 0.11). The steroid response group consisted of 10 patients (50%). There were no differences of patient's baseline characteristics between four groups . And among the four groups, only the steroid response group achieved a change in score of ≥0.5 on the ACQ (data not shown).Twenty asthmatics were with persistent FENO elevation (≥40 ppb) and blood eosinophilia (≥3%) even after treatment with systemic steroid. As shown in Fig. Our study revealed two important clinical findings. First, in the patients with severe asthma there was variability in the responses to systemic corticosteroids in FeNO and blood eosinophils. The reason for this might be pathophysiologic differences between these two biomarkers. Type‐2 driven cytokines IL‐4, IL‐5, IL‐13 are associated with systemic and airway inflammation in asthma Second, it was necessary to suppress both persistent eosinophilia and high FeNO for the improvement of asthma control. Interestingly, there is one study that analyzed the association between a combination of increased levels of FeNO, a local biomarker of Type‐2 inflammation, and blood eosinophils, a systemic Type‐2 marker, and asthma morbidity in a clinical study of patients with asthma n = 7) and non‐responders (n = 3). Drug treatment, lung function, FeNO levels, and blood eosinophil numbers were similar between the groups. The non‐responders were all ex‐smokers, whereas in responders there were as many as five never‐smokers . Thus, smoking status might be influenced the change of symptom in the steroid response group. These results suggest that they are steroid‐resistant asthma patients who may need different treatment such as molecularly targeted therapies. Many antagonists of Type‐2 cytokines are under development as eosinophilic asthma therapeutics In the present study, 50% of the patients with severe asthma could not achieve suppression of either or both FeNO and blood eosinophils even after treatment with systemic steroid. Furthermore, 30% of the patinets with steroid rensponse group could not achieved a change in score of ≥0.5 on the ACQ. To investigate the factor that improve the ACQ score in the steroid response group, we compared the baseline characteristics between ACQ responders (There would be some limitations in our study. First, the sample size was relatively small. Second, this study was an extended analysis from a previously published uncontrolled trial. Third, blood eosinophilia was not expressed in absolute numbers, since systemic corticosteroids might affect other leukocytes subsets besides blood eosinophils.In summary, in the severe asthma patients, there was variability in the responses to systemic corticosteroids in FeNO and blood eosinophils. It is essential to suppress both FeNO and blood eosinophils for the improvement of asthma control.The authors declare no conflict of interests.


Previous research shows that, besides risk factors in adult life, the early-life environment can influence blood pressure and hypertension in adults. However, the effects of residential traffic exposure and residential greenness in the early-life on blood pressure in young adulthood are currently unknown.Ambulatory (24-h) blood pressures of 278 twins (132 pairs) of the East Flanders Prospective Twins Study were obtained at the age of 18 to 25 years. Prenatal and adulthood residential addresses were geocoded and used to assign prenatal and postnatal traffic and greenness indicators. Mixed modelling was performed to investigate blood pressure in association with greenness while adjusting for potential confounding factors.n = 97, 34.9%). An interquartile increase in residential greenness exposure (1000 m radius) was associated with a 3.59 mmHg  lower adult night systolic blood pressure. Among twins who were living at a different address than their birth address at time of the measurement , night-time blood pressure was inversely associated with residential surrounding greenness at adult age as well as with residential greenness in early-life. However after additional adjustment for residential greenness exposure in adulthood, only residential greenness exposure in early-life was significantly associated with night systolic blood pressure. While no significant effect of adult residential greenness with adult blood pressure was observed, while accounting for the early-life greenness exposure.Night-time systolic blood pressure was inversely associated with greenness at the residential address in twins living at the same address their entire life  contains supplementary material, which is available to authorized users. High blood pressure is the leading global risk factor for cardiovascular disease and mortality in the world , 2. LongGiven that an unfavorable intrauterine environment may contribute to increased blood pressure , we hypon = 4), parental education level (n = 17), BMI (n = 1), 24 h urinary sodium and potassium (n = 6), Gamma-Glutamyl Transferase (n = 9), age mother (n = 9), neigbourhood SES 1994 (n = 3), blood pressure (n = 6), resulting in a final study population of 278 persons, 170 monozygotic and 108 dizygotic twins. Informed consent was obtained and ethical approval was given by the Ethics Committee of the Faculty of Medicine of the Katholieke Universiteit Leuven.The East Flanders Prospective Twin Study (EFPTS), a population based register of multiple births in the province of East-Flanders (Belgium), started in 1964 to enrol twins at birth . The twi2), the smallest administrative entity for which statistical data are produced by the Belgian National Institute of Statistics (NIS). Belgian census data (FOD Economie/DG Statistiek) derived from the NIS were used to define neighborhood SES based on annual household income in the year 1994.Data recorded by the obstetrician at birth included gestational age, birth weight, sex of the twins and parental ages. Gestational age was based on the mother’s last menstruation and was calculated as the number of completed weeks of pregnancy. Zygosity was determined by sequential analysis based on sex, choriontype, blood groups based on umbilical cord blood, placental alkaline phosphatase, and, since 1982, DNA fingerprints . After DBiometric and laboratory measurements were obtained at the research centre during a 2 h morning session. Standing height and weight were measured as described in detail before . BMI wasFasting blood samples were drawn; Gama-Glutamyl Transferase was measured on an Olympus AU600 Auto-Analyzer . Potassium and sodium were determined in 24 h urine with ion-selective electrodes . Before urine collection, participants were asked to select a day of normal routine, to drink normally and refrain from caffeine use, and to refrain from heavy exercise.Ambulatory blood pressure was monitored using the SpaceLabs 90,207 device , as previously described . The ambResidential addresses of the mothers at time of birth of the twin and the residential addresses of the twin at time of the measurement were geocoded. Distance to the nearest major road, a proxy for traffic-related exposure, was determined using Geographic Information System (GIS) functions. All GIS analyses were carried out using ArcGIS 10 software.Semi-natural-, forested -, and agricultural areas (greenness), residential and industrial areas in a 5000 m radius from the residential address were estimated based on CORINE Land Cover 2000 (European Environment Agency). This was repeated for 4000, 3000, 2000, 1000, 500, 300 and 100 m buffers. CORINE, the acronym for ‘coordination of information of information on the environment’, was initiated by the European Union and has been taken over by the European Environment Agency. The land cover data is based on satellite data and is dived in 44 classes. It is presented as a cartographic product, at a scale of 1:1,000,000. This database is available for most areas of Europe.A GIS-based noise model including the Flemish street and railway networks was used to estimate traffic noise levels at the residential address of the mother at time of birth in 5 dB(A)-intervals according to the European Noise Directive (2002/49/EC) . The modelling of road noise level included road traffic intensity, vehicle-type-specific traffic density, type of street surface, small-scale topography of the area, and the presence or dimensions of buildings and reflecting objects. Railway noise modelling included the amount of passing trains, type of trains, speed, small-scale topography of the area, and the presence or dimensions of buildings and reflecting objects. Weighted equivalent noise levels in dB(A) for traffic over day-time  and at night (yearly average noise level between 11 p.m. and 7 a.m.) were modelled. Exposure to traffic noise was categorized as ≤55 dB, >55 to ≤60 dB, and >60 dB.p-values are two-sided and were considered statistically significant when p < 0.05.For data management and statistical analyses, we used SAS software, version 9.3 . All reported Mixed modeling was performed to investigate blood pressure in association with distance to major road and land-use indicators. The twins were analyzed as individuals in a multilevel regression analysis to account for relatedness between twin members by adding a random intercept to the model. The variance-covariance structure was allowed to differ between the three zygosity-chorionicity groups including dizygotic dichorionic, monozygotic dichorionic, and monozygotic monochorionic. Covariates were selected a priori including sex, gestational age, birth weight, birth year, zygosity–chorionicity group, maternal age, age, smoking, physical activity, BMI, 24 h sodium and potassium, gamma-glutamyl transferase, indicators of socioeconomic status , smoking during pregnancy and noise exposure during the night. To distinguish between exposure early and late in life, we divided the twins in two groups; twins who were living at the same address their whole life (non-movers) and twins who were living at a different address than their birth address at time of the measurement (movers). In the twins who moved during life, we additionally adjusted for land use/distance to major road in adulthood/early-life. Correlation coefficients between greenness in adulthood and early-life are shown in Additional file In addition, we tested potential effect-modifications of the association between land-use indicators and blood pressure by zygosity–chorionicity group.n = 264) of the participants included both twins from each twin pair, whereas the remaining 5% (n = 14) only had one participating twin from each twin pair. A total of 181 (65.1%) of the twins moved between birth address and young adulthood (Table p ≥ 0.81) was observed in the model of land-use indicators and blood pressure.The average age of mothers was 27.4 years at the time twins were born and 14.4% of the mothers smoked during pregnancy (Table p = 0.005) in night-time systolic blood pressure. Diastolic blood pressure during night and day was also inversely associated with greenness in a 300 m radius .In 97 twins living at the same address their entire life (non-movers), significant associations were observed between systolic blood pressure during the night and all land use indicators in a 1000 m buffer after adjustment for previously mentioned covariates  decrease in adult night systolic blood pressure, after additional adjustment for residential greenness exposure in adulthood. Diastolic blood pressure during the night was significantly associated with residential greenness in a 300 m buffer (−2.4 mmHg for IQR increase; 95% CI: -4.2 to −0.6; p = 0.01; Fig. In the twins who had moved since birth, an increased systolic blood pressure during night was significantly associated with lower greenness and higher residential area in early-life after adjustment for previously mentioned covariates (Additional file p = 0.03; Additional file In the movers, night-time systolic blood pressure was inversely associated with residential surrounding greenness at adult age when no adjustments for early-life exposure were made (Additional file The key finding of our paper is that in this twin population, increased early-life exposure to residential greenness was associated with lower blood pressure in young adulthood. These results lend further evidence in support of the developmental origins of disease hypothesis for blood pressure  and the Our findings are in line with previous studies, showing an association between high residential greenness and low blood pressure in children and adults , 9. HoweResidential green space might act via three routes. First, we postulate that the underlying mechanism between surrounding greenness in early-life and blood pressure in young adulthood could be stress. Higher levels of green space in residential neighborhoods, are linked with lower perceived stress and a healthier cortisol levels in women in a deprived urban population . MoreoveIt might be possible that low air pollution concentrations in areas with more surrounding greenness result in a lower blood pressure. Studies in adults show that a long-term exposure to air pollution is associated with higher blood pressure , 22–26. Studies on early-life stressors, such as ambient air pollution, noise and stress, that may influence blood pressure in adulthood are limited. One study shows that prenatal exposure to ambient air pollutants are associated with an increased risk for adverse cardiovascular health outcomes . AnotherA major advantage of this study is that we individually estimated greenness exposure of each participant. Our study is the first to include information on greenness exposure in the early-life when investigating adult blood pressure. Since we cannot differentiate between prenatal and postnatal exposure to residential greenness, our study is limited to define the exact time period of the exposure. Nevertheless, residential greenness in early-life remained significant even after additional adjustment for residential greenness exposure in adulthood. We found no significant effect of adult residential greenness with adult blood pressure, while accounting for the early-life greenness exposure.Strengths include the use of ambulatory blood pressure and the possibility to control for potential confounding factors and covariates of blood pressure such as age, gender, smoking status, physical activity, BMI, sodium and potassium intake and alcohol consumption. Ambulatory blood pressure was measured at home during usual daily activities and is, compared to office measurements, a better predictor of all cause and cardiovascular mortality and has a moderate-to-relatively high tracking stability and predictability over time , 35. TheSince high blood pressure is the leading global risk factor for cardiovascular disease and mortality in the world , these fOur findings indicate that more surrounding greenness at the residential address in early-life shows lower blood pressure in adult life. This may be especially relevant for policy makers and urban planners for designing healthier urban environments.