To investigate the relationship between serum cystatin C (CysC) levels and renal microvascular perfusion in patients with diabetic kidney disease (DKD).A total of 57 patients with high CysC levels and 45 patients with normal CysC levels were enrolled. Data on clinical characteristics and laboratory examination results were also collected. Contrast-enhanced ultrasound (CEUS) of the kidneys was successively performed. The time-intensity curve (TIC) and related quantitative parameters of the kidneys were obtained by CEUS and the correlations between CysC and CEUS parameters were analyzed.p < 0.05). In the high CysC group, patients with Stage IV–V CKD had lower wash-in AUC compared to patients with Stage I–II CKD (p = 0.023). The renal cortex microvascular perfusion parameters AUCs were positively correlated with the estimated glomerular filtration rate (GFR) , and CysC was inversely correlated with AUCs .Compared to the normal CysC group, the high CysC group had significantly lower wash-in area under the curve (WiAUC), wash-out area under the curve (WoAUC), and wash-in and wash-out area under the curve (WiWoAUC). In the normal CysC group, patients with Stage III chronic kidney disease (CKD) had higher AUCs than those with Stage I–II CKD (CEUS parameters reflected changes in renal microvascular perfusion in patients with DKD, while AUCs might be useful indicators of declining GFR in DKD patients with increased CysC. DM has become one of the most serious health problems worldwide because of its high prevalence, disability, and mortality rates. Microvascular and macrovascular complications associated with DM are also increasing sharply . DiabetiAt present, the formula calculation of serum creatinine (Scr) level is the most used clinical method to estimate the glomerular filtration rate (GFR). However, Scr cannot sensitively reflect GFR in early renal impairment because Scr levels increase only when GFR had decreased to 50% of the normal value . CystatiAs a noninvasive and sensitive blood pool imaging method, contrast-enhanced ultrasound (CEUS) can sensitively evaluate the blood perfusion of organ microcirculation and provide microcirculation information for clinical diagnosis . MoreoveBased on the results described above, the correlations between CysC and CEUS parameters are of interest. Whether CysC is directly involved in renal microvascular injury remains unclear. Therefore, this study investigated the relationship between CysC and quantitative parameters of CEUS in patients with DKD.2), patients with stage III CKD (60 > eGFR ≥30 mL/min/1.73 m2), and patients with Stage IV–V CKD (<30 mL/min/1.73 m2). This study was approved by the hospital ethics committee . All participants signed an informed consent form for ultrasound imaging before the examination.The participants were recruited from our hospital. All patients underwent renal biopsies to confirm kidney injury. The inclusion criteria were type 2 DM patients with kidney injury based on the renal biopsies results. The exclusion criteria were non-CKD; allergy to the contrast-enhanced agent; severe heart, brain, or pulmonary disease; pregnancy; congenital renal abnormalities (such as duplicate kidneys and fusion kidneys) or renal cysts or renal tumors; unilateral kidney atrophy; a combination with unilateral or bilateral renal artery stenosis; complications, such as systemic disease or urinary tract infection; and age < 18 or > 80 years. The clinical data collected included age, sex, body mass index (BMI), systolic blood pressure (SBP), and diastolic blood pressure (DBP). Before CEUS examination, blood was drawn from all subjects for blood urea nitrogen (BUN), Scr, and serum CysC measurement. According to the biochemical test results, the normal range of CysC levels was 0.45–1.25 mg/L, with levels >1.25 mg/L defined as high CysC. The patients were then divided into the normal and high CysC groups. The estimated glomerular filtration rate (eGFR) was calculated by the CKD-EPI formula: Scr ≤0.9 mL/dL:eGFR = 144 × (Scr/0.9) − 0.411 × (0.993)*Age and Scr >0.9 mL/dL: eGFR = 144 × (Scr/0.9) − 1.209 × (0.993)*Age for male; Scr ≤0.7 mL/dL:eGFR = 144 × (Scr/0.7) − 0.329 × (0.993)*Age and Scr > 0.7 mL/dL:eGFR = 144 × (Scr/0.7) − 1.209 × (0.993)*Age for female). Patients in each group were stratified according to eGFR level: patients with Stage I–II CKD , with a frequency of 2–6 MHz. The patients lay on their side. The left kidney was displayed to capture its form, echo, and size in the long-axis view. The contrast agent SonoVue , consisting of sulfur hexafluoride microbubbles, was prepared according to the manufacturer’s instructions. After the CEUS mode was initiated, 0.5 mL of contrast agent was administered through the superficial elbow vein using the bolus injection method, followed by a 5 mL flush with 0.9% saline. Image acquisition was performed by a physician with more than 5 years of CEUS experience. The patients were asked to hold their breath for at least 30 s and then breathe slowly and smoothly for up to 3 min.2. Movement compensation was applied to all participants. The DICOM data of the ROI were converted into echo-power data. A time-intensity curve (TIC) of the ROI was generated, from which the analysis parameters were calculated  format. Renal perfusion was analyzed in VueBox version 7.0 . Three regions of interest (ROIs) were defined: a reference ROI and two analysis ROIs. The segmental or interlobular arteries were set as the reference ROI in each kidney image and two ROI regions were set at the cortical zones in each image. The analysis ROI was placed on the middle pole to the lower pole of the renal cortex. The area of the ROI was 0.3 cmlculated . The part tests, while those among three groups were performed using one-way analysis of variance or Mann–Whitney U tests, according to the type of data. Differences in sex distribution between the groups were analyzed using chi-squared tests. Spearman’s correlation analysis was performed to assess the relevance of CysC and renal microvascular perfusion parameters. All statistical analyses were conducted using IBM SPSS Statistics version 26.0 . p < 0.05 was considered statistically significant.Continuous variables with normal distributions were expressed as means ± SD; otherwise, they were expressed as medians (IRQ). Categorical data were expressed as numbers (proportions). Comparisons between groups were performed using Student’s p=0.996; p > 0.05, p < 0.01, Among 150 recruited patients with DM and CKD, 48 were excluded . Thus, 1p < 0.05, All subjects were recorded at four stages: ‘start to enhance’, ‘cortical enhancement’, ‘cortical peak’, and ‘wash-out phase’ . QuantitThe patients in the normal Cys C and high Cys C groups were divided into three subgroups based on CKD stage. In the normal CysC group, 39 patients had Stage I–II CKD, six patients had Stage III CKD, and no patients had Stage IV–V CKD. In the high CysC group, six patients had Stage I–II CKD, 26 patients had Stage III CKD III, and 25 patients had Stage IV–V CKD. The clinical characteristics of the participants according to CKD stages are shown in p < 0.01). In the high CysC group, patients with Stage IV–V CKD had higher SBP, BUN, Scr, and CysC levels and lower eGFR than patients with Stage I–II and III CKD (p < 0.01, In the normal CysC group, patients with Stage I–II CKD had higher eGFR and lower Scr and CysC levels than those with stage III CKD (p < 0.05, p = 0.023, In the normal CysC group, patients with Stage III CKD had higher WiAUC, WoAUC, and WiWoAUC than those with Stage I–II CKD I (The renal cortex microvascular perfusion parameters WiAUC, WoAUC, and WiWoAUC were positively correlated with eGFR . And WiADKD onset is often not recognized and its clinical manifestations lack specificity. Albuminuria, Scr, and other laboratory indicators commonly used to evaluate renal function lack sensitivity for the early-stage evaluation and diagnosis of renal function damage . HoweverThis study also applied CEUS, an emerging tool for evaluating the microcirculation of the kidney in DKD. CEUS can quantitatively evaluate renal microcirculation perfusion and improve the sensitivity and specificity of ultrasound in the diagnosis of DKD. CEUS has been used to evaluate renal microvascular perfusion in CKD, acute kidney injury, and other kidney diseases . The hisAs CysC is superior to sCr-based CKD staging in evaluating renal function of early-stage CKD ,29, thisWe also explored the correlations between CysC level and microvascular perfusion assessed by CEUS. WiAUC, WoAUC, and WiWoAUC were selected because of their early performance in CEUS. The results showed that CysC was negatively correlated with WiAUC, WoAUC, and WiWoAUC. We also analyzed the relationship between eGFR, BUN, Scr, and the three CEUS parameters. The eGFR was positively correlated and BUN and Scr levels were negatively correlated with WiAUC, WoAUC, and WiWoAUC. Between the two methods of evaluating renal function, the correlation coefficient of CysC was higher than that of eGFR. Basic studies have shown that CysC might participate in diabetic microangiopathy by activating the neutrophil-mediated inflammatory response to cause endothelial dysfunction, or by interacting with homocysteine and cathepsin to promote the proliferation of vascular smooth muscle cells and damage to vascular endothelial cells ,30. At pOur study had some limitations. First, owing to the limited sample size and single-center design, additional studies with larger sample sizes and more medical centers are needed. Second, contrast medium was injected using the bolus method rather than an injection pump at a continuous rate. Although manual injection may reduce the accuracy of contrast injection, most studies still use this method.CEUS parameters reflected changes in renal microvascular perfusion in patients with DKD. Moreover, WiAUC, WoAUC, and WiWoAUC might be useful indicators of declining glomerular filtration rate in patients with DKD with increased CysC levels. However, these predictions warrant further validation. CEUS, as a noninvasive method, has potential clinical value for evaluating changes in renal function in patients with DKD.


P < 0.001 versus non-pregnant dimensions in both; P = 0.983 HDP versus controls). This thinning response continued to delivery in all controls and in 7 women with HDP superimposed on chronic hypertension. Macular thinning was lost after 20 weeks gestation in the other 20 women with HDP. MAP at loss of macular thinning in women without prior hypertension (n = 12) was identical to MAP at enrollment. However, mean MAP subsequently rose 19 mmHg  leading to de novo HDP in all 12 women. Loss of thinning leading to a rise in MAP was also observed in 8 of 15 women with HDP superimposed on chronic hypertension. We conclude the macula thins in most women in early pregnancy. Those who lose this early macular thinning response often develop blood pressure elevations leading to HDP.Optical coherence tomography of the eye suggests the retina thins in normal pregnancy. Our objectives were to confirm and extend these observations to women with hypertensive disorders of pregnancy (HDP). Maternal demographics, clinical/laboratory findings and measurements of macular thickness were repeatedly collected at gestational ages <20 weeks, 20-weeks to delivery, at delivery and postpartum. The primary outcome was the change in macular thickness from non-pregnant dimensions in women with incident HDP compared to non-hypertensive pregnant controls. Secondary outcomes were the relationship(s) between mean arterial pressure (MAP) and macular response. Data show macular thicknesses diminished at <20 weeks gestation in each of 27 pregnancies ending in HDP  and 11 controls (mean 3.92 µm; 5.05, 2.79;  Hypertensive disorders of pregnancy (HDP), including preeclampsia (PE), gestational hypertension (GHTN) and pre-existing chronic hypertension (cHTN) are common. In aggregate, they occur in 7–10% of all pregnancies and worldwide are a leading cause of maternal and perinatal morbidity and mortality [Early imaging studies looking at the brain in patients with non-pregnant forms of severe hypertension point to breach of the upper threshold of autoregulation with hyperperfusion and vasogenic edema as the cause of microvascular CNS injury in hypertensive emergency . ClinicaThe neurosensory retina is unique in that it possesses 2 blood retinal barriers; one at its capillary interface with the central retinal artery regulating movement of water into this tissue, the other at the retinal pigment epithelium (RPE) where cells that comprise this barrier pump chloride ion and lactate to its outward-facing side  participants were instructed to remove their face from the examining platform and the instrument reset to default in order to match the effect of an independent scan. Scans were examined systematically for signal strength, definition of vessel architecture, centrality and motion artifact to determine image quality, and the better of the 2 was prospectively selected for analysis. Segmentation was verified on every scan. Macular thickness is a standard measure calculated by the instrument from the internal limiting membrane to the retinal pigment epithelium. Scans were referenced to a control image obtained in the same individual in the non-pregnant state. A certified ophthalmologist reviewed all SD-OCT images.The primary outcome was the change in macular thickness from its non-pregnant baseline over the 3 gestational intervals in women with HDP compared to non-hypertensive pregnant controls. Secondary outcomes were the differences in macular response between subgroups with incident HDP  and their relationships to systemic blood pressure.Preliminary data revealed an effect size of ≥4 µm change in macular thickness and a probability of developing PE of 50% in high-risk cohorts. The probability of correctly detecting retinal injury in those with PE was 63%, and 33% in those (1 - PPV) without that outcome, giving a sample size estimate of 20 controls and 40 HDP. These sample sizes were increased to 30 and 125, respectively, to allow for dropouts, missing data and inclusion of a planned secondary outcome of those with and without cHTN.P = 0.047. The decision support tool was used to allocate participants into HDP sub-cohorts according to their macular response. This formed the basis of our stratified analysis. The 2 eyes were considered independent variables in summary analyses . However, both eyes had to be normal in order to classify an individual as having no evidence of microvascular injury.Given the exploratory nature of our study and its small subject numbers, we considered both summary statistics and measures of individual response. In respect to the latter, a decision support tool was derived whereby clinically meaningful change was arbitrarily defined as a directionally identical difference ≥ ±4 µm (two times the test re-test coefficient of repeatability of our instrument) in 3 or more contiguous segments on the Early Treatment of Diabetic Retinopathy Study  (ETDRS) P < 0.05.Participant characteristics were summarized using means and standard deviation (SD) for continuous variables and frequencies for categorical variables. A linear, mixed effects model was used to estimate macular thickness in the 3 gestational intervals with random effects considered at three hierarchical levels: patient level, eye side (right or left) and position on the ETDRS grid. A continuous autocorrelation structure was applied to adjust for correlation of variables repeatedly measured at differing clinical encounters. Ninety-five per cent confidence intervals were computed for all outcome variables. Multiple regression analysis was performed to verify the findings of the stratified analysis and to identify the effects of potentially confounding variables. Statistical significance was a P = 0.51) and mean weight 11.3 kg heavier at 76.2 kg  compared to non-hypertensive controls. Mean gestational age at enrollment was similar (P = 0.81) in the 2 cohorts. However, gestational age at delivery was 37 weeks 2 days (P < 0.05), almost 2 weeks earlier due to an expedited delivery in 27 of 28 HDP pregnancies. Delivery was by caesarean section in 16 women (57%). Twenty-seven HDP pregnancies ended in a singleton live birth; 1 woman delivered twins. There were no fetal losses. The incidence of postpartum complications was higher in women with HDP (54%) and was commonly associated with postpartum hemorrhage. Three of 28 pregnancies had fetal growth restriction (11%) as defined by standard criteria [P = 0.25) in both cohorts. Fundoscopy revealed diffuse arteriolar narrowing in 4 cases. One participant had clinical and OCT evidence of new bilateral papilledema. There were no SD-OCT findings of sub-retinal edema or detachment, retinal vessel occlusion, or neovascularization.Maternal co-morbidities and demographics of the 11 control and 28 incident HDP participants appear in Table One participant had a hypertensive emergency with evidence of retinal injury at enrollment. This was not known until completion of her final postpartum scan. She was removed from all subsequent analyses, but her case brings important information to bear and will be discussed separately. Of the remaining 27 HDP participants, 26 demonstrated macular thinning in the first 20 weeks of gestation and all 27 had thinned by 32 weeks. The pattern and extent of thinning  was identical to that of non-hypertensive pregnant controls . MAP at the time of loss of thinning was 87 mmHg , similar to MAP at enrollment (P = 0.19). However, in the 2–8 weeks that followed MAP rose on average 19 mmHg  to a mean MAP of 101 mmHg  at delivery (P < 0.001 compared to both earlier measurements). The only participant not showing this pattern of loss of thinning at a normal systemic blood pressure followed by a meaningful rise in MAP presented at 37 weeks gestation with a systemic blood pressure of 123/79 mmHg (MAP up 8.3 mmHg from previous measurements), new onset proteinuria and severe fetal growth restriction/fetal distress leading to urgent caesarean section. Her clinical diagnosis was PE at a normal blood pressure. The diagnosis in the other 11 participants was PE in 5 women (42%), of which 2 (40%) were severe, and GHTN in 6 women.Twelve of the 20 pregnancies (60%) where HDP was associated with loss of macular thinning occurred in women with no prior history of hypertension. Average MAP at enrollment in these 12 individuals was 84 mmHg , or 112/70 mmHg by conventional methods of reporting. This was not meaningfully different from MAP in non-hypertensive pregnant controls (n = 15). Six were on anti-hypertensive treatment at enrollment; all were on treatment by delivery. Three participants had an accelerated clinical course where systemic blood pressures rose steeply with loss of thinning first noted at delivery. Thus, the true MAP at loss of thinning could not be reliably estimated in these individuals. All 3 were classified as PE, 2 of which were severe. In the other 5, mean treated MAP at loss of thinning was 98 mmHg , 11 mmHg higher than MAP at enrollment (P < 0.05) and 11 mmHg higher than MAP at loss of thinning in de novo HDP (P < 0.03). As in de novo HDP, loss of thinning was followed by an 8–20 mmHg (median 14) rise in systemic blood pressure to a mean treated MAP at delivery of 102 mmHg . All 5 were classified as GHTN.Eight of 20 HDP pregnancies (40%) with loss of macular thinning occurred in women with HDP superimposed on cHTN (Macular thicknesses remained consistently thinned from <20 weeks to the time of delivery in 7 of 15 pregnancies (47%) in women with HDP superimposed on cHTN. Four were on anti-hypertensive treatment at enrollment; all but one was on treatment by delivery. MAP rose sharply in late pregnancy by 23–28 mmHg in all 7 women to a mean maximal MAP of 117 mmHg , or 150/100 mmHg. These were the highest mean MAP of any cohort in our study. Two of the 7 pregnancies were classified as PE. Both were early onset and severe and both had intrauterine growth restriction. The other 5 were classified as GHTN.Five women with HDP (17%) developed sudden and confluent macular thinning concomitant with a significant drop is systemic blood pressure most often due to peripartum hemorrhage. Antecedent loss of thinning was present in 4 of the 5 cases. Two had de novo HDP; the other 3 had HDP superimposed on cHTN. Two of these participants are presented in Fig. Our data supports earlier observations that the neurosensory retina thins in normal human pregnancy . In contCardiac output increases 1.5-fold between 16 and 20 weeks gestation; circulating blood volume increases 1.3 to 1.4-fold by late pregnancy . These aIf this paradigm is correct, other observations relating to this response should fall into place. Specifically, loss of macular thinning could represent hyperperfusion injury due to breach of the upper threshold of autoregulation with edema formation as has been reported by others in the eye , 28, andIt must be emphasized 7 of 15 women with HDP superimposed on chronic hypertension did not develop retinal edema despite possessing some of the highest systemic blood pressures in our study. Clearly, other factors contribute to blood pressure elevations. These could include an expanded circulating blood volume; kidney disease was 3–4 times more prevalent in this cohort compared to HDP with evident capillary leak. Also, 3 of 4 women with very poorly controlled hypertension at inception might possess a right-shifted end-tissue response. These factors explain why systemic blood pressures rise in women with complex pre-existing hypertension.Ours is the only study to prospectively follow non-hypertensive and treated hypertensive participants through a hypertensive crisis. Its focus and strengths rest on the notion that a measure of microvascular response in a relevant end-tissue such as the eye may bring greater understanding of the mechanism(s) and timing of vascular injury in severe hypertension. New findings are that vasogenic edema of the eye is more common in both PE and GHTN (74%) than previously reported –6. SeconThere are other conditions that affect the microcirculation of the eye that can be associated with pregnancy. These include central serous chorioretinopathy, retinal occlusive disorders such as branch retinal artery and vein thrombosis and choroidal neovascularization . CentralThe weaknesses of our study are the small sample sizes and the diversity of participants in both hypertensive and non-hypertensive cohorts. Issues surrounding sample size were substantially offset by our repeated measures approach; regression analyses independently confirm the findings of the stratified analyses. There were no major confounding variables. However, given the heterogeneity of our control and HDP cohorts, it is unlikely these would be reliably identified. The prospective observational cohort design is both a strength and a weakness. This is a “real life study” of high-risk hypertensive pregnancy. However, over-sampling did occur in patients with high care needs. Thus, further studies are needed to assure the validity these findings. Criticisms relating to diversity of the cohort are legitimate. However, the fact macular thinning is consistently observed in every healthy eye of every individual with or without major co-morbidities suggests the response is integral to continuing microvascular health. This is to be expected with autoregulation. There are also questions relating to the need and veracity of a non-pregnant baseline measurement. A non-pregnant baseline was needed to reveal the full extent and chronology of the macular response. However, loss of thinning, hypoperfusion injury and loss-of gain in autoregulation can all deduced by interval change on sequential images without the need for a baseline image. Finally, it might have helped to include other measures of CNS injury such as MRI of the brain to validate our findings. Given MRI has much lower spatial resolution than OCT and misses vasogenic cerebral edema in children with a “crowded cranium”, and in many established cases of preeclampsia and eclampsia , 35, it In summary, the neurosensory retina of the eye thins at <20 weeks gestation in human pregnancy. Macular thinning is a predictable downstream effect of vasoconstriction of the microcirculation of the central retinal artery of the eye due to high flow rates and circulating blood volume in pregnancy. Thinning is lost in mid to late pregnancy in many women who go on to develop HDP. This loss of thinning can occur at a normal systemic blood pressure suggesting breach of autoregulation is due to high flow rates and hyperperfusion injury. These observations help to explain the mechanisms of blood pressure elevation in pregnancy and hypertensive emergency. A brief section on what to take away from this study appears at the end of Supplementary Data.Final Supplemental Data - Clean


Thrombotic microangiopathy (TMA) can sometimes manifest only histologically. Our aim was to retrospectively compare biopsy-proven adult TMA patients showing only histological (h-TMA) or both histological and clinical (c-TMA) TMA in 2006–2017. All native kidney biopsies with TMA were included. Biopsies were re-evaluated by light and electron microscopy, and immunofluorescence. Clinical characteristics, laboratory variables, and treatments were recorded from the electronic medical database. Patients were categorized into h-TMA and c-TMA and these groups were compared. In total, 30 biopsy-proven cases among 7943 kidney biopsies were identified and, of these, 15 had h-TMA and 15 c-TMA. Mean follow-up was 6.3 y, and 73.3% had secondary hemolytic uremic syndrome (HUS) and the rest were atypical HUS. Patient characteristics, treatments, and kidney, and patient survival in the groups were similar. Statistically significant differences were found in histological variables. Vascular myxoid swelling and vascular onion-skinning were almost exclusively detected in c-TMA and, thus, vascular occlusive changes indicate clinically apparent rather than merely histological TMA. In addition, regardless of clinical presentation, kidney and patient survival times were similar in the patient groups highlighting the importance of a kidney biopsy in the case of any kidney-related symptoms. Thrombotic microangiopathy (TMA) is a pathologic description of microvascular occlusive disorder leading to characteristic histological lesions of thrombus formation, and vascular endothelial injury . ClinicaTMA can show a variety of different histological lesions, depending on the activity and timing of the disease. Active lesions include fragmented red blood cells, endothelial swelling, or occlusion of glomeruli or arterioles, mesangiolysis, or microaneurysms in glomeruli, whereas chronic lesions include double contours in glomerular basement membranes (GBM), and fibrous intimal thickening (“onion-skinning”) of arteries . As chroE. coli (EHEC) Shiga toxin mediated HUS (STEC-HUS), while ischemia was more common in the latter [Some reports have shown that TMA-associated glomerular and vascular changes are more frequent in certain TMA patient groups. Neto et al. observed that microthrombi were more frequent in aHUS than in enterohemorrhagic e latter . Yu et ae latter . Howevere latter ,13. TMA e latter . Histoloe latter .Clinically, TMA can present with heterogenous symptoms, such as acute kidney injury, neurological abnormalities, gastrointestinal symptoms, or purpura. Patients are often critically ill, but there are also patients who have a more benign, or even asymptomatic presentation . TMA canTraditionally, TMA has been classified into thrombotic thrombocytopenic purpura (TTP), based on severe ADAMTS13 deficiency, typical hemolytic-uremic syndrome (HUS) based on a Shiga toxin-producing pathogen, secondary HUS (sHUS), which is caused by multiple factors, including medications, infections, malignancies, organ transplantations, connective tissue diseases, and, nowadays, COVID-19, etc., and into aHUS for complement dysregulation-mediated HUS ,15. MostThe aim of this study was to gain deeper understanding on the histological spectrum of native kidney TMA and the characteristics of these patients, regardless of their clinical presentation. The goal was also to analyze features of clinical presentation as opposed to a mere histological diagnosis, effects of a given treatment and to find possible associations between histology and prognosis.This was a retrospective, single-center study of Helsinki University Hospital, a district of Finland covering about 1.7 million inhabitants . All adult patients over 18 y of age with native kidney biopsy proven TMA or similar histological changes between the years 2006–2017 were included. All patients were divided into clinical TMA (c-TMA), or histologic TMA (h-TMA) groups based on whether they had also clinically evident TMA disease or not. C-TMA had typical TMA findings in peripheral blood, whereas h-TMA had no anemia, thrombocytopenia, red blood cell fragments, or abnormal hemolytic tests at the time of biopsy-proven diagnosis. We also categorized the patients based on the clinical presentation to TTP, aHUS, sHUS and typical STEC-HUS.Identification of the patients was carried out from the database of the Department of Pathology yielding a total of 7.943 kidney biopsies during 2006–2017. Search criteria were TMA, thrombus, and malignant hypertension, with all their synonyms and abbreviations from the pathologic-anatomic diagnosis and the report. MPGN, its pattern of injury, and C3G were also re-evaluated to detect any misdiagnosed cases. Exclusion criteria were insufficient biopsy material for re-evaluation and primary MPGN diagnosis or pattern of injury resulting from another underlying disease, such as IgA nephropathy or systemic lupus erythematosus. The eligibility and clinical diagnosis of problematic cases was judged independently by two nephrologists having expertise in TMA. Study was reviewed by the hospital’s Ethical Committee (HUS/2520/2018) and research permit (HUS/459/2018) was granted. The study was conducted according to the Declaration of Helsinki.Electronic medical records were reviewed for family history, age, and sex distribution, possible triggering factors, clinical information including laboratory values and therapies employed at the onset of the disease and during follow-up. The follow-up time started from the time of diagnostic biopsy (2006–2017) until the patient’s death or until the end of year 2019.9/L at diagnosis, the patient was considered to have TTP. Typical HUS was identified with stool samples positive for Shiga toxin-producing bacteria. If stool samples were not available, typical HUS was excluded based on clinical grounds. For the remaining patients, we determined whether there existed any known cause for sHUS, such as drugs associated with TMA, transplantation, other infections (non-Shiga toxin-producing pathogens), autoimmune diseases, malignancies, cobalamin C deficiency, myeloproliferative diseases, or malignant hypertension [ADAMTS13-activity test was used to identify patients with TTP. If ADAMTS13 was not assessed, creatinine levels and platelet count were utilized to determine the probability of severe ADAMTS13 deficiency, as Coppo et al. established in 2010 . If serurtension . If a coProgressive disease was defined as the need of kidney-replacement therapy during the follow-up. Classic triad was defined as microangiopathic hemolytic anemia, thrombocytopenia, and kidney manifestation. Increased serum creatinine concentration and decreased estimated glomerular filtration rate (eGFR), or hematuria and/or proteinuria were observed as a sign of kidney manifestation.Primary outcomes were to compare clinical, laboratory, and histological characteristics between c-TMA and h-TMA. Secondary outcomes were to compare kidney, and overall prognosis as well as to compare prescribed treatments between c-TMA and h-TMA.2. Complement analyses were performed using the Wieslab complement system screen method  and nephelometrically measuring serum levels of complement C3 and C4, . C3 nephritic factor (C3Nef) was analyzed by in-house immunofixation electrophoresis, in which the ability of the patient’s serum to activate the alternative pathway of complement in normal serum in the presence of magnesium ethylene glycol tetra-acetic acid (MgEGTA) was examined.Laboratory variables were analyzed at the accredited Helsinki University Hospital laboratory (HUSLAB) using standard chemical methods. Kidney function was measured and estimated using serum creatinine, for which upper normal values were 100 μmol/L in males and 90 μmol/L in females, and eGFR calculated according to the Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI), for which cut-off for lower normal value was 60 mL/min/1.73 mGenetic analyses were performed utilizing aHUS mutation panel , complement factor B, complement factor H, complement factor H related protein 5, complement factor I, diacylglycerol kinase epsilon (DGKE), and thrombomodulin) at Blueprint Genetics laboratory, Helsinki, Finland.2SO4, and a spectrophotometer was used to measure the optical density of samples at 492 nm wavelength.Factor H-antibodies were quantified using an ELISA assay with the Helsinki protocol . Human sFactor H and the factor H-related proteins were analyzed by immunoblotting having normal human serum as a control. Into a 4–12% SDS-PAGE gel, appropriately diluted samples were added at 1:100 and 1:300 dilutions. The samples were then run for 45 min at 165 V in 1× MES buffer, whereafter they were transferred onto a filter membrane. Non-specific binding sites were blocked for 1 h at room temperature with 1 mL of 5% non-fat dry milk prepared in 1× PBS and 0.05% Tween 20. Later, primary goat anti-factor H antibody was added into the solution and incubated overnight at 4 °C. The membranes were then washed at room temperature for 1 h with 15–20 min changing interval of 2–3 mL 1× PBS and 0.05% Tween 20. Secondary rabbit-anti-goat HRP-conjugated antibody was added with 5% non-fat dry milk and incubated at room temperature for 1 h. The washing with PBS changing intervals was then repeated at room temperature for 1 h. The bands were then visualized with an in-house protocol for electrochemiluminescence recipe for 1 min at room temperature. Films were then developed at different exposure times.Kidney biopsy was re-evaluated by a nephropathologist (AR-S) together with, at that time, the pathology resident in training (MK). The final histological diagnosis was defined by the nephropathologist blinded to the clinical diagnosis.The light microscopy (LM) sections were fixed with formaldehyde, after which 2 µm paraffin sections were stained with Periodic-Acid-Schiff, hematoxylin-eosin, Jones silver stains, Congo red stain, and, depending on the availability of the stain, Masson’s trichrome stain. LM findings were classified according to the Definition of Glomerular Lesion by Renal Pathology Society  and 2018Immunofluorescence (IF) staining results were obtained from the previously written pathology reports and photographs. If there were any discrepancies, the staining was reperformed on frozen sections (F-IF), which were stained with goat-anti-human IgG, IgA, IgM, C3, C1q, and kappa antibodies and burro-anti-human for lambda antibody . The findings were graded 0–4, according to the intensity of positive staining, where 0 was negative, 1 trace, 2 mild, 3 moderate, and 4 strong. Paraffin-section IF (P-IF) after proteinase K retrieval of antigen  was perfElectron microscopy (EM) findings were obtained from the original pathology reports and photographs and were re-evaluated according to previously mentioned criteria of consensus report . If EM wStatistical analysis was completed by a professional statistician using R software version 4.0.4 . T-test was used for assessing the differences in means, test of proportions (Fischer’s exact test) for assessing the differences between proportions, and Mann–Whitney U test for assessing the differences in medians. As the sample size or the number of values of interest was in many cases low, Fischer’s exact test was chosen instead of z-test, which is based on the normal approximation. In addition, the estimation of factors influencing the changes in binary dependent variables was carried out using binary logistic regression. The significance level of the statistical tests mentioned above was set to 0.05.The study flow of the research is depicted in Clinical characteristics at the time of diagnostic kidney biopsy are summarized in Predisposing and causative factors and differential diagnostics of aHUS and sHUS are shown in p = 0.01). Lactate dehydrogenase (LDH) and erythrocyte-schistocyte levels were significantly higher in c-TMA than in h-TMA .Variables indicative of hemolysis are shown in Complement variables along with paraprotein findings are summarized in Paraproteins were analyzed for seven patients, and in 5/7 (71.4%)  a paraprotein either in urine or in serum was observed. It was observed in blood plasma in three patients, and in two patients the paraprotein was found both in blood, and urine. Serum IgG-kappa and IgG-lambda were the most common paraprotein types. Both were observed in two patients each. The fifth patient had both IgG-kappa and IgM-kappa in the plasma sample. Hematological disease was classified as MGUS/monoclonal gammopathy of renal significance (MGRS) in 4 of the 5 patients. An overt malignancy occurred in the fifth patient.In p = 0.005). Onion-skinning was seen in 6/15 (40%) c-TMA patients, but not in any h-TMA patients (p = 0.017). Vascular intramural fibrin and vascular thrombus formation were more common in the c-TMA group than in the h-TMA group, but the differences were not statistically significant. The degree of arterial sclerosis was similar in both groups.Histological findings are summarized in F-IF or PIF was available for all biopsies to verify the diagnosis. Traces (1+) or weak (2+) positivity of immunoglobulins, C3 and/or C1q were noted in few patients. No biopsy showed moderate or strong (3+–4+) IF staining.By EM, loss of endothelial fenestration was more often found in c-TMA cases. In addition to the observed features of TMA, thin basement membrane disease was observed in two (20%) h-TMA patients and two (15.4%) c-TMA patients .In addition, the timeframe in which the patient was biopsied in comparison to the onset of clinical symptoms (c-TMA), or from kidney-related symptoms (h-TMA) was analyzed between groups, which did not show statistically significant differences between the patient groups.p = 0.017). Acute dialysis was needed for 6 (40%) of c-TMA patients and for 1 (6.7%) h-TMA patient (p = 0.08), immunosuppressive medication for 8 (53.3%) and 3 (20%) patients, respectively. Blood pressure medication alone was used for one (6.7%) patient both in c-TMA and h-TMA groups.Plasma exchange at the time of histological diagnosis was used for 6 (40%) c-TMA patients, but none of h-TMA patients (p = n.s.), but this might be explained by the fact that of the five patients who died during the follow-up, four were h-TMA (two had cancer-related TMA and two hypertension-related TMA), and only one c-TMA (cancer treatment- related TMA) (The mean follow-up time from a kidney biopsy was not significantly different between the groups being 6.9 y for h-TMA and 5.6 y for c-TMA . There wted TMA) .In univariate analysis of the whole patient group, severe doubled GBM, glomerular thrombi, mesangiolysis, arterial myxoid intimal swelling, arterial onion-skinning, and degree of podocyte foot process effacement were statistically significant determinants of progressive kidney disease. However, in multivariate analysis none of these factors were significant , whereas in only h-TMA the vascular changes are rare. The occlusive changes cause acute ischemic injury to the glomeruli. Thus, kidney function deteriorates causing clinical symptoms and signs of c-TMA. Predisposing factors of aHUS were only observed in c-TMA, but not in h-TMA group. This might merely reflect the fact that since the precise origin of TMA was difficult to know for certain in h-TMA patients, the potential predisposing or triggering factors were infeasible to reveal, too. Interestingly, our study showed that c-TMA and h-TMA have surprisingly similar kidney and patient survival. This indicates that also h-TMA is a serious pathological condition leading to an abnormal kidney function, despite lacking clinical symptoms of TMA.Most TMA patients in the clinical routine practice do not undergo a kidney biopsy, but rather the diagnosis is based on the clinical laboratory variables. TTP patients usually have no or only minimal kidney disease abnormalities. Therefore, they are virtually never biopsied. All HUS patients, on the contrary, have various degrees of kidney abnormalities either in kidney function and/or urine tests. However, most of HUS patients are anyhow treated without histological confirmation. Diagnosis of TMA does not require histological confirmation. Clinically the patient is often critically ill and, therefore, undergo kidney biopsy only rarely. These reasons most likely explain the low number of biopsy-proven TMA cases (0.4%) in our extensive material of more than 7000 kidney biopsies. A nationwide cross-sectional analysis from Japanese kidney biopsy registry showed that 0.39% had a diagnosis of TMA of various causes . Also, aBased on the literature it is unclear, if biopsy-proven TMA showing only histological features shares the same underlying etiology, prognosis, and clinical course than TMA with also clinical features. Most reports have compared different TMA subtypes  ,24 or reIt is not known what the optimal treatment for h-TMA patients is, and whether the treatment should be adjusted according to the clinical presentation of the disease. Should aHUS presenting as h-TMA be treated differently than aHUS presenting as c-TMA? The same dilemma applies to sHUS, as well, although sHUS is more heterogenous in terms of etiology. In our study, none of the h-TMA patients received anti-complement medication, or plasma exchange therapy compared to 66.7%, and 40% of the c-TMA patients, respectively. Similarly, only 20% of the h-TMA patients received any form of immunosuppressive therapy compared to 53% in the c-TMA group.TMA histology comprises several different characteristics and the changes seen by LM and EM can be thought to result from continuum of time and the stage as well as the severity of the disease. In the very early phases of the disease the changes may be evident only as subendothelial widening evident only in EM proceeding later to changes visible in LM. As the overall biopsy morphology was divided into acute, subacute, and chronic changes, our study showed that in the whole study population the incidence of chronic changes increased substantially after 12 w from the onset of disease. There were no statistical differences as we compared these between the patient groups.In our study vascular occlusive changes were almost exclusively linked to c-TMA as myxoid swelling was observed in 60% and onion-skinning in 40% of the c-TMA patients. Vascular intramural fibrin and thrombus formation were also more common in c-TMA group, although not statistically significantly. This might be explained by occlusive vascular changes causing ischemic glomerular injury and, thus, more severe functional kidney impairment at the onset of the disease. Furthermore, it can be speculated that smoldering endothelial injury causes remodeling of GBM leading to a milder clinical presentation and subclinical TMA. A Chinese study observed that acute changes were more common in aHUS than in conditions with malignant hypertension or pregnancy-related HUS, whereas chronic and arterial changes were more common in malignant hypertension . HoweverTMA has a provisional status among various MGRS diagnoses, but the mechanisms of monoclonal gammopathy-associated TMA are not fully understood . In a seConsidering the ultrarare nature of all TMA diagnoses and the fact that only a minority will ever be biopsied during their illness, our study represents a relatively large one center analysis of TMA patients. However, our study has a few limitations as well, as it was a single-center study, generalizability to a broader population is limited. Moreover, it covers only sHUS and aHUS and, therefore, it cannot be applied to all TMA patients. C-TMA patients with a kidney biopsy during the acute phase of the disease are highly selected and may not fully represent the histological map of c-TMA patients. The limited number of TMA patients affects the size of the study population and, thus, the validity of multivariate logistic regression carried out is restricted. The retrospective nature of our study may also hinder firm conclusions and generalizability, and not all patients had all variables of interests analyzed.In conclusion, our study indicates that there is a large number of cases with smoldering endothelial injury causing renal TMA that has similar patient and kidney survival despite the clinical presentation. The comparison between h-TMA and c-TMA implies that more attention should be paid on h-TMA patients despite the etiology of their TMA. These patients might benefit on more aggressive treatments than currently used. However, further studies focusing on various aspects on h-TMA are needed.


Background: Adenosine deaminase (ADA) is a key enzyme that catalyzes the deamination of adenosine into inosine, which eventually decomposes into uric acid (UA). A body of papers have reported that adenosine and UA are closely related to cerebrovascular events. However, the association between serum ADA activity and acute cerebral infarction (ACI) remains unclear.Methods: 7913 subjects were enrolled, including 3968 ACI patients and 3945 controls, in this study. An automatic biochemistry analyzer was used to determine serum activity.p < 0.001). After Logistic regression analysis, ADA concentrations were negatively correlated with ACI . Smoking and alcohol consumption decreased serum ADA concentrations in patients with ACI, whereas diabetes and hypertension had the opposite effect.Results: Serum ADA activity was found that was significantly decreased in patients with ACI (10.10 ± 3.72 U/L) compared to those without ACI (11.07 ± 2.85 U/L, Conclusions: Serum ADA concentrations in patients with ACI are markedly decreased, suggesting that the decreased ADA concentrations may be involved in the pathogenesis of ACI. We hypothesized that decreased ADA activity may be an adaptive mechanism to maintain adenosine levels and protect against ischemic brain injury. Adenosine deaminase (ADA) is a 41 kDa monomer protein whose functions included not only catalyst activity, co-stimulatory, allosteric modifications, and cell-cell communication, but it also plays a vital role in purine metabolism . DeficieWith the development of medical technology, the survival expectancy of patients with ACI has greatly improved, but it is still a major threat to human health . AdenosiThe study enrolled a total of 7913 participants in the Affiliated Hospital of Qingdao University from December 2012 to June 2019, including 3968 subjects who met the diagnostic criteria for ACI and 3945 controls. Patients with a diagnosis of ACI were supported by magnetic resonance imaging (MRI) findings. The study excluded (1) individuals who underwent incomplete laboratory tests; (2) individuals with autoimmune diseases, such as systemic lupus erythematosus, liver disease, blood diseases, tuberculosis, and other serious illnesses; and (3) individuals with hemorrhagic stroke. The 3945 participants in the control group had no signs and symptoms of ACI, and MRI did not support the diagnosis. The written consent of all subjects or their legal representatives has been obtained. The study was approved by the Ethics Committee of the Affiliated Hospital of Qingdao University.A detailed medical history and risk factors for ACI were recorded for all participants. Height and weight were recorded in centimeters (cm) and kilograms (Kg) respectively. Body mass index (BMI) was calculated as weight (kg) divided by the square of height (m). Systolic and diastolic blood pressure were measured twice every 30 minutes with an automatic oscilloscope device, and the mean values of systolic and diastolic blood pressure were taken respectively. Hypertension was diagnosed when systolic blood pressure (≥140 mmHg) and/or diastolic blood pressure (≥90 mmHg), or using antihypertensive medications. Diabetes mellitus (DM) was diagnosed if hypoglycemic drugs were used or fasting blood glucose (FBG) level ≥7.0 mmol/L or glycosylated hemoglobin (HbA1c) concentration ≥6.5%.All subjects with ACI in the study underwent three-dimensional time-of-flight (3D TOF) magnetic resonance angiography (MRA) (3D- TOF MRA) with 3.0 T magnetic resonance scans. We defined intracranial vascular stenosis using the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) test criteria . IntracrBlood samples from all participants were taken after overnight fasting of at least 8 hours. Whole blood samples from participants were collected by vacuum tube in the absence of anticoagulant and centrifuged at 1500 × g for 15 min. Serum concentrations of alanine aminotransferase (ALT), total cholesterol (TC), low--density lipoprotein cholesterol (LDL-C), serum creatinine (SCr), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), fasting blood glucose (FBG), UA, and ADA was measured with an automatic biochemistry analyzer .2O2) under xanthine oxidase (XOD). Finally, H2O2 was also reacted with N-Ethyl-N- (2-hydroxy-3-sulfopropyl) -3-methylaniline and 4-aminoantipyrine in the presence of peroxidase to generate quinone dye that is monitored kinetically. Under standard assay conditions, the amount of enzyme required for adenosine to release 1 mmol of ammonia per minute was defined as 1 unit (1U) of ADA. ADA concentrations were tested at 37°C based on Giusti and Galanti . ADA actt-test, and Spearman’s correlation coefficients was used to assess interrelationships. To investigate the interaction of other variables between ADA concentrations and ACI, logistic regression was used in this study. A two-sided test was used for statistical analysis, and P < 0.05 were considered statistically significant.SPSS statistical software was used for statistical analysis . The mean ± standard deviation (SD) was used to describe continuous data, while frequency and percentage were used to describe categorical variables. For comparisons in categorical variables, we used the Chi-square test. The study variables were compared between the patient group and the control group using the unpaired student’s A total of 7913 participants were enrolled including 3968 patients with ACI (68.33 ± 11.08 years) and 3945 controls without ACI (60.79 ± 14.51years). Of the 3968 ACI patients, 536 patients had single-diseased blood vessels, 313 patients presented two-diseased blood vessels and 1290 had three-diseased blood vessels. The concentrations of TG, BMI, FBG, TC, LDL-C, and ALT in the ACI group were higher than those in the control group. Patients with ACI were significantly older than those in the control group. Furthermore, the rates of hypertension, DM, smoking, and alcohol consumption were higher in the patient group than in the control group. We observed no statistical difference in SCr between the control group and the patients. There was no significant difference in ADA activity between different ICAS groups classified by the number of stenotic arteries . The infP < 0.001), FBG , TG , LDL-C , TC  and ALT  levels in patients with ACI. Furthermore, we observed a negative relationship in UA , and HDL-C  with serum ADA. These results are shown in We found that serum ADA activity was positively correlated with age  (p < 0.001)  . After a< 0.001) .The present study was the first to identify an independent correlation between the attenuated concentrations of serum ADA activity and the occurrence of ACI. However, ADA activity across ICAS groups defined by the number of stenotic arteries did not show significant differences.Our results showed that serum ADA concentrations were positively correlated with TG, LDL-C, and TC levels in the ACI group. Atherosclerosis is the most common risk factor for ACI. It has been reported that purinergic signal transduction is to participate in the regulatory process of vascular inflammation and atherosclerosis and plays a key role . IncreasHDL-C has long been considered good cholesterol and epidemiological studies have shown that its plasma level is negatively correlated with cardiovascular and cerebrovascular risk . We alsoIn this work, DM was also observed to significantly increase ADA activity in stroke patients. A study showed that ADA concentrations of subjects with DM were significantly elevated than that in healthy controls and ADA concentrations of DM subjects were positively correlated with FBG levels . PreviouIn this study, we also observed a significant effect of smoking on serum ADA activity in patients with ACI. The main components of cigarettes are nicotine, tar, carbon monoxide (CO), and other substances . NicotinIn a previous study, several metabolites were found to be risk factors for ACI such as homocysteine (Hcy), asymmetric dimethylarginine (ADMA), and UA –31. HoweThe underlying mechanism of attenuated ADA activity in patients with ACI is unclear, but we believe that a complex metabolic process is involved. ADA is a key enzyme that is related to cellular metabolism and its activity, biosynthesis, and catabolism and is regulated by the neurohormone axis. When ACI occurs, adenosine activity increases rapidly, acting on endothelial cells and causing vasodilation and neuroprotection effects. Under these conditions, to maintain higher adenosine activity to protect the cerebrovascular system. ADA activity undergoes negative feedback regulation and reduces adenosine decomposition. However, this study is preliminary, and the specific mechanisms involved need to be further studied.This study has several limitations. First, we used 3D MRA to assess intracranial arterial stenosis, but MRA is not the gold standard for assessing intracranial stenosis. Second, in this study, not all control participants underwent exhaustive MRA. Third, the ADA activity exam was a one-time exam, which may not effectively represent the fluctuation of mediator levels. Fourth, in this study, only the differences in total ADA were observed, and the differences in its isoenzymes ADA1 and ADA2 between the study group and the control group were not further evaluated. Elevated serum isoenzyme ADA2 is commonly found in viral diseases, such as immunodeficiency virus infections. Studies have detected elevated levels of tADA and its isoenzymes ADA1 and ADA2 in saliva in patients diagnosed and convalescent with the new coronavirus disease 2019 (COVID-19). Finally, our study did not evaluate interactions with oral medications that may have affected ADA levels.Our study provides proof that ADA concentrations are decreased in patients with ACI. We also show that ADA is influenced by hypertension, diabetes, and lifestyle. The results suggest that the decreased ADA activity may be involved in the pathogenesis of ACI. The exact physiopathological mechanism of ADA in ACI needs further study in the further.


Chronic kidney disease (CKD) is a condition that can be caused due to any etiology leading to structural damage to the kidney, which can be measured by a decrease in estimated glomerular filtration rate (eGFR) and the presence of damage biomarkers for more than three months. This article has discussed the causal relationship between atrial fibrillation (AF) and CKD, a few of them being inflammation, renin-angiotensin-aldosterone system (RAAS) activation, anemia, and uremia associated with CKD. This review mentioned the clinical impact of the presence of AF in CKD patients. The presence of AF in CKD patients aggravates the renal dysfunction, which in turn adds to the generation of AF. This article explores the various pharmacological and interventional treatment modalities, including antiarrhythmics, anticoagulants, and cardiac ablation, and their complications, leading to restricted usage in CKD patients. The commonly used markers of kidney damage are urine albumin and serum creatinine [Chronic kidney disease (CKD) is a declined state of kidney function where the estimated glomerular filtration rate (eGFR) is <60 mL/min/1.73 mRichard Bright, an English physician, was the first to publish his findings on kidney diseases in 1827. He was the first to correlate abnormal renal anatomy and urine findings  to clinical signs. Kidney disease was called Bright's disease for almost a century and is still familiar to this day . The worThe leading risk factors for CKD in many countries, both developed and developing, are diabetes and hypertension. In contrast, conditions like glomerulonephritis and some unknown causes are more common in Sub-Saharan Africa and Asian countries . PatientPathogenesis of AF in CKDInflammationThe occurrence of AF in patients with CKD is multifaceted, one of the causative factors is inflammation which is linked with CKD Figure . CKD patInflammasomes are high-molecular-weight, multiprotein complexes present in the cytoplasm of immune cells and can also be found in non-immune cells like renal tubular cells as well as podocytes -19. TheyIn kidney injury of any underlying etiology, there is cell damage which leads to the release of several DAMPs like high-mobility group box 1, heat shock protein 70, biglycan, and hyaluronan synthase 1, which bind to NOD-like receptor P3 (NLRP3) a subtype of NLRs leading to activation of NLRP3 which in turn activates the inflammasome. The NLRP3 inflammasome can also be activated as a result of mitochondrial and endothelial dysfunction in CKD patients with uremia undergoing dialysis . In CKD,According to the ion flux model, NLRP3 can be activated by potassium, calcium, and proton flux . The lysChronic systemic inflammation can cause fibrosis, hypertrophy, and cellular apoptosis in the atria. Cardiac fibroblasts, which cause fibrosis, are activated by cytokines and growth factors which in turn are associated with systemic inflammation . FibroblRenin-Angiotensin-Aldosterone System, Neurohormonal, and Other PathwaysSodium and water balance in the human body are maintained by the renin-angiotensin-aldosterone system (RAAS), sympathetic nervous system (SNS), natriuretic peptides (NP), and antidiuretic hormone (ADH), which is also known as arginine vasopressin (AVP) . Increas2, respectively, and the prevalence of AF was 10.4%, 10.5%, 14.8%, and 16.8%, respectively. This concluded that the prevalence of AF is more in patients with increasing left atrial volume due to left ventricular structural changes [Anemia is a known complication in CKD patients due to decreased erythropoietin (EPO). Anemia can cause an increase in circulating volume by decreasing afterload and increasing preload as a result of a decrease in oxygen supply to the tissues ,42. The  changes . The ris changes ,47,48. C changes ,49. Calc changes .In CKD patients, the pulmonary vein (PV) cardiomyocytes are calcium overloaded. This leads to faster PV beating rates and may cause ryanodine receptor (RyR) dysfunction prolonging the sarcoplasmic reticulum (SR) calcium release predisposing to AF . AF can Clinical impact of AF on CKD2 which were 1.32 (1.08-1.62) and 1.57 (0.89-2.77), respectively. On further follow-up, 7791 of them developed renal dysfunction, and 11307 developed proteinuria. The HR (95% CI) for the development of renal dysfunction in AF was 1.77 (1.50-2.10), and that of proteinuria in AF was 2.20 (1.92-2.52). At the completion of the study, they concluded that kidney dysfunction augmented the risk of new-onset AF, and the AF increased the risk of development of kidney disease , a score of three or more in females and two or more in males warrants oral anticoagulative therapy. Furthermore, a decline in renal function increases the risk of stroke in AF patients [2 out of which 6639 had AF and 55820 did not have AF, during a median follow-up of 4.1 years a total of 19094 patients died and the cause of death of 18854 was known. AF had a 23% (95% CI 18-29%) higher risk of all-cause mortality, 45% (95% CI 31-61%) higher risk of cardiovascular mortality, and 13% (95% CI 3-22%) lower risk of malignancy-related mortality after multivariable adjustment. The study concluded that the presence of AF in the non-dialysis-dependent CKD population was associated with higher all-cause and cardiovascular mortality , class IC , and class III  antiarrhythmic drugs in the general population . The lipCardioversion and Cardiac Ablation2, II 60-90 mL/min/1.73 m2, III 30-59 mL/min/1.73 m2, and IV <30 mL/min/1.73 m2). The recurrence rate of AF was significantly higher in patients with severely or moderately decreased renal function. The study concluded that there is an increased risk of AF recurrence after successful electric cardioversion in patients with impaired renal function [Cardioversion: Direct current cardioversion as a treatment choice is recommended in case of AF with a rapid ventricular response that doesn't respond to drug therapy and worsens the already present cardiovascular problems like hypotension and HF. It is also done in the case of patients with AF having hemodynamic instability . Withoutfunction .2 were excluded from the study. After a median of 115 post-ablation, eGFR significantly increased in CKD stage two , three A , three B , and decreased in CKD stage one . The study concluded that there was a significant improvement in renal function in patients with CKD after a successful ablation [Cardiac ablation: Catheter ablation is done in the case of symptomatic paroxysmal AF refractory or intolerant to at least one class I or III antiarrhythmic medication when a rhythm control strategy is thought to be effective . Cardiacablation .Prevention of Stroke and Risk of Thromboembolism2DS2VASc score. A score of >3 in males and >2 in females warrants initiation of Warfarin which is a vitamin K antagonist (VKA) or direct oral anticoagulants (DOACs) like dabigatran, apixaban, and rivaroxaban [Anticoagulants: There is an increased risk of thromboembolism in CKD patients with AF as a result of disorganized atrial contraction; paradoxically, there is an increased risk of bleeding as well in CKD patients compared to the general population . The prearoxaban . Hypertearoxaban .2 and >90 mL/min/1.73 m2 were 63.4 (95% CI 24.9-161.6) and 6.1 (95% CI 1.9-19.4), respectively. The increase in major bleeding rates was mainly due to gastrointestinal (GI) bleeding, which was 3.5-fold greater in eGFR with <15 mL/min/1.73 m2 compared to eGFR >90 mL/min/1.73 m2. The study concluded that reduced kidney function was associated with an increased risk of major bleeding in adults with AF on warfarin, and the risk was greater in the first 30 days of starting warfarin [There is data that says the use of anticoagulants in patients with AF and CKD decreases the incidence of thromboembolic events without increasing the bleeding risk . Hart etwarfarin . Warfariwarfarin . Patientwarfarin .DAOCs: DOACs are newer anticoagulants mainly composed of two classes, direct thrombin inhibitors  and direct Xa inhibitors . They are safe compared to VKAs because they have few drug interactions and rapid onset/offset, and they do not require monitoring of coagulation . A studyAntiplatelets: The use of aspirin for stroke prevention in AF is quite common, but the recent guidelines suggest not to use aspirin for stroke prevention because of its inferiority to warfarin in the general population . VazquezPractical aspects during treatment initiation to be consideredBefore starting these medicines, patients must undergo a baseline renal function test. Monitoring has to be done annually or more frequently in high-risk patients because the renal function can deteriorate while on treatment. The renal function must be re-assessed in case of acute illnesses  because they transiently affect the kidney's function and proper care must be taken in prescribing other drugs which may affect the kidney .To prevent patients with severe renal failure from over-anticoagulating, a start-low, go-slow strategy for warfarin dose is advocated. This is due to the fact that compared to the management of normal kidney function patients, individuals with severe renal failure need a much lower daily dosage of warfarin to achieve therapeutic INR. Which is most likely connected to the decreased cytochrome P450 activity in CKD. As a result, the INR has to be monitored frequently in patients on warfarin therapy .The dosing of DOACs drugs is also determined by renal function. For instance, in patients with a creatinine clearance (CrCl) of <15 mL/min rivaroxaban is contraindicated, and in those with a CrCl of 15-49 mL/min, it is reduced from 20 mg to 15 mg daily. Apixaban is to be given twice daily with a dose of 2.5 mg in patients with CrCl 15-29 mL/min .LimitationsThe drawbacks of this study are that we used only PubMed as our database. As CKD leads to AF through multiple mechanisms, not all of them were briefly discussed and covered. The role of anticoagulants in the prevention of thromboembolic events in ESRD patients was not highlighted due to the lack of enough studies.On and after covering studies in this article, AF is a common arrhythmia in CKD patients which can manifest as a consequence of many conditions, a few of them being inflammation, anemia, imbalance in electrolytes, RAAS, neurohormonal system activation, and uremia. Keeping the above-mentioned facts in mind, we attempted to emphasize AF in patients with CKD in this review article to address the clinical impact of AF in CKD patients and its management. Due to the bidirectional relationship between AF and CKD, proper management can help prevent the deterioration of the existing CKD, avoid events like stroke, and ultimately reduce mortality. Medical practitioners should try to avoid drugs like  that are commonly used to treat AF in the general population, as patients with CKD have reduced renal function and cannot eliminate them, causing unwanted complications. We believe that this article will serve as a foundation and invoke interest in researchers to dig deep into this issue. We recommend researchers perform and publish more studies on this topic, especially in the ESRD population in the future.


Methods: We performed a cross-sectional study of 50 kidney transplanted patients  estimated by Chronic Kidney Disease Epidemiology Collaboration formula: 52.19 ± 22.6 mL/min/1.73 m2; and a mean duration after transplant of 10.09 ± 5 years). For every patient, we obtained five valid measurements of renal stiffness , and also tissue viscosity, with a C6-1X convex transducer using the Ultra-Fast™ software available on the Aixplorer Mach 30 ultrasound system . The median values of elastographic and viscosity measures have been correlated with the patients’ demographic, biological, and clinical parameters. Results: We obtained a cut-off value of renal cortical stiffness of <27.3 kiloPascal(kPa) for detection of eGFR < 60 mL/min/1.73 m2 with 80% sensitivity and 85% specificity , a cut-off value of <26.9 kPa for detection of eGFR < 45 mL/min/1.73 m2 with 82.6% sensitivity and 74% specificity , and a cut-off value of <23 kPa for detection of eGFR < 30 mL/min/1.73 m2 with 88.8% sensitivity and 75.6% specificity . We found a positive correlation coefficient between eGFR and the median measure of renal cortical stiffness , between eGFR the median measure of viscosity , between median depth of measures and renal cortical stiffness , and between median depth of measures and body mass index (BMI) . Our study showed good intra-operator agreement for both 2D SWE PLUS measures—with an intraclass correlation coefficient (ICC) of 0.9548 and a 95% CI of 0.9315 to 0.9719—and Vi PLUS, with an ICC of 0.8323 and a 95% CI of 0.7457 to 0.8959. The multivariate regression model showed that 2D SWE PLUS values were associated with eGFR, Vi PLUS, and depth of measures. Conclusions: Assessment of renal allograft stiffness and viscosity may prove to be an effective method for identifying patients with chronic allograft injury and could prove to be a low-cost approach to provide additional diagnostic information of kidney transplanted patients.Elastography is a useful noninvasive tool for the assessment of renal transplant recipients. 2D-shear wave elastography (SWE) PLUS and viscosity plane-wave ultrasound (Vi PLUS) have emerged as novel techniques that promise to offer improved renal stiffness and viscosity measures due to improved processing algorithms.  The most prevalent cause of renal graft failure following transplantation is chronic allograft injury . The cliIt is critical to detect an early decline in the eGFR and properly track the disease’s course using a variety of markers . Traditional ultrasound is used to assess the kidneys; however, this technology only provides us with a few pieces of quantitative information about the renal size and parenchyma thickness, which both decrease as chronic kidney disease (CKD) progresses . A non-iUltrasound-based elastography approaches have become well-accepted non-invasive evaluation tools in the differential diagnosis of benign and malignant superficial organs such as breast and thyroid,  and for Transient elastography (TE)  was the first and most widely used technology for assessing renal allograft nephropathy. ,7,8,9, fBy detecting the velocity of shear waves produced by a focused ultrasonic beam, 2D SWE PLUS enables a real-time qualitative and quantitative tissue elasticity evaluation. The initial 2D SWE method was developed by Supersonic Imagine (SSI), and multiple research and meta-analyses, confirmed its utility in assessing fibrosis ,14,15,16This study aimed to evaluate the feasibility and the performance of this new ultrasound-based technique (ShearWave Elastography and Viscosity Plane-wave UltraSound) embedded in the new Aixplorer Mach 30 system , for the non-invasive assessment of renal allograft fibrosis and viscosity.A monocentric cross-sectional study was performed during a 3-month interval (March 2022 to May 2022) in a tertiary department of nephrology. Ultrasound-based measurements were performed in all patients, in the same session, using ShearWave Elastography (2D SWE PLUS) and Viscosity Plane-wave Ultrasound (Vi PLUS) from Aixplorer .The study was approved by the Research Ethics Committee and the Institutional Review Board of our University (number 41/04.03.2022) and was performed following the World Medical Association Declaration of Helsinki, revised in 2000, Edinburgh. All the patients provided written informed consent before study entry.2, and a mean duration after transplant of 10.09 ± 5 years) were enrolled after obtaining informed consent.Fifty kidney transplanted patients , immunosuppressive treatment, and history of hypertension, diabetes, or previous glomerular disorders.For every patient, blood specimens were obtained, and the following assessments were performed: complete blood count, urea, serum creatinine, sodium, potassium, calcium, phosphorus, parathyroid hormone, uric acid, ESR, C reactive protein, cholesterol, triglycerides, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin. The patients were instructed to collect urine specimens for proteinuria/24 h and urine culture.3), and cs is shear wave velocity (in m/s) [2D SWE PLUS measurements were performed with a C6-1X convex transducer using the UltraFast™ software available on the Aixplorer Mach 30 ultrasound system . The Young’s modulus (YM) of the region of interest (ROI) was calculated with the apparatus’s software using the formula E = ρ × cs2, where E is tissue elasticity (in kPa), ρ is tissue density (in kg/m(in m/s) . A quant(in m/s) .Measurements were performed for the middle portion of the renal graft, in the subcapsular cortex, with the patient in dorsal decubitus immediately after emptying the bladder. For each measurement , the software of the apparatus provided the following information: the mean value of YM—the weighted arithmetic mean of all values in the ROI (displayed as Mean); the minimum value of the YM in the ROI (displayed as Min on the screen); the maximum value of YM in the ROI (displayed as Max on the screen); the standard deviation of the YM values in the ROI (displayed as SD); the sum of all Vi PLUS values in the ROI divided by the number of values (displayed as Vi PLUS Mean); the median values of Vi PLUS (displayed as Vi PLUS Med); the standard deviation of the Vi PLUS values in the ROI (displayed as Vi PLUS SD); the distance between the skin and the examined cortical region ; and the diameter of the ROI (displayed as Diam in mm) .For every patient, we obtained 5 valid measurements of renal stiffness , and also tissue viscosity blinded to the patients’ medical information. The median value of the five elastographic measurements was correlated with the demographic and clinical parameters of the patients.After selecting the best acoustic window by ultrasound examination and obtaining a suitable image, the shear-wave measurement box was positioned in the mid-portion of the renal parenchyma, under the renal capsule. Acquisitions were performed during neutral respiratory apnea. After the 2D SWE PLUS map was deemed appropriate, image acquisition was performed, and then, the Q-Box was positioned in an area of relative uniform elasticity, at a depth of 2–4 cm. The median value of five 2D SWE PLUS measures (from 5 different frames), expressed in kPa, was considered an indication of renal cortical stiffness.Five tissue viscosity measures are expressed in Pascal-seconds (Pa.s). The information on tissue shear wave dispersion  can be displayed using Vi.PLUS. The degree of the shift in shear wave speed across frequencies is qualitatively depicted in a color-coded graphic and numerically expressed in Pa.s throughout a range of values. Vi.PLUS was used in conjunction with the 2D-SWE mode acquisitions and took place at the same time and followed the same technique.p” value of <0.05 was considered to be statistically significant. Areas under receiver operating characteristic curves (AUC) were determined for 2D SWE PLUS to identify the optimal cut-off points that maximized the Youden index for staging CKD by eGFR. Positive predictive value , negative predictive value , and diagnostic accuracy  were calculated. Univariate and multivariate statistical analyses were also implied.MedCalc Version 19.4  and Microsoft Office Excel 2019 were used for the statistical analysis (Microsoft for Windows). For demographic, anthropometric, and laboratory findings, descriptive statistics were employed. The distribution of numerical variables was determined using the Kolmogorov–Smirnov test. Numerical variables having a normal distribution are represented by means and standard deviation, whereas non-normal distribution variables are represented by median values and range. Percentages and figures were used to represent qualitative variables. The Pearson or Spearman correlation coefficient was used to express correlations between variables. A “2. Twenty received their new kidney from a living related person and 30 from a deceased donor. The mean time elapsed after transplant was 10.5 years. Thirty-seven out of them had a history of hypertension, 8 of diabetes, and 19 of previous glomerular disorders. The arithmetic mean of the median of the five measures using 2D SWE PLUS was 25.95 kPa, and the arithmetic mean of the median of the five measures using Vi PLUS was 2.82 Pa.s. We found a positive correlation coefficient between eGFR and the median measure of renal cortical stiffness , between eGFR and the median measure of viscosity  (p = 0.0493), and between median depth of measures and BMI   , between 0.0001) .Our study showed good intra-operator agreement for 2D SWE PLUS measures with an ICC of 0.9548 and a 95% CI of 0.9315 to 0.9719, and for Vi PLUS, with an ICC of 0.8323 and a 95% CI of 0.7457 to 0.8959 .As the CKD stage advances, our results indicate a clear decline in mean 2D SWE PLUS measures. No statistically significant correlations were found between mean measures of cortical stiffness and height, weight, BMI, time from transplant, received from a living related or deceased donor, kidney length, hemoglobin, hematocrit, urea, uric acid, cholesterol, triglycerides, ALT, AST, total bilirubin, sodium, potassium, C reactive protein, age, hypertension, diabetes, previous glomerular disease, or if the kidney was attained from a living related or a deceased donor. 2 with 80% sensitivity and 85% specificity     , a cut-o 0.0001) , and a c 0.0001) .Univariate and multivariate statistical analyses were used to examine the relationships between the median 2D SWE PLUS measures and the following parameters: age, gender, height, weight, BMI, transplanted kidney length, time from transplant, deceased or living donor, immunosuppressive treatment, complete blood count, urea, creatinine, sodium, potassium, calcium, phosphorus, PTH, uric acid, urine culture, VSH, C reactive protein, cholesterol, triglycerides, proteinuria/24 h AST, ALT, total bilirubin, and history of hypertension, diabetes, or previous glomerular disorders.p = 0.007), eGFR (p < 0.001), median Vi PLUS (p < 0.001), and median depth (p < 0.001) were independently associated with 2D SWE PLUS measures.Univariate analysis showed that urea (p = 0.0001), median Vi PLUS (p = 0.0015), and median depth (p = 0.0018) were independently associated with 2D SWE PLUS measures (p < 0.0001).In multivariate regression analysis, only eGFR (p = 0.0180), sodium, potassium, calcium, phosphorus, PTH, uric acid, urine culture, VSH, C reactive protein, cholesterol, triglycerides, proteinuria/24 h AST, ALT, total bilirubin, and history of hypertension, diabetes, or previous glomerular disorders. The only correlation found in the univariate regression was between eGFR and Vi PLUS. No statistically significant multivariate regression model was found.Univariate and multivariate statistical analyses were used to examine the relationships between the Vi PLUS values and the following parameters: age, gender, height, weight, BMI, transplanted kidney length, time from transplant, deceased or living donor, immunosuppressive treatment, complete blood count, urea, creatinine, eGFR [We obtained a cut-off value of renal cortical stiffness of <27.3 kPa for detection of eGFR < 60 mL/min/1.73 m. (2018)  obtained. (2018)  obtainedOur study found no link between estimated stiffness measures and the presence of diabetes. Previous ones found significant differences in shear wave values in ARFI examinations between diabetes with microalbuminuria and diabetes with macroalbuminuria , or betwWhen analyzing the factors potentially influencing cortical stiffness estimation, no correlation between BMI and the median measures of 2D SWE PLUS was found. The influence of BMI on kPa estimates was also investigated in previous studies ,25,30,31Inflammation is a key factor in the progression of fibrosis . Vi PLUSOur study presents a positive correlation between eGFR and median Vi PLUS measures and between median measures of Vi PLUS and 2D SWE PLUS. Only a few studies have used non-invasive methods to assess tissue viscosity. Deffieux et al. (2015) were the first to use this imaging technique to evaluate liver viscosity . The finNon-invasive approaches such as 2D SWE PLUS and Vi PLUS will never be able to match the diagnostic strength of the gold standard, which is represented by renal allograft biopsy, and are unlikely to replace histology for determining fibrosis and loss of renal function after transplantation; but the most promising and appealing use would be the ability to track changes in allografted parenchymal structure over time. A progressive decrease in parenchymal stiffness over consecutive 2D SWE PLUS and Vi PLUS measures may help to define those individuals who may benefit most from a renal biopsy, even while serum creatinine levels are steady. Whether to perform a protocol biopsy can often be debated.Renal biopsy has been shown to be a useful method for diagnosing subclinical allograft failure, particularly in cases of chronic allograft fibrosis or calcineurin inhibitor toxicity . HoweverThere are a few limitations to our study that should be mentioned: the study’s small number of patients (the limited number of patients with G1T and G5T KDIGO stages), the lack of correlations between analyzed clinical data (may have resulted from the former), the magnitude of fibrosis proven by kidney biopsy, not taking into consideration renal perfusion problems, and the analysis of a limited number of factors that could influence cortical stiffness.Assessment of renal allograft stiffness and viscosity may prove to be an effective method for identifying patients with chronic allograft injury and could prove to be a low-cost approach to provide additional diagnostic information on kidney transplanted patients.


Aplastic anemia (AA) is an uncommon disease, characterized by pancytopenia and hypocellular bone marrow, but it is common in the blood system. The medication rules of traditional Chinese medicine (TCM) in the treatment of AA are not clear, for which it is worth exploring the medication rules by data mining methods.  This study used SPSS Modeler 18.0 and SPSS statistics to analyze the cases of AA from Zhejiang Provincial Hospital of Chinese Medicine (ZJHCM) from March 1, 2019, to March 1, 2022. Data mining methods, including frequency analysis, cluster analysis, and association rule learning, were performed in order to explore the medication rules for AA.  (1) A total of 859 prescriptions, which met the inclusion criteria, consisted of 255 herbs. In descending order of the frequency of herbal medicine, we have Danggui, Huangqi, Shudihuang, Fuling, Gancao, Shanyao, Shanzhuyu, Baizhu, Dangshen, and Xianhecao. (2) Frequency analysis of herb properties: the Four Qi of 255 kinds of TCMs are mainly warm and neutral medicines. The Five Flavors are mainly sweet medicines, followed by bitter medicines. The main meridians are the liver, spleen, and kidney. (3) Clustering of medications: TCMs with the top 20 frequencies are classified into 9 groups by cluster analysis. (4) Association rule analysis of high-frequency herbs: using the Apriori algorithm, the results showed that there were 3 herb pairs with support of over 0.3 and 12 herb pairs with confidence above 0.85.  The basic pathogenesis of AA (Sui Lao) is spleen and kidney essence deficiency, Qi deficiency, and blood stasis. The main herbs have warm and neutral properties, sweet tastes, and liver, spleen, and kidney meridian tropisms, whose purpose is to tonify the kidney and invigorate the spleen, tonify Qi, and promote blood circulation. Aplastic anemia (AA) is a disease associated with bone marrow failure, which is mainly characterized by pancytopenia and infection due to decreased hematopoiesis in bone marrow , 2. PatiThe name “aplastic anemia” does not appear in the ancient Chinese classics, whose clinical manifestations tend to be “consumptive disease” or “hemorrhagic syndrome” in traditional Chinese concepts . In the With the popularity of medical informatization, a large amount of medical data can be collected, stored, and analyzed, which also promotes the development of data mining in the medical field. Data mining technology  is a decκB signaling pathway , where the value 1 represents a perfect correlation, value 0 means no correlation, and value −1 represents negative correlation.The Pearson correlation coefficient is used to calculate the relationship between two variables Association rule analysis is an unsupervised learning method, which reveals the internal structure of a dataset. It was first proposed to discover the relationship between different commodities in supermarket sales data to make better sales plans. In the study of medication rules, association rule analysis can also be used to explore the co-occurrence rules between herbs. To explore combinatorial rules for the treatment of AA, an SPSS modeler was adopted to perform association rule learning for all herbs in this study. The Apriori algorithm is chosen to obtain candidate item sets , where sX=herb 1 and Y=herb 1, and X∩  Y=herb 1 are the set of all items in D. If the percentage of X ∪  Y in the dataset D is a%, then the support of the association rule X⟶Y is a%. In fact, the support is a probability value. The lift is the ratio of the probability of item Y appearing in the presence of X to the frequency of Y. Support and confidence are often used to eliminate meaningless combinations, and lift could show the validity of the rules.X and Y are examples of associations represented by association rules. For example, To extract more representative rules, the minimum threshold of support was set to 0.20 and the minimum value of confidence was set to 0.8. Besides, the maximum number of antecedent items was set to 2.After data collection and processing, the frequency of herbal medicine use  was calce of drug action. Medicine meridian matches the effect of herbs with the theory of viscera and meridians to illustrate the selectivity of drug action to a certain site of the body.The medicinal properties of TCM are divided into Yin and Yang. The “Four Qi” of TCM are as follows: cold, hot, warm, and cool. Besides, herbs with moderate effects are mild. Five flavors of TCM refer to the taste of herbs, including sour, bitter, sweet, pungent, and salty, which are commonly known as the most basic tastes. In addition, they are weak, astringent, etc. In order to correspond to the theory of the five elements in imperial China, astringency was attached to the sour and weakness attached to the sweet, with which all of them could be called Five Flavors. A medicine meridian denotes the sitIt can be shown in g (c) that the herb's meridian tropisms are ranked as liver, spleen, kidney, lung, heart, stomach, gallbladder, large intestine, bladder, small intestine, pericardium, and triple energizer in descending order based on the frequency. The frequency of herb's meridian tropisms above 15% are liver, spleen, and kidney.Most herbs of Group 1 can be used to invigorate the kidney, cool the blood, and stop bleeding, except MaiyaIn Group 2, Baishao and Chuanxiong belong to Chinese traditional Siwu decoction, and it was described by the ancients that the effect of Danshen is equivalent to that of Siwu DecoctionHerbs of Group 3 have the effect of improving indigestionHerbs of Group 4 can invigorate spleen to nourish original QiThe goal of Group 5 is to tonify Qi and consolidate superficiesGroup 9 is contributing to nourishing kidney essenceThe cluster analysis results of high-frequency herbs were obtained by SPSS statistics:The first six categories are meaningful in clinical prescription, and the results are shown in The results of association rule analysis can mine the combination of potential core herbs from commonly used prescriptions. The results showed that there were three herb combinations with support over of 30% , whose objective is mainly to nourish blood, activate blood, and tonify the kidneys and Qi . From thAA is a bone marrow hematopoietic dysfunction disease called “Suilao” or “Consumptive disease” in TCM. The main clinical symptoms of AA are hypodynamia, hemorrhage, and infection. In our center, we treated AA by integrating traditional Chinese medicine and western medicine, to reduce the clinical symptoms of patients, improve their quality of life, and alleviate their economic burden.Based on data mining, we studied the regularity of TCM for the treatment of AA in our center. The top three herbs are Danggui , Huangqi , and Shudihuang . In terms of TCM, Danggui can replenish blood and activate blood. Besides, Danggui has an immunomodulatory effect . ShudihuAncient medical books called “Jingyue Quanshu” indicated that the therapy of TCM for patients with blood deficiency and stasis is enriching blood and promoting blood circulation, which is the origin of the method of Bushen Huoxue. According to experience, the Chinese medical pathogenesis of AA is generated by “deficiency”. However, it is found that “stasis” should be added to the pathogenesis. In our previous study , we foun