Diastolic blood pressure was manipulated by intravenous infusions, during the jejunal perfusions, of vasodilators  and a vasoconstrictor (arginine vasopressin), each of which acts through a different cellular mechanism. The outcome was that fluid flux was related by a parabolic relationship with diastolic blood pressure in which net secretion occurred over the range 40–100 mmHg, whereas net absorption was recorded at diastolic pressures exceeding 100 mmHg and below 40 mmHg. Against a background of normal absorption promoted by perfusion with 145 mmol L−1 Na+/5 mmol L−1 glucose solution, reductions in diastolic blood pressure markedly reduced the mean rate of fluid absorption by 58% overall, whereas the rate of glucose absorption remained unchanged. Our results were explained on the basis that vasodilatation led to increased capillary pressure and then to net filtration of fluid from the mesenteric capillary bed. Experiments in which Escherichia coli heat-stable toxin was added to the jejunal perfusate confirmed the absence of a secretory response, which was consistent with the absence of effect of the toxin on diastolic blood pressure.The effects of changes in the steady level of diastolic blood pressure on fluid flux across the jejunum has been investigated in the anesthetized rat during perfusion with a nutrient-free and Na Cl− ion flux is thus regarded as the driving force for the accompanying secretion of Na+ and water  has been demonstrated after luminal exposure to V. cholerae toxin both in vitro and in vivo . As denervation, particularly extirpation of the coeliac ganglion as in the case of Claude Bernard, must inevitably affect the pressure within the mucosal vasculature, we have sought to investigate the extent to which intestinal fluid movement is affected by the prevailing arterial blood pressure (ABP) in conditions in which intestinal absorption was minimized by use of a Na+-free and nutrient-free perfusate. Manipulation of the peripheral resistance of the vasculature was achieved by intravenous (I.V.) infusions of vasoactive agents over the duration of the perfusion of the jejunum. A depressor action through vasodilatation was mediated with (1) vasoactive intestinal polypeptide (VIP), the neurotransmitter form of secretin, which through receptor binding activates adenylate cyclase to cause cAMP production, activation of PKA and phosphorylation of myosin light chain kinase , a stable analog of acetylcholine, which binds to muscarinic receptors to activate phospholipase C to cause an elevation of intracellular IP3 and intracellular Ca2+, subsequent activation of nitric oxide synthase leading to NO production −1. The criterion for anesthesia was abolition of the hind limb flexor withdrawal reflex. In order to maintain the level of anesthesia, supplementary I.P. injections (24 mg kg−1) were given as required. At the end of the experiments, the animals were killed with an I.V. injection of 100 mg Euthatal .Experiments were carried out on male rats of 250–400 g in accordance with the Animals (Scientific Procedures) Act 1986. The animals were fasted overnight but were allowed a 5% sucrose drink in addition to water. They were anesthetized with an intraperitoneal (I.P.) injection of pentobarbitone sodium  at a dose of 80 mg kg−1, Leo Laboratories Ltd., Princes Risborough, UK) and bilateral vagotomy to abolish vago-vagal reflexes. Following a midline incision of the abdominal wall, the pyloroduodenal junction was ligated to prevent entry of gastric secretions into the duodenum and the small intestine was exposed. Cannulae of 4.0 mm outer diameter were inserted and tied in at both ends of a 30 cm length of jejunum located distal to the ligament of Treitz. The animal's temperature was maintained as near as possible to 37°C and at the end of the experiment, the length of the perfused jejunal loop was measured and a sample taken for histology.The surgical procedures consisted of the following: tracheostomy to allow tracheal aspiration and artificial ventilation if necessary, cannulation of the carotid artery to monitor the ABP, cannulation of the external jugular vein and occasionally the external iliac vein for slow infusions  and the perfusate discarded. The experimental perfusate consisted of 40.0 mL 154 mmol L−1 choline chloride solution containing 100 μmol L−1 EIPA (5-(N-Ethyl-N-isopropyl) amiloride: Sigma A3085; Sigma) (Na+/H+ antiport antagonist) at 37°C and pH 7.0, which was recirculated from the measuring cylinder standing in the water bath for a timed period of at least 1 h after which the perfused fluid was then recovered from the jejunal loop and any change in the amount of perfusate was determined as the difference in the weight of fluid before and after perfusion. Steady reductions in peripheral resistance, indicated by the systemic blood pressure recordings, were achieved by slow I.V. infusions over 45–60 min using a micrometer-driven syringe of either 10–50 μg VIP  or 100–300 μg acetyl-β-methylcholine bromide  dissolved in 1.5 mL isotonic saline, whereas 200–500 μg phentolamine mesylate  was injected by slow bolus injection in 0.2 mL isotonic saline. Increases in peripheral resistance were achieved by slow I.V. infusions of 2.5–8.0 μg arginine vasopressin  also dissolved in 1.5 mL isotonic saline. In addition, further experiments were undertaken involving the perfusion of the jejunum with Krebs-phosphate solution containing 145 mmol L−1 Na+ and 5.0 mmol L−1 glucose pH 7.4 in order to promote absorption. In one set of experiments, the effects of the vasodilator agents I.V. on fluid absorption, measured by the method described above, and on glucose absorption, measured in duplicate with the Accu-Chek glucose meter , were determined. In the second set of experiments, the effect of the addition of 1.0 μg E. coli heat-stable toxin (STa)  to the luminal perfusate was tested.The warmed perfusate was circulated by a Watson–Marlow peristaltic pump at a rate of 1.0 mL minAfter completion of the experiments, a 5 cm length of the perfused jejunum was infused with 10% formal saline and immersed in 10% formal saline overnight and then processed for paraffin embedding. Transverse sections were made from several locations in each segment of gut and stained with hematoxylin/eosin and alcian blue for light microscopy.t-test, comparisons of changes in ABP and heart rate were made with the paired t-test and the coefficient of determination (R2) was obtained by regression analysis, with statistical significance taken as P < 0.05. The results throughout are expressed as the mean ± SEM.Application of the appropriate statistical tests was made with Minitab 15 . Comparisons against zero were made with the ± 2.0 mmHg, a pulse pressure of 28 ± 1.0 mmHg and a heart rate of 388 ± 5 bpm (beats per minute). While many experiments ended with the infusion of a vasoactive agent, in nine animals a second control perfusion was undertaken. In these cases, after 4–5 h, the mean ABP of 116 ± 3.6 mmHg and the pulse pressure of 27 ± 2.1 mmHg were unchanged compared with the starting values (P = 0.41). There were also no adverse effects of perfusion of the jejunum with 154 mmol L−1 choline chloride and 100 μmol L−1 EIPA when these were perfused as an initial control procedure in 10 animals  was not significantly different from that at commencement of perfusion (113 ± 5.1 mmHg) (P = 0.40).The results were obtained from a total of 39 rats in which the ABP at the commencement of the experiments had the mean values of 132/104 mmHg with a mean ABP of 114 mals Fig.: the DBPP > 0.20). The pulse pressure remained unchanged with VIP (P = 0.64) though there was a small, but significant reduction in heart rate by 26 ± 7 bpm (6%) (P = 0.006). While these results indicate a degree of constancy of cardiac function, this was not the case with AVP which significantly increased pulse pressure by 26 ± 7.0 mmHg (100%) (P < 0.001) and was associated with a significant reduction in heart rate by 58 ± 7 bpm (15%) (P < 0.01).During the jejunal infusions, the diastolic blood pressures through I.V. infusion of vasoactive agents ranged from 128 mmHg during AVP infusion down to as low as 20 mmHg with continuous I.V infusion of VIP and MC and with a single bolus injection of phentolamine which caused sustained reductions Fig.–D. Initi± 4.8 μL cm−1 h−1 (P = 0.94). However, further analysis showed a significant inverse relationship between net fluid flux and the DBP , such that net secretion was recorded for blood pressures of <100 mmHg and net absorption was recorded for blood pressures of >100 mmHg  or absorbed (denoted −) by the jejunal loop did not seem, at first sight, to follow a consistent pattern with a nonsignificant mean value of −0.4 R2 = 72%, P < 0.001) , absorption of increasing magnitude was recorded. A similar relationship with that shown in FigureR2 = 66%, P < 0.001).When the results for the four vasoactive agents were included, now giving a total of 52 results, a definite pattern emerged in the form of a highly significant paraboloid relationship between flux rate and DBP (± 1.1 mmHg which was associated with a significant net absorption rate of −20 ± 2.5 μL cm−1 h−1 (P = 0.001) (5 experiments). By contrast, VIP infusion (13 experiments) resulted in a significant fall in DBP to 62 ± 5.8 mmHg which was associated with net secretion at a significant rate of +20.9 ± 5.5 μL cm−1 h−1 (P = 0.003). When AVP and VIP were coinfused in four experiments  . Overall, the mean control rate of −97 μL cm−1 h−1 was significantly reduced by 58% to −41 μL cm−1 h−1 when the DBP was reduced (P < 0.001) (TableP = 0.78).The effects of reduced DBP produced by I.V. infusion of VIP, MC or phentolamine on normal absorption, which was enabled by perfusion of the jejunum with 150 mmol LThese results thus demonstrate the effectiveness of reduced DBP in markedly reducing the rate of fluid absorption in the presence of normal glucose absorption.viz. absence of glucose and Na+ (which was replaced by the impermeant ion choline) and inhibition of the Na+/H+ antiport by EIPA, net secretion was possible with rates as high as +60 μL cm−1 h−1. This net secretion, however, very much depended on the prevailing ABP such that net absorption occurred at high and low DBPs, whereas net secretion occurred in the range between 40 and 100 mmHg for the DBP  and the vasoconstrictor AVP each acts through a different cellular mechanism (Introduction). Given that phentolamine has its actions through its antagonism of the sympathetic neurotransmitter noradrenaline, all four vasoactive agents have been shown to act on the mesenteric vasculature, including the villous arcade, predominantly through actions on the arterial vasculature thus affecting inflow into the mesenteric capillary beds , indicating that DBP was the determining factor. The results for VIP infusion which, overall, caused appreciable net secretion were the subject of further investigation. When, while VIP was being infused I.V., simultaneous infusion of AVP was undertaken to neutralize the anticipated fall in ABP  still occurred  expressed in relative units was incremented from 0.90 at DBP = 125 mmHg to 1.92 at DBP = 10 mmHg  which is taken to be proportional to r, thus giving a filtration coefficient of 1.0 r. The outcome for the projected rate of fluid secretion/absorption is shown in FigureR2 = 68%, P < 0.001) and goes some way to supporting the plausibility of the proposed process for intestinal fluid secretion.The form of the resulting relationship was that the capillary pressure increased almost linearly from DBP = 125 mmHg to a peak value of 42 mmHg at DBP = 60 mmHg after which it declined linearly as the DBP continued to fall Fig.. TransfoThe applicability of the present results which indicate a role for filtration of fluid from the mucosal capillary bed as a consequence of increased capillary pressure needs to be considered in the context of toxins reported to cause secretory diarrhea.E. coli STa toxin reduced absorption, it did not promote active secretion of fluid into the jejunum   Fig., which iV. cholerae toxin causing systemic vasodilatation and consequently increasing mucosal capillary pressure to cause exudation of fluid. However, there has to be a recognition that our conclusion is based on inferences about capillary pressure which remains to be measured directly during exposure to V. cholerae toxin and that our results pertain to the rat model, whereas validation in a large animal model would be desirable. While methodologically, this will require further technically demanding experiments, there is a parallel direction in which work could proceed: this would be to explore the efficacy of administration of a specific vasoconstrictor agent devoid of cardiac actions to test the effects of restoration of the ABP during exposure to V. cholerae toxin. While we have already demonstrated that vasopressin I.V. promotes absorption (Fig.In conclusion, our results strongly suggest that at least a major component of the secretory response in secretory diarrhea has a vascular origin due to the systemic effect of tion Fig., there ition Fig.. This an


Raised blood pressure is the leading attributable risk factor for global morbidity and mortality. Real world data demonstrates that half of treated patients are at elevated cardiovascular risk because of inadequately controlled BP. In addition to pharmacotherapy, certain interventional strategies to reduce blood pressure and cardiovascular risk in hypertension can be considered according to international guidelines. One of the newer technologies entering this field is a proprietary arteriovenous coupler device that forms a fixed flow arteriovenous conduit in the central vasculature. In this review, we examine the development of and rationale for the creation of a central arteriovenous anastomosis in patients with hypertension and review the proposed mechanisms by which it may ameliorate hypertension. We critically review the clinical trial evidence base to date and postulate on future therapeutic directions. Raised blood pressure (BP) remains the leading attributable risk factor for mortality worldwide , despiteAlthough there are current advances in improved iterations of established anti-hypertensive medication classes and entirely new medication classes for both established and recently apparent pathophysiological mechanisms , additioshunts that do not participate in gaseous exchange due to the parenchymal destruction in advanced COPD. Furthermore, the increase in venous return would cause a commensurate increase in cardiac output, therefore further increasing oxygen delivery to tissues [The CE-marked ROX Medical arteriovenous (AV) coupler is a stent-like device made of nickel/titanium alloy (nitinol) that exhibits shape memory to self-expand on deployment into a pre-formed configuration. It is deployed via percutaneous trans-arterial and -venous access from the external iliac vein into the adjacent external iliac artery, just above the level of the femoral head, to form a fixed diameter AV anastomosis delivering an arterial–venous shunt estimated to be ~0.8–1 L/min when sized to 4 mm in diameter . The cou tissues ••.Initial pilot studies were conducted in two cohorts of patients with advanced/end-stage COPD. Whilst these initial studies demonstrated improvements in arterial blood oxygen content and tissue oxygen delivery, there were heterogeneous results with respect to functional improvements in exercise capacity , 15. AltHistorical reports show that experimental very large-calibre, non-fixed diameter AV anastomoses in canines caused significant, sustained reduction in BP, though the maladaptive responses to such fistulae were not desirable , 18. Then = 95). In post hoc analyses of 24 patients with co-existent  hypertension (mean resting BP 145/86 mmHg), insertion of the AV coupler (sized to 4 mm) was associated with 13/18 mmHg reduction in resting BP at 12 months post-central AV anastomosis formation [Whilst neither of the two initial published studies in normotensive COPD patients reported changes in systemic arterial BP, an interesting signal was apparent in a pooled cohort from two separate clinical trials in COPD patients  [Following these observations, a small, prospective study (unpublished) in eight RHTN patients (mean 4 anti-hypertensive medications) was conducted using both office and ambulatory BP measurements to 6 months post-AV anastomosis (4 mm diameter) formation. Office BP (OBP) and ambulatory BP (ABP) decreased by 17/13 mmHg and by 6/13 mmHg, respectively , with son = 5) .These pilot data spurred the design of a larger, international, multi-centre, open-label, randomized, controlled trial in patients with confirmed office and out-of-office RHTN. In the ROX CONTROL HTN trial ••, 83 pan = 10) who had previously received RSD, there was an equivalent BP response [p = 0.03) of patients in the intervention group whilst in the control group, 29.4 % (p = 0.04) of patients increased antihypertensives. This may have led to an underestimate of the true BP-lowering effect of the coupler as BP analysis was done independent of medication changes [The trial cohort was well balanced between the limbs and the patients had significant hypertension despite taking >4.6 medications. Baseline OBP was 175/100 mmHg, with out-of-office RHTN confirmed by ABP (24 h mean 157/93 mmHg). OBP was significantly reduced by 27/20 mmHg and ABP by 14/14 mmHg from baseline in the active treatment group, with no significant change in the control group ••. The mresponse ••, suggeresponse . Importaresponse . In the  changes ••.n = 1), severe contrast reaction in a patient with known dye allergy (n = 1) and localized time-limited pain (n = 2). Late, device-related events were exclusively related to venous stenosis causing limb oedema in 29 % of patients that were treated successfully by balloon venoplasty and/or stenting. Venous stenosis is caused by venous neointimal hyperplasia (VIH) and is a leading cause of AVF dysfunction in ESRD, with 2-year patency rates of only 75 % [Procedural complication rates were common (31 %) and included an ipsilateral iliac artery dissection, which required no further intervention  Investigational Device Exemption (IDE) trial for radio-frequency (RF) RSD was designed to do. However, in the case of the AV coupler technology, a sham-controlled study may not be necessary or feasible. Firstly, upon opening of the anastomosis, there is immediate imaging confirmation of anatomical success of the procedure and this is confirmed by immediate, on-table, large reduction in BP , unlike The mechanisms that regulate BP and can contribute to the pathophysiology of hypertension and RHTN are complex and manifold . Two theTonic elevation of sympathetic tone is widely recognized as a hallmark of hypertension, particularly in renal- and obesity-driven forms and in the young . FurtherLarge, central artery stiffening is due to elastin fatigue, collagen deposition and medial calcific arteriosclerosis , 45, andImpedance mismatch in the distal aorta, predominantly at major arterial branching points, leads to pressure-wave reflection and return of a backward wave that augments systolic BP on top of the forward, propagation wave that leaves the heart . This auWindkessel effect within the central arterial vasculature [BP cushioning) increases rate of pressure change within systole in the aorta and predisposes to increased systolic BP levels, greater BP variability and enhanced volume sensitivity of BP levels [Loss of arterial compliance necessarily involves loss of the culature . This loP levels  Fig. 2)WindkesseP levels .There are several mechanisms by which creation of a central, fixed calibre AV anastomosis will target abnormal mechano-circulatory aspects of vascular physiology in hypertension that are likely to be additive and work in a beneficial feed-forward loops.The addition of a low-resistance, high-compliance venous segment in parallel to the systemic arterial circulation will reduce overall systemic vascular resistance (SVR) , similaPerhaps most importantly, merely reducing effective arterial volume and cardiac afterload with a central AV anastomosis will alter the strain–stress intercept that reflects the non-linear volume/pressure dependency that determines arterial compliance . This relationship is pathophysiologically shifted leftwards in hypertension related to arterial stiffening Fig. . This chIn addition to several mechano-circulatory aspects that may contribute to mean BP and BP variability improvements discussed above, there may well be anticipated benefits from neurohumoral and sympathomodulatory aspects. Increased flow to the cardio-pulmonary circuit will stimulate release of atrial natriuretic peptide, which may augment BP reduction as it is a potent vasorelaxant peptide that additionally has tubular effects in the glomerulus to reduce sodium reabsorption . FurtherThe combination of increased cardiac output  and arteIn common with similar early-phase investigations of interventional strategies for hypertension, ROX CONTROL HTN was designed to evaluate safety and efficacy of a primary endpoint and not designed to evaluate reductions in target organ damage or hard CV endpoints, and therefore, longer-term follow-up in global registries and investigator-led studies will be necessary to demonstrate an equivalent evidence base to guideline-based pharmacotherapy . In addiOther avenues that are being explored in nascent clinical trials include evaluating the effects of the coupler in paroxysmal atrial fibrillation (AF), as an adjunct to AF ablation  and in neurally mediated syncope  where it is postulated that increases in cardiac pre-load will reduce symptoms. Due to the expected reduction in cardiac afterload related to reduction in SVR and improvements in arterial compliance, it has been suggested that improvements in cardiac mechanics and reductions in myocardial oxygen consumption may be apparent , which wIn common with more established interventional technologies in the field of hypertension, such as RSD and BAT, iteration of the device and deployment technique may be possible to improve efficacy and enhance safety. One possibility is for graded sizing of the AV anastomosis, so that patients first have a smaller calibre anastomosis formed  and that if BP reduction related to this effect is not sufficient to control BP to guideline-driven targets, then the anastomosis could be further dilated to achieve the necessary haemodynamic effect. Furthermore, procedural modification is desirable to minimize venous trauma and modulation of artery-to-vein flow to avoid neo-intimal hyperplasia in order to reduce the prevalence of venous stenosis.Formation of a central AV anastomosis via a proprietary anastomotic coupler device has joined the burgeoning suite of interventional strategies for the reduction of BP in  RHTN. Although its beneficial effects are likely to be related to mechano-circulatory improvement in SVR and arterial compliance, there is the possibility that it is sympathomodulatory in addition. Clinical trial data to date is encouraging, but both regulatory authorities and international guideline-writing societies will require further safety and hard CV end-point data before it becomes an established weapon in the anti-hypertensive armamentarium.


Liquorice ingestion often elevates blood pressure, but the detailed haemodynamic alterations are unknown. We studied haemodynamic changes induced by liquorice consumption in 20 subjects versus 30 controls with average blood pressures of 120/68 and 116/64 mmHg, respectively.Haemodynamic variables were measured in supine position before and after two weeks of liquorice consumption (daily glycyrrhizin dose 290–370 mg) with tonometric recording of radial blood pressure, pulse wave analysis, and whole-body impedance cardiography. Thirty age-matched healthy subjects maintaining their normal diet were studied as controls.P<0.05), and increased extracellular volume by 0.5 litres (P<0.05 versus controls). Also augmentation index adjusted to heart rate 75/min  and aortic pulse pressure  were elevated indicating increased wave reflection from the periphery. In contrast, peripheral (−3/−0.3 mmHg) and central blood pressure (−2/−0.5 mmHg), aortic pulse pressure (−1 mmHg), and augmentation index adjusted to heart rate 75/min (from 9% to 7%) decreased numerically but not statistically significantly without changes in extracellular volume in the control group. Heart rate, systemic vascular resistance, cardiac output, and pulse wave velocity did not differ between the groups.Two weeks of liquorice ingestion elevated peripheral and central systolic and diastolic blood pressure (by 7/4 and 8/4 mmHg, 95% confidence intervals [CI] 2-11/1-8 and 3-13/1-8, respectively, Two weeks of daily liquorice consumption increased extracellular volume, amplified pressure wave reflection from the periphery, and elevated central systolic and diastolic blood pressure.EU Clinical Trials Register EudraCT 2006-002065-39</url>NCT01742702ClinicalTrials.gov  During recent years there has been a growing research interest concerning the role of mineralocorticoids and the mineralocorticoid receptor (MR) in hypertension in vitroBoth aldosterone and cortisol can bind to the MR with comparable affinity In the kidneys the MR is also protected from cortisol by 11β-HSD2 The enzyme 11β-HSD2 is also present in the human vascular wall in both smooth muscle cells and endothelial cells, where it can influence vascular tone by modulating the access of glucocorticoids to the MR The sensitivity of human subjects to the liquorice-induced elevation of blood pressure varies individually and patients with hypertension show higher sensitivity The original study protocol (in Finnish) and English summary of study protocol, and supporting Consort checklist, and data are available as supporting information; see All participants signed informed study consent. This study was approved by the Ethics Committee of the Tampere University Hospital (study code R07053M), complies with the principles outlined in the Declaration of Helsinki, and is registered in the database of clinical trials .The haemodynamic recording protocol was registered in the EU Clinical Trials Register (EudraCT-number 2006-002065-39), and the study was approved by the Ethics Committee of Tampere University Hospital and by the Finnish Medicines Agency (code numbers R06086M for controls and R07053M for liquorice diet). The ongoing haemodynamic study was also registered in the database of clinical trials . The authors confirm that all ongoing and related trials for this intervention are registered.www.fazer.com) advised us that a product that would have authentic liquorice taste in the absence of glycyrrhizin could not be prepared, and therefore a double-blind crossover study design was not possible. The study subjects were recruited through noticeboard or email announcements from the personnel and students of the University of Tampere and Tampere University Hospital. In addition, professionals in local occupational health care units were informed that their patients could participate in an ongoing study on haemodynamics that included medical inspection and routine laboratory analyses  or the 1–3 week follow-up . Experts from a Finnish sweet manufacturer , who ingested liquorice daily for two weeks. Preceding the study, the subjects were instructed to abstain from liquorice-containing products for 3 weeks. The participants were allowed to choose between two commercial products  so that the estimated daily dose of glycyrrhizin was 290–370 mg. If the daily glycyrrhizin dose exceeds 400 mg, the risk of adverse events would be increased The To distinguish the possible effect of repeated haemodynamic measurements from the cardiovascular effects of liquorice consumption we recruited an age-matched group of 30 people. These subjects were not aware of serving as a control group for the liquorice study and during the measurements they were advised to maintain their normal diet. None in the normal diet group reported to consume liquorice containing products daily or weekly.Exclusion criteria were office blood pressure over 140/90 mmHg, any cardiovascular disease with regular medication, or pregnancy. The participants were advised to inform the study group immediately if they gained weight over 4 kilograms, observed oedema in the lower extremities or encountered other problems during liquorice ingestion. Such problems were not reported, and 21 subjects maintained the liquorice diet for 2 weeks.The suitability of all subjects for the study was confirmed by medical and laboratory examinations. The lifestyle habits, medical history and family history were recorded. In the liquorice group one subject was on regular medication for asthma (160 µg budesonide +4.5 µg formoterol twice daily), one for depression , one on postmenopausal oestrogen replacement therapy, and five female subjects used oral contraceptives. In the normal diet group 5 female subjects used oral contraceptives and 3 had hormonal intrauterine devices. There were 4 current smokers in the liquorice diet group, and 3 current and 4 previous smokers in the normal diet group.Standard electrocardiograms with 12 leads were taken with MAC5000 , and the recordings were normal in all participants. Before the study, blood and urine samples were collected after 12 hours of fasting, while in the normal diet group laboratory samples were not obtained from one subject. Plasma sodium, potassium, creatinine, glucose, cholesterol lipoproteins were analysed using Cobas Integra 700/800 , and blood haemoglobin by ADVIA 120 or 2120 . Plasma aldosterone concentration was determined using radioimmunoassay .AIx@75) were also determined. In addition, blood pressure was monitored from the left 3rd finger .Blood pressure and pulse wave form were continuously recorded for 5 minutes from the left radial artery by a tonometric sensor . The tonometric recordings were calibrated twice during every 5-minute period using automated contralateral brachial blood pressure measurements. The SphygmoCor PWMx pulse wave monitoring system  was used to derive aortic blood pressure by previously reported generalized transfer function R, JR Medical Ltd., Tallinn, Estonia), based on the changes in electrical impedance of the body during cardiac cycle, was used to determine beat-to beat heart rate, stroke volume, cardiac index, extracellular volume, and pulse wave velocity (PWV) R whole-body impedance cardiography method, i) the measurement of stroke volume shows good correlation with 3-dimensional echocardiography recordings Whole-body impedance cardiography  was manually measured in the supine position using a standard sphygmomanometer, and Korotkoff sounds at phase V were used for estimating DBP.rd left finger. The extended left upper limb was held at the level of the heart. Hemodynamic variables were captured continuously for 5 minutes, and average values from the whole period were used in the analyses. We have previously shown the good repeatability and reproducibility of the measurements The haemodynamic measurements were performed in a temperature-controlled laboratory before and after 2 weeks of liquorice ingestion. In the normal diet group the interval between the recordings was 1–3 weeks. The subjects were in the supine position on the examination table with electrodes on the surface of thorax and distally on the medial surface of extremities, tonometric sensor for pulse wave analysis on the left radial artery, and a cuff for the calibration of radial blood pressure in the right brachium P<0.05 was considered significant. Statistical analyses were made using SPSS 17.0 .The primary endpoints were significant changes in BP and other haemodynamic variables during the study. Secondary endpoints were changes in weight and plasma aldosterone and potassium concentrations. The power calculations were based on expected changes in SBP according to the primary aim of the study. The required minimum sample size was 17 experimental and 26 control subjects to detect a 9 mmHg difference in the change in SBP from baseline  10 for variability, power analysis method for two-sample t-test). Normally distributed data was expressed as mean ± SD or 95% confidence interval (95% CI). The results are given as mean ± SD unless otherwise stated. General linear model of repeated measurements and t-test for paired samples were used to compare differences between measurements and groups. A chi-square test was used to compare gender distribution in groups, and Pearson's or Spearman's correlations (r) were calculated, as appropriate. P = 0.04 and P = 0.002, between the groups, respectively)  .P = 0.310 for SBP and P = 0.031 for DBP) and decreased by −3/−4 (±5/6) mmHg in the normal diet group (P = 0.002 for SBP and P = 0.004 for DBP) (P = 0.007 for SBP and P = 0.001 for DBP). Liquorice ingestion significantly decreased plasma aldosterone (P<0.001) and potassium concentrations (P = 0.02)  mmHg in the liquorice diet group (for DBP)  during t = 0.02) .P-value <0.001 for SBP and P = 0.016 for DBP) and in the normal diet group −3/−0.3 (−5-0.4/−3-2) mmHg (P = 0.346 for SBP and P = 0.664 for DBP). The differences between the groups were significant   between the visits in radial SBP/DBP in the liquorice group was 7/4 (2-11/1-8) mmHg  . The manP = 0.010 for SBP and P = 0.102 for DBP), and in the normal diet group −2/−2 (−7-3/−5-2) mmHg (P = 0.402 for SBP and P = 0.352 for DBP). The mean change in finger SBP differed between the groups (P = 0.030), while the change in DBP did not reach statistical significance (P = 0.065). The manual measurements of brachial blood pressure and the plethysmographic measurements of finger blood pressure confirmed the significant effect of the liquorice intervention on blood pressure.Comparable changes in blood pressure were also observed in finger measurements, as the mean change (95% CI) between the visits in finger SBP/DBP in the liquorice group was 5/4 (1-9/−1-8) mmHg (within group P = 0.001 for SBP and P = 0.012 for DBP), while no significant change was observed in the normal diet group . The mean change between the visits in aortic SBP/DBP differed between the groups  mmHg  mmHg (P = 0.281), AIx values were 13.3% vs. 12.4% , and AIx@75 values were 8.6% vs. 6.9% . The differences between the groups were significant for aortic PP, AIx, and AIx@75 .In the liquorice group aortic PP, AIx, and P = 0.191 and P = 0.481, liquorice and normal diet groups, respectively), and did not significantly differ between the groups . There were no significant differences in heart rate, cardiac index, and systemic vascular resistance index in the measurements within the groups , or between the groups  of cardiac output and peripheral vascular resistance Although liquorice ingestion is a known cause for diet-induced hypertension, the detailed haemodynamic changes underlying the elevation of blood pressure have not been reported after regular liquorice exposure. In this study we captured haemodynamic data before and after two weeks of liquorice ingestion, and found that the diet elevated both peripheral and central blood pressure and increased extracellular volume. The findings that central PP, AIx, and The recordings of tonometric radial and plethysmographic finger blood pressure, pulse wave analysis, and whole-body impedance cardiography were automated procedures devoid of subjective components, which can be argued to increase the reliability of the recordings. The study groups were homogenous so that different haemodynamic profiles associated e.g. with excess body weight and ageing could be avoided The type 1 and type 2 isoforms of 11β-HSDs regulate local cortisol metabolism. The 11β-HSD2 is mainly expressed in aldosterone target tissues Recent studies have suggested that central blood pressure and PP are superior to brachial blood pressure in evaluating the risk of future cardiovascular events www.tulli.fi), the amount of imported liquorice root extract was 686.000 kg during a period of 12 months (statistics from May 2013), and this would correspond to a daily dose of glycyrrhizin of approximately 21 mg per every Finnish citizen. Although glycyrrhizin containing products are exported, this indicates high domestic consumption of liquorice products.In the present study, the elevation of SBP and DBP caused by liquorice (on average 7/4 mmHg) was close to the efficacy of antihypertensive monotherapy in meta-analysis on pharmacotherapy of hypertension (average reduction 9/6 mmHg) A limitation of the present study is the rather small number of participants, although significant haemodynamic changes were observed in the 20 subjects. Due to the small number of subjects, the possible blood pressure-independent haemodynamic effects of liquorice could not be examined by the use of multivariate analysis. However, as the effect of liquorice on blood pressure is well-established, the objective of the present study was to examine the haemodynamic changes that can explain the elevation of blood pressure. Furthermore, in addition to glycyrrhizin, the present liquorice diet also contained carbohydrates, mainly starch-derived glucose. The average intake of carbohydrates from liquorice was 150 grams per day, which could have influenced cardiovascular status. Diets with high glycaemic index are also associated with higher degree of vascular oxidative stress In order to avoid the excess carbohydrate intake, the participants could be given pure glycyrrhizin. However, we especially tested the hypothesis whether daily glycyrrhizin intake from liquorice would induce changes in cardiovascular regulation that could be detected with our recording system. As the effect of liquorice may differ between sexes, the present study subjects were chosen so that the distribution of genders in the groups did not differ. In a study concerning individual sensitivity to the harmful influences of liquorice intake, women were suggested to be more sensitive to the adverse effects of liquorice than men In conclusion, the results of this study with normal volunteers indicated that already two weeks of liquorice ingestion increased extracellular volume, amplified pressure wave reflection from the peripheral circulation, and elevated central systolic and diastolic blood pressure.Protocol S1Trial protocol.(PDF)Click here for additional data file.Protocol S2English summary of trial protocol.(PDF)Click here for additional data file.Checklist S1CONSORT checklist.(PDF)Click here for additional data file.Data S1Leskinen data.(TXT)Click here for additional data file.


Asthma and chronic obstructive pulmonary disease (COPD) are chronic inflammatory diseases of the airway, although the drivers and site of the inflammation differ between diseases. Asthmatics with a neutrophilic airway inflammation are associated with a poor response to corticosteroids, whereas asthmatics with eosinophilic inflammation respond better to corticosteroids. Biologicals targeting the Th2-eosinophil nexus such as anti–interleukin (IL)-4, anti–IL-5, and anti–IL-13 are ineffective in asthma as a whole but are more effective if patients are selected using cellular  or molecular  biomarkers. This highlights the key role of individual inflammatory mediators in driving the inflammatory response and for accurate disease phenotyping to allow greater understanding of disease and development of patient-oriented antiasthma therapies. In contrast to asthmatic patients, corticosteroids are relatively ineffective in COPD patients. Despite stratification of COPD patients, the results of targeted therapy have proved disappointing with the exception of recent studies using CXC chemokine receptor (CXCR)2 antagonists. Currently, several other novel mediator-targeted drugs are undergoing clinical trials. As with asthma specifically targeted treatments may be of most benefit in specific COPD patient endotypes. The use of novel inflammatory mediator-targeted therapeutic agents in selected patients with asthma or COPD and the detection of markers of responsiveness or nonresponsiveness will allow a link between clinical phenotypes and pathophysiological mechanisms to be delineated reaching the goal of endotyping patients. Asthma and chronic obstructive pulmonary disease (COPD) affect more than 500 million people worldwide representing the 2 most common chronic inflammatory diseases of the lower airways.The current consensus definition of asthma is “an (sic) heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable airflow obstruction.”The analysis of airway biopsies after bronchoscopy and the introduction of induced sputum analysis allowed the inflammatory nature of the asthmatic airways to be confirmed.10Later studies showed that although eosinophils were present in many asthmatic biopsies, some subjects, particularly those with more severe disease, also demonstrated increased levels of neutrophils.10The Global Initiative for Chronic Obstructive Lung Disease guidelines define COPD as “a common preventable and treatable disease, characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Exacerbations and comorbidities contribute to the overall severity in individual patients.”17The pathologic features of COPD are lung parenchymal destruction (pulmonary emphysema), inflammation of the small  airways (respiratory bronchiolitis), and inflammation of the central airways. Inflammation occurs within all these compartments .201), was ignored. In common with most chronic inflammatory diseases, corticosteroids are able to attenuate all measures of inflammation in asthmatic airways leading to a reversal in the decline in FEV1 associated with the disease and a reduction in AHR back to normal levels. However, ICSs do not cure asthmatics as many of the symptoms of asthma and the inflammation return on their discontinuation.25Asthma was implicated as a chronic inflammatory disease, and this was confirmed when the potent anti-inflammatory prednisolone was shown to be of benefit in patients with asthma. Some of the original studies with oral prednisolone highlighted that blood levels of eosinophils were not altered in patients who were more refractory to treatment. This provided early evidence for the concept of relatively corticosteroid-resistant asthma.Asthmatic patients who respond poorly to ICSs or even oral corticosteroids, termed severe asthmatics, often have more frequent exacerbations requiring hospitalization and depression associated with the chronic nature of the disease, which is not controlled by conventional therapy.Asthma is now recognized as a syndrome with many potential phenotypes and endotypes and understanding these is essential in determining the most effective therapeutic regimen suitable for each patient.36More than 100 mediators have now been implicated in asthmatic inflammation, including multiple cytokines, chemokines, and growth factors.The Th2 cell cytokine, IL-5, plays an important role in eosinophil maturation, differentiation, recruitment, and survival. IL-5 knockout mice appeared to confirm a role in asthma models in which eosinophilia and AHR are markedly suppressed. The humanized anti–IL-5 monoclonal antibodies (MAbs), mepolizumab (formerly termed SCH55700) and reslizumab (formerly Res-5-0010), have been developed for clinical use.It has been demonstrated in earlier studies that using mepolizumab in mild-moderate asthmatics was very effective at reducing sputum and blood eosinophils but had no effect on clinical signs and symptoms suggesting that the concept of asthma as a Th2-driven eosinophilic disease was incorrect.P < 0.001) and sputum (P = 0.002), and this was associated with a reduction in exacerbations (2.0 vs 3.4 mean exacerbations per subject) compared with placebo. There were no significant differences between the groups with respect to symptoms, FEV1 after bronchodilator use, or AHR.On the basis of earlier work showing a cluster of patients with severe asthma had inappropriate levels of sputum eosinophils, Haldar et al examined whether reducing eosinophilia in these patients would have any effect on the clinical features of asthma particularly exacerbations.1 or fraction of exhaled nitric oxide were seen after cessation of mepolizumab therapy. This supports the concept that these events are related and have pathophysiological importance.An unblinded follow-up analysis of 56 of the original 61 subjects for 12 months indicated that withdrawal of mepolizumab resulted in an increase in blood and sputum eosinophils that preceded the rise in exacerbations. Twelve months after stopping mepolizumab, exacerbation frequency was similar in the placebo and mepolizumab groups. Not unexpectedly, no effects on FEVClinicalTrials.gov number, NCT01000506) in 621 patients with similar characteristics as the original study. There was a 52% reduction in clinically significant exacerbations with 75 mg mepolizumab, and blood eosinophils appeared to be the best predictor of response.These results were replicated in a follow-up multicenter, double-blind, placebo-controlled study  also reported an increase in FEV1 in all patients receiving mepolizumab of approximately 100 mL and a resultant improvement in asthma quality of life and asthma control questionnaire scores.ClinicalTrials.gov number, NCT01691508).Furthermore, similar results were observed whether mepolizumab was delivered intravenously (75 mg) or subcutaneously (100 mg) for 32 weeks with a 47% and 53% reduction in exacerbations, respectively. This study .Two other anti–IL-5R MAbs, benralizumab and reslizumab, had effects similar to mepolizumab with respect to decreasing rates in asthmatic patients with poorly controlled disease and high levels of blood and/or sputum eosinophils despite high doses of ICS therapy. The anti–IL-5Rα MAb benralizumab delivered either intravenously or subcutaneously reduced eosinophil counts in airway mucosa and submucosa, sputum, bone marrow, and peripheral blood.Reslizumab reduces sputum eosinophils in patients with eosinophilic asthma that is poorly controlled with high-dose ICSs compared with placebo.As part of the Th2 hypothesis of asthma, IL-13 has been shown to play a critical role in various aspects of airway inflammation and epithelial remodeling including goblet cell metaplasia and epithelial-mesenchymal signaling. This leads to increased subepithelial fibrosis or airway smooth muscle hyperplasia.Airway epithelial cells are a major target for corticosteroids and their effectiveness in asthma may relate to their ability to modulate the production of inflammatory mediators from these cells, which have downstream effects on other inflammatory cells. In an attempt to address this issue, Woodruff et al collected epithelial cells obtained by bronchial brushings from asthmatic subjects undergoing a randomized controlled trial of ICSs and from healthy subjects.Transcriptomic analysis of these cells identified 2 distinct groups termed Th2-high and Th2-low based on the differential expression of IL-13–inducible genes —a Th2-high signature. Corticosteroid treatment downregulated the expression of these 3 genes and markedly upregulated the expression of FK506-binding protein 51. High basal expression of this Th2-high signature was associated with a good clinical response to corticosteroids, whereas high FK506-binding protein 51 expression was linked to a poor clinical response. These results were confirmed in primary epithelial cell cultures. Overall, the Th2-high group was associated with sputum eosinophilia and AHR and consistent with the predictive value of sputum eosinophilia, the Th2-high phenotype responded clinically to corticosteroids (CS) resulting in reduced expression of these Th2 biomarkers.50Measurement of the Th2 signature in bronchial epithelium depends on invasive airway sampling and hence noninvasive biomarkers of this phenotype are desirable. Sputum is a more accessible compartment to determine airway Th2-high vs Th2-low status. Real time quantative polymerase chain reaction (RT-qPCR) analysis of sputum cell pellets from 37 asthmatic patients and 15 healthy control subjects demonstrated that the gene expression levels of chloride channel regulator 1 and periostin, but not serpin peptidase inhibitor, clade B, member 2, were significantly higher than normal in sputum cells from asthmatic subjects.P = 0.007).A comparison of IgE levels, blood eosinophil numbers, fraction of exhaled nitric oxide levels, and serum periostin levels in 59 patients with severe asthma indicated that serum periostin level was the single best predictor of airway eosinophilia .1 than those in the placebo group. When patients were divided according to high or low serum periostin levels, those with high periostin had greater improvement in lung function with lebrikizumab (8.2%) than those with low periostin levels (1.6%). Patient selection, however, is the key to success with these drugs because lebrikizumab failed to increase FEV1 in 212 adult asthmatics not receiving ICSs irrespective of periostin levels.Lebrikizumab, an MAb to IL-13, improved lung function in a randomized, double-blind, placebo-controlled study of 219 adults who had asthma that was inadequately controlled despite inhaled glucocorticoid therapy .Similarly, subcutaneous tralokinumab (formerly CAT-354), an IL-13–neutralizing IgG4 MAb, improves lung function but not global asthma control scores in adults with moderate-to-severe uncontrolled asthma despite controller therapies.IL-4 analogs that act as antagonists have been developed, which fail to induce signal transduction and block IL-4 effects in vitro. These IL-4 antagonists prevent the development of asthma in vivo in animal models.1 decrease in atopic asthmatics.A soluble IL-4 receptor (sIL-4R) that acts as an IL-4R antagonist and for this reason is a dual IL-4/IL-13 pathway antagonist, termed pitrakinra, has also been developed. A single nebulized dose of sIL-4R prevents the fall in lung function induced by glucocorticoid withdrawal in moderate to severe asthmaticsDupilumab (SAR231893/REGN668) is a fully humanized anti–IL-4Rα MAb, which reduced asthma exacerbations when long-acting beta-adrenoceptor agonists (LABAs) and ICSs were withdrawn from patients with persistent asthma, moderate-to-severe asthma, and who had a blood eosinophil count >300 cells/μL or a sputum eosinophil level >3%. This was associated with improved lung function and reduced levels of Th2-associated inflammatory markers.In a short 4-week double-blind randomized study, MK-7123/SCH527123, a CXC chemokine receptor (CXCR)2 antagonist, reduced sputum neutrophilia by 36% in patients with severe asthma, although it had no effect on lung function or on an asthma quality of life questionnaire.1, symptom scores, or number of symptom-free days in 302 subjects with inadequately controlled moderate-severe asthma taking regular ICSs. Subgroup analysis of the high-reversibility group was of uncertain significance and will require a further clinical study .NCT01478360).Despite good results in preclinical studies, brodalumab, an anti–IL-17Rα MAb, had no effect on asthma control questionnaire score, FEVhttps://www.clinicaltrials.gov/ct2/show/NCT02054130).Thymic stromal lymphopoietin (TSLP) is a bronchial epithelial cell–derived cytokine that may be important in initiating allergic inflammation. MEDI9929 (formerly AMG 157) is a human anti-TSLP MAb that binds human TSLP and prevents receptor interaction.These classifications and biomarkers are useful as a start  but are The progressive chronic airflow limitation in COPD results from 2 major pathologic processes: remodeling and narrowing of small airways and destruction of the lung parenchyma (pulmonary emphysema) with consequent loss of the alveolar attachments of these airways. This results in diminished lung recoil, higher resistance to flow, and closure of small airways at higher lung volumes during expiration, with consequent air trapping in the lung. This leads to the characteristic lung hyperinflation, which gives rise to the sensation of dyspnea and decreased exercise tolerance. Both small-airway remodeling and narrowing and pulmonary emphysema result from chronic peripheral lung inflammation.There are increased number of macrophages, neutrophils, T lymphocytes, dendritic cells, and B lymphocytes in the lower airways of patients with stable COPD.1 or mortality rates.In contrast to asthma, glucocorticoid treatment of stable COPD is rather ineffective in reducing airway inflammation and the decline of lung function.1, quality of life, and respiratory symptoms in stable COPD patients, with no greater risk of adverse effects than that with use of either component alone. Increased risk of pneumonia is a concern; however, this did not translate into increased exacerbations, hospitalizations, or deaths.Several large controlled clinical trials of inhaled combination therapy with ICSs and LABAs in a single device in stable COPD have shown that this combination therapy is well tolerated and produces a modest but statistically significant reduction in the number of severe exacerbations and improvement in FEVhttps://clinicaltrials.gov/ct2/show/NCT02130635) on the efficacy of a highly selective inhaled PI3Kδ inhibitor (GSK2269557) in patients with stable COPD are awaited with interest.Corticosteroid suppression of many inflammatory genes requires recruitment of histone deacetylases (HDACs) to the gene activation complex by the activated glucocorticoid receptor. Oxidative stress reduces HDAC2 expression and activity, thus potentially limiting glucocorticoid effectiveness in suppressing inflammation in vitro studies and in patients with COPD.There is ample evidence of enhanced inflammation in COPD particularly of cytokines linked to cell recruitment and activation.1 . MK-7123 resulted in a dose-dependent 67 mL improvement in FEV1 over placebo, a significant reduction in sputum neutrophils and reduced levels of sputum and plasma matrix metallopeptidase-9 and myeloperoxidase. The effect seen was greater in smokers compared with ex-smokers.CXCL1, CXCL5, and CXCL8 are neutrophil chemoattractants whose expression is increased in COPD airways and who signal through CXCR2. This suggests that blocking this common receptor could reduce the chemotaxis of neutrophils.ClinicalTrials.gov identifier, NCT00581945). IL-6 concentrations increased in sputum, BAL, and serum, and because of its role in amplifying inflammation may be a useful therapeutic agent in COPD. An IL-6R–specific antibody (tocilizumab) is effective in patients with rheumatoid arthritis who are refractory to anti–TNF-α therapyIn addition, although IL-1β amplifies inflammation and its concentration is increased in the sputum of patients with COPD, canakinumab, an anti–IL-1β-specific antibody, also had no clinical efficacy in COPD after 45 weeks of treatment  or molecular  biomarkers. This demonstrates the key role of individual inflammatory mediators in driving the inflammatory response in asthma and highlights the need for accurate disease (sub)phenotyping to optimize disease management and drug development.The use of novel inflammatory mediator-targeted therapeutic agents in selected patients with asthma or COPD and the detection of markers of responsiveness or nonresponsiveness will allow a link between clinical phenotypes and pathophysiological mechanisms to be delineated reaching the goal of endotyping each patient. Early blood or exhaled biomarkers of subphenotypes and/or treatment response will be important to ensure that patients can be taken off a treatment early if it is ineffective to reduce the risk of any possible adverse effects in an adaptive design clinical study or in real life.


Background. Blood pressure variability (BPV) independent of average blood pressure is related to cardiovascular damage. Meanwhile, BPV is also associated with measures of endothelial injury. Decoction, a traditional used form of Traditional Chinese Medicine (TCM), is inconvenient to prepare, carry, and store. Dispensing granules is now developing as an alternative to decoction, but the evidence supporting its clinical efficacy the same as decoction remains unclear. Objective. To examine the therapeutic effects on mean blood pressure (MBP), blood pressure variability, and endothelial function by giving Bushen Qinggan Formula, a compound Chinese Herbal Medicine and also to evaluate the difference in efficacy between decoction and granule. Methods. A total of 150 patients with hypertension were enrolled and randomly assigned to receive the placebo, Bushen Qinggan decoction, or Bushen Qinggan granule in addition to the standard medications (amlodipine-5 mg/d) for the treatment of essential hypertension (EH). The outcome was the reduction in the MBP and BPV and also included changes in the endothelial markers including endothelin-1 (ET-1) and nitric oxide (NO) after 8 weeks of treatment. Results. Compared with the control group, the Bushen Qinggan decoction and granule groups had significant improvement (P < 0.01) in BPV and endothelial founction. The level of BPV and endothelial function between decoction and granule group had no significant difference (P > 0.05). Conclusion. Based on the standard treatment, Bushen Qinggan Formula further improved BPV and endothelial function. The efficacy of Bushen Qinggan decoction and granule is similar in improving BPV and endothelial function. However, no significant antihypertensive effects could be demonstrated. In developed countries, during one's lifetime, the risk of becoming hypertensive exceeds 90% . Now, daHypertension is one of the most prevalent vascular risk factor; the mechanisms contributing to the increased end-organ damages and vascular events risk as yet are unclear . NeverthWhen considering that impaired endothelial function has been strongly associated with cardiovascular morbidity and mortality, the previously observed associations between high BPV and increased cardiovascular risk could be mediated via the impairment of endothelial function. Our preliminary study shows that Chinese herbal medicine “Bushen Qinggan Formula” improved endothelial injury in patients with high blood pressure . The purDecoction, a traditional and commonly used form of Traditional Chinese Medicine (TCM), is prepared by decocting different kinds of medicinal herbs together . While tDispensing granule is the granule of individual herb. Dispensing granules now are developing as an alternative to decoction, prescribed by traditional medicine practitioners in China, Japan, Korea, Singapore, even United States, and some European countries. The popularization of the dispensing granules may be because that one of the most obvious inconveniences of TCM is the preparation. Therefore, this research group decided to compare the effect of granule and decoction. Gastrodia elata  30 g, Uncaria  30 g, Eucommia bark  30 g, radix Scutellariae  15 g, and bitter butyl tea  15 g. In Traditional Chinese Medicine (TCM) theory, most hypertensive patients show unbalance of Yin and Yang. There is a therapeutic strategy, namely, using “reinforcing” and “reducing” herbs together to balance Yin/Yang [Chinese herbal formulas are known to have an advantage with regard to prevent and treat target organ damage (TOD) . ResearcYin/Yang , and thiOn the basis of previous, we hypothesize that BPV plays a role in the development of endothelial injury and leads to cardiovascular disease finally. Therefore, the aim of this clinical study is (1) to evaluate if the efficacy of Bushen Qinggan granule for blood pressure variability and endothelial injury in patients with hypertension is equivalent to that of the decoction and (2) to evaluate the difference in efficacy between the TCM formula and placebo.This study was designed as a randomized, placebo-controlled study based on standard therapy and parallel groups. It was conducted in accordance with the Declaration of Helsinki. The study protocol was reviewed and approved by the Ethics Committee of Xiyuan Hospital of China Academy of Chinese Medical Sciences (2010XL016).The target enrollment was 150 patients from the Cardiovascular Disease Clinic at the Xiyuan Hospital, the teaching hospital of China Academy of Chinese Medical Sciences. The enrollment criteria consisted of patients aged from 18 to 75 years and clinical findings of essential hypertension (EH) for at least 3 months prior to screening. Both men and women were included. Level 1 and level 2 hypertension was diagnosed in accordance with Chinese guidelines published in 2005 and 2010 for the management of hypertension . To be iFrom January 2010 to May 2012, participants were recruited from outpatients or via mailed brochures. Patients were evaluated based on physical examinations, laboratory screening, and ambulatory blood pressure monitor. Eligible patients were randomly assigned to 3 groups in a 1 : 1 : 1 ratio, who would have receive Bushen Qinggan granule, Bushen Qinggan decoction, or placebo in addition to a standard medication. A total of 150 patients who met the selection criteria were recruited. This study is designed as a pilot study and allowing for a 20% dropout rate. Participants will be assigned with a 1 : 1 : 1 allocation ratio according to a randomization list generated with an SAS software package. The allocation will be concealed in sequentially numbered, opaque, sealed envelopes. Each participant received an envelope upon recruitment sequence. The random allocation envelops will be opened only after the participant has satisfied all selection criteria and completed baseline assessments. The researchers will know the allocated group but the participants, outcome assessors, and statisticians will not. The dosage used in this study was one bag of Bushen Qinggan granule, decoction, or placebo 2 times daily. Patients attended follow-up appointments at the secondary, fourth, 6th, and 8th weeks of treatment. At each visit, patients were asked about the occurrence of any clinical event or adverse effect.The study period lasted 8 weeks.The participants of all three groups used amlodipine 5 mg per day (Batch no. H10950224). Uncaria  30 g, Eucommia bark  30 g, radix Scutellariae  15 g, and bitter butyl tea  15 g. Granules were dissolved in boiling water and drunk while still warm.The Bushen Qinggan formula was taken orally by patients in both groups. The Bushen Qinggan formula was produced in the form of granules and decoction by Sichuan New Green Pharmaceutical Technology Development Co., LTD (Batch no. 100718206). Both granule and decoction were composed of Gastrodia elata  30 g,Placebo was taken by patients in the control group. The appearance, taste, and smelling of the placebo granules were made up to be extremely similar to the Bushen Qinggan granules. Instruction for usage was the same as Bushen Qinggan granules.All patients were evaluated at baseline and weeks 2, 4, 6, and 8. The following clinical and laboratory variables were assessed at the first and last visit.The primary endpoints were mean blood pressure and BPV, both measured by ambulatory blood pressure monitoring. We recorded 24-hour ambulatory blood pressure monitoring with 9027-ABP (SP(a) celabs Medica, USA). The cuff was programmed to inflate every 30 minutes between 6 a.m. and 10 p.m. (daytime) and every 60 minutes between 10 p.m. and 6 a.m. (night-time). The blood pressure data were edited by blood pressure data analysis software and processed by experienced analysts. 24-hour ambulatory blood pressure monitoring data were recorded at baseline and 8 weeks. There was no limit on activities during the monitoring.Blood pressure variability (BPV) was defined as the standard deviation of mean blood pressure depending on its time period.According to above definition, blood pressure data were collected both daytime (d) and nighttime (n) including SBP, DBP, SBP variability (SBPv), DBP variability (DBPv), SBP deviation (SBPd), and DBP deviation (DBPd) over 24 h.After at least 8 h of fasting, we collected venous blood from all participants at 8:00 a.m., for the test of endothelium related factors: endothelin-1 , and nitric oxide .At each visit, patients were asked if there were any adverse effects. When an adverse event appeared, the timing relative to the administration of the drugs was noted. Blood cell count, electrolytes, serum creatinine, liver function test, urinalysis, and electrocardiogram results were recorded before and after treatment.H test. The paired t-test was used to compare data before and after treatment. All data were checked for normal distribution. Data that were not normally distributed were analysed using Wilcoxon rank sum test. Chi-square test was performed for dichotomous variables. For dropout and withdrawal patients, perprotocol (PP) analysis was adopted, considering one of the main purposes is to prove the equivalence of granule and decoction. P value of less than 0.05 was considered significant.Analyses were performed using SPSS for Windows, version 14.0 . Data were described as mean ± standard deviation. Proportions were used to express dichotomous variables. One-way analysis of variance (ANOVA) test was used to compare the difference between three groups. Consistent with the requirement for ANOVA, all data were checked for variance homogeneity and for normal distribution. Data that were not normally distributed were analysed using Kruskal-Wallis A total of 137 patients (91.3%) completed the 8-week study, with premature termination occurring in 5 patients in the placebo group, 6 patients in the granule group, and 2 patients in the decoction group see .There were 45 patients enrolled in the granule group (31 men and 14 women), and the average age was 49.93 ± 3.49 years old. There were 47 patients enrolled in the decoction group (33 men and 14 women), and the average age was 47.58 ± 5.02 years old. The control group had 45 cases (29 men and 16 women) with an average age of 48.34 ± 4.25 years old. The baseline characteristics were comparable and statistically insignificant among three groups see .Prior to interventions, there was no statistically significant difference in the blood pressure parameters measured by 24 h ABPM among three groups.P < 0.01 or P < 0.05). There was significant decrease (P < 0.05) in the level of dSBP in the decoction group compared with the other groups  in the levels of 24-hSBPd, dSBPd, nSBPd, 24-hDBPv, 24-hDBPd, dDBPd, and nDBPd in the decoction and granule group compared with the control group; no significant differences were between granule and decoction group (P > 0.05)  see .P < 0.05); no significant differences were between granule and decoction group (P > 0.05)  see .Most scientific literature about comparison between granule and decoction focused on animal and cell experiments, including the animal experiment showing that Bushen Qinggan Formula improved NO in SHR (spontaneously hypertensive rat) . AccordiTCM practitioners treat patients based on certain syndromes of patients, that is, “Syndrome Differentiation and Treatment” or “Correspondence of Prescription and Syndrome.” Bushen Qinggan Formula is also guided by this concept. Use of the combination of 5 herbal medicines in Bushen Qinggan formulation for the antihypertensive effects was a common practice according to the experts in TCM. The use of Bushen Qinggan formulation highlights the combination of syndrome and disease which coincides with the concept and treatment of modern medicine .A lot of clinical evidence shows that CM (Chinese Medicine) was effective for hypertension in clinical use , also poCurrently, TCM granules are commonly used in the clinic, but the role and efficacy comparing with traditional decoction are still controversial. For this research, the efficacy of two different forms of Bushen Qinggan Formula is similar in improving BPV and endothelial function. This study is designed as a pilot clinical trial. From its results, we find the trends of equivalent conversion for the two formulations. However, the approximate effect of decoction and granules is noteworthy and deserving further study, in order to make more patients willing to accept TCM treatment.Hypertension in three groups has no statistical difference; however, it is well controlled at the end of the study maybe because of the application of antihypertensive. These results suggest that blood pressure changes may not be the main function of the Chinese herb formula.


Current methods do not predict the acute renal allograft injury immediately after kidney transplantation. We evaluated the diagnostic performance of urinary calprotectin for predicting immediate posttransplant allograft injury.In a multicenter, prospective-cohort study of 144 incipient renal transplant recipients, we postoperatively measured urinary calprotectin using an enzyme-linked immunosorbent assay and estimated glomerular filtration rate (eGFR) after 4 weeks, 6 months, and 12 months.2 four weeks after transplantation . Higher urinary calprotectin concentrations predicted impaired kidney function 4 weeks after transplantation, as well as 6 months and 12 months after transplantation. When data were analyzed using the urinary calprotectin/creatinine-ratio similar results were obtained. Urinary calprotectin was superior to current use of absolute change of plasma creatinine to predict allograft function 12 months after transplantation. Urinary calprotectin predicted an increased risk both in transplants from living and deceased donors. Multivariate linear regression showed that higher urinary calprotectin concentrations and older donor age predicted lower eGFR four weeks, 6 months, and 12 months after transplantation.We observed a significant inverse association of urinary calprotectin concentrations and eGFR 4 weeks after transplantation . Compared to the lowest quartile, patients in the highest quartile of urinary calprotectin had an increased risk for an eGFR less than 30 mL/min/1.73 mUrinary calprotectin is an early, noninvasive predictor of immediate renal allograft injury after kidney transplantation. The immediate function of a renal allograft within the first weeks after kidney transplantation may vary considerably. The renal allograft may immediately start urine production. In contrast, the renal allograft may be damaged. An impaired renal allograft function within the first weeks or within the first year is detrimental to the longevity of the allograft and accounts for a 40% decrease in long-term graft survival Current methods do not predict the acute renal allograft injury immediately after kidney transplantation The study protocol was in accordance with the ethical standards of the Declarations of Helsinki and Istanbul. The study was approved by the local ethics committees .We performed a multicenter prospective-cohort study of 144 patients receiving kidney transplants. Patients who were at least 18 years old and who were scheduled to receive living donor kidney transplants or deceased donor kidney transplants were recruited. Written informed consent was obtained from all patients before entry into the study. Baseline characteristics of donors and recipients and information on organ procurement were prospectively obtained from medical records. Induction therapy, immunosuppressive therapy, concomitant medications, and transplant biopsy were all made by the clinicians at each institution according to their local protocols. Delayed graft function was defined by at least one dialysis session within 7 days of transplantation We collected one urine sample postoperatively. We aliquoted urine supernatants into cryovials, labeled each with a random barcode, and stored samples at −20°C. The enzyme-linked immunosorbent assay (ELISA) for urinary calprotectin was performed as previously published by our group using the PhiCal-Calprotectin assay kit  according to the manufacturer’s protocol Plasma creatinine was routinely measured. The absolute change in plasma creatinine was calculated as plasma creatinine preoperatively minus the first postoperative day. Four weeks, 6 months, and 12 months after transplantation we determined estimated glomerular filtration rate (eGFR) in kidney recipients according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation α×max−1.209×0.993Age×1.018 [if female]×1.159 [if black], where Cr is plasma creatinine in mg/dL, κ is 0.7 for females and 0.9 for males, α is −0.329 for females and −0.411 for males, min indicates the minimum of Cr/κ or 1, and max indicates the maximum of Cr/κ or 1.eGFR = 141×minCKD-EPI equation is recommended in transplanted patients because it more accurately gives true glomerular filtration rate measured by plasma clearance of (99 m)Tc-diethylenetriamine pentaacetic acid In 98 patients a baseline biopsy was performed at transplantation as benchmark for comparison of post-transplantation histology in case a post-transplant indication biopsy was necessary. Median number of glomeruli in the baseline biopsy was 7 . The severity of lesions  was scored semiquantitatively as published Continuous data are presented as median and interquartile range (IQR). Non-parametric Mann-Whitney test or Kruskal-Wallis test with Dunn’s Multiple Comparison Test were used as appropriate to detect differences between the groups. Frequency counts were calculated for categorical data. Differences in these categorical variables between the groups were analyzed by Chi-square test or Fisher’s exact text as appropriate. Associations between variables were determined using non-parametric Spearman correlation. We performed receiver operating characteristic (ROC) curve analysis to detect the accuracy of urinary calprotectin, urinary KIM-1, and absolute change in plasma creatinine for predicting eGFR after transplantation.We performed linear regression for associations between urinary calprotectin and eGFR four weeks after kidney transplantation while adjusting for donor age, donor gender, living-donor vs. deceased-donor status, recipient age, recipient gender, delayed graft function, recipient months on dialysis before transplantation, and use of prednisolone. For regression analyses urinary calprotectin concentrations were log-transformed to obtain normal distributed data to obtain normal distributed data as tested by Kolmogoroff-Smirnov-test. Multivariate models were constructed with backward variable selection, using P<0.05 for variable retention.Data were analyzed using GraphPad prism software  and SPSS for windows . All statistical tests were two-sided. Two-sided p-values less than 0.05 were considered to indicate statistical significance.Urinary calprotectin concentrations were measured in 144 patients after renal allograft transplantation. 85 transplant recipients were male (59%), and 59 were female (41%). Median age of recipients was 52 years . The cause of chronic kidney disease was diabetic nephropathy in 14 cases (10%), hypertensive nephropathy in 19 cases (13%), chronic glomerulonephritis in 53 cases (37%), polycystic kidney disease in 22 cases (15%), and other/unknown in 36 cases (25%). The number of patients with second or more transplants was 17 (12%). Median time on dialysis before transplantation was 26 months . 31 patients (22%) were smokers, 125 patients (87%) had hypertension, and 15 patients (10%) had a history of cardiovascular events. There was no association of calprotectin and cardiac events . 68 patients (47%) received kidneys from living donors, and 76 patients (53%) from deceased donors. 101 patients (70%) received tacrolimus, 43 patients (30%) cyclosporine A, 144 patients (100%) mycophenolate acid, and 75 patients (52%) prednisolone, respectively. The clinical characteristics of patients and their allograft are shown in 2 , then eGFRs were 46 mL/min/1.73 m2  and 40 mL/min/1.73 m2 , and finally in the highest calprotectin quartile eGFR was 33 mL/min/1.73 m2   and 40 mL/min/1.73 m2  in the lowest and highest calprotectin quartile, respectively  and 44 mL/min/1.73 m2  in the lowest and highest calprotectin quartile, respectively . In the lowest calprotectin quartile eGFR was 51 mL/min/1.73 mWe observed a significant association of urinary calprotectin levels with eGFR 4 weeks after transplantation  4 weeks after renal transplantation. On the other hand, only 8.3% of patients with urinary calprotectin concentrations in the lowest quartile  showed an eGFR in the lowest quartile . As the likelihood ratio equals 1.78, patients with higher urinary calprotectin concentrations more likely showed worse renal function.The predictive effect of urinary calprotectin could be observed both in transplants from living donors and deceased donors. In transplants from living donors the relative risk was 4.9 . In transplants from deceased donors the relative risk was 3.5 .2) 4 weeks after renal transplantation. Urinary calprotectin resulted in an area under curve (AUC) of 0.75 .Receiver-operating characteristic (ROC) curves showed that urinary calprotectin was able to predict the eGFR in the lowest quartile  to 0.69  with eGFR less than 40 mL/min/1.73 m2 (n = 58).2  whereas the highest quartile showed an eGFR of 36 mL/min/1.73 m2 . Receiver-operating characteristic (ROC) curves showed that urinary calprotectin/creatinine ratio was able to predict the eGFR in the lowest quartile  4 weeks after renal transplantation .When data were analyzed using the urinary calprotectin/creatinine-ratio similar results were obtained: The median urinary calprotectin/creatinine-ratio was 1.15 ng/g (IQR 0.67 to 3.00 ng/g). In the lowest calprotectin/creatinine quartile eGFR 4 weeks after renal transplantation was 46 mL/min/1.73 m2 , then eGFRs were 34 mL/min/1.73 m2  and 40 mL/min/1.73 m2 , and finally in the highest KIM-1 quartile eGFR was 28 mL/min/1.73 m2  (P = 0.06). 6 months after transplantation eGFRs were 54 mL/min/1.73 m2  and 34 mL/min/1.73 m2  in the lowest and highest KIM-1 quartile, respectively (P = 0.17). 12 months after transplantation eGFRs were 51 mL/min/1.73 m2  and 32 mL/min/1.73 m2  in the lowest and highest KIM-1 quartile, respectively (P = 0.25). Urinary KIM-1 levels were associated with eGFR 4 weeks after transplantation . We observed that 55.0% of patients with urinary KIM-1 in the highest quartile  showed an eGFR in the lowest quartile  4 weeks after renal transplantation, and 25.0% of patients with urinary KIM-1 in the lowest quartile  showed an eGFR in the lowest quartile . As depicted in 2).For comparison, data were obtained using urinary kidney injury molecule-1 (KIM-1). The median urinary KIM-1 was 0.56 ng/mL . In the lowest KIM-1 quartile eGFR was 48 mL/min/1.73 m2 12 months after transplantation, whereas the absolute change of plasma creatinine resulted in an AUC of 0.57   to predict eGFR less than 30 mL/min/1.73 m and Table S1 using mixed model analyses for estimated glomerular filtration rate 4 weeks after kidney transplantation confirmed these results. We also found that that higher urinary calprotectin concentrations and older donor age predicted lower eGFR 6 months as well as 12 months after transplantation.Univariate and multivariate linear regression analyses are shown in 2; IQR, 33 to 53 mL/min/1.73 m2; vs. 43 mL/min/1.73 m2; IQR, 25 to 59 mL/min/1.73 m2; P = 0.66). Furthermore, median urinary calprotectin concentrations were not significantly different between the subgroups without or with prednisolone .Median eGFR 4 weeks after transplantation were not significantly different between the subgroups without or with prednisolone . Multivariate logistic regression showed that living-donor vs. deceased-donor status (P = 0.003) predicted delayed graft function. In contrast urinary calprotectin (P = 0.51), donor age (P = 0.54), donor gender (P = 0.68), recipient age (P = 0.57) as well as recipient gender (P = 0.19) did not show significant effects. For delayed graft function urinary calprotectin resulted in an AUC of 0.59 . For delayed graft function urinary KIM-1 resulted in an AUC of 0.52 .We also analyzed urinary calprotectin levels in a subgroup of 38 patients who were anuric before renal transplantation. We would like to emphasize that that subgroup of 38 patients were anuric before renal transplantation, but not after transplantation. 5 out of 10 previously anuric patients (50.0%) with urinary calprotectin concentrations in the highest quartile showed a creatinine clearance in the lowest quartile. On the other hand, none out of 10 previously anuric patients (0.0%) with urinary calprotectin concentrations in the lowest quartile showed a creatinine clearance in the lowest quartile (P = 0.03).Histological evaluation could be performed in 98 baseline biopsies obtained at the time of transplantation. Urinary calprotectin concentrations were similar in patients receiving a graft without or with arteriolar hyalinosis ; vs. grade >0, median, 659 ng/mL ). Urinary calprotectin concentrations were also similar in patients receiving a graft without or with arteriolosclerosis  vs. grade 1, median, 616 ng/mL ) and receiving a graft without or with interstitial fibrosis  vs. grade 1, median, 724 ng/mL ). Only 13 patients had suspected rejection during the first 4 postoperative weeks, only 1 patient showed BANFF grade 1A rejection. These data may indicate that preexisting renal lesions per se may not affect postoperative urinary calprotectin concentrations.In the present study we showed that postoperative urinary calprotectin predicts kidney allograft function after transplantation. We observed that use of urinary calprotectin was superior to current use of absolute change of plasma creatinine to predict allograft function after transplantation. It is noteworthy to acknowledge the biologically plausible role of calprotectin in the mechanisms of ischemic reperfusion injury after kidney transplantation. The tubular damage leads to a secondary activation of the innate immune system with immigration of granulocytes and monocytes. Moreover it leads to an amplification and activation of toll-like receptors Looking at the results for urinary calprotectin and urinary KIM-1 it may be speculated that an increased neutrophil and macrophage response to ischemia-reperfusion injury may cause increased calprotectin levels. This may be supported by the finding that urinary calprotectin but not urinary KIM-1 was significantly associated with renal allograft function.A study by Szeto et al. in 63 kidney transplant recipients investigated urinary mRNA of neutrophil gelatinase-associated lipocalin, kidney injury molecule-1, interleukin-18, surfactant protein-C, and S100 calcium-binding proteins A8 and A9 according to histologic groups observed in biopsies from biopsy because of progressive worsening of allograft function. They showed that urinary mRNA of KIM-1 may provide prognostic information about renal function decline, irrespective of the kidney pathology The present study confirms previous reports that donor age has a large impact on allograft function. However, there is no treatment to adjust for the fact of using allografts from older subjects. It should be noted that urinary calprotectin predicted allograft function even after adjustment for donor age. Hence, measurements of urinary calprotectin may add to the diagnostic procedures.Beside the use of urinary calprotectin for prediction of immediate renal allograft injury, its determination immediately after kidney transplantation may be helpful and a necessary step for the implementation of future strategies to improve outcome after kidney transplantation. In summary, urinary calprotectin is an early, noninvasive predictor of acute renal allograft injury after kidney transplantation.Table S1Mixed model analyses for estimated glomerular filtration rate 4 weeks after kidney transplantation.(DOC)Click here for additional data file.


Endothelial dysfunction plays a key role in the pathogenesis of cardiovascular disease. However, the gender-related differences in risk factors for endothelial dysfunction are controversial. We investigated the gender differences in the risk factor profiles for endothelial dysfunction in Chinese hypertensive patients.Vascular endothelial functions in 213 hypertensive patients were measured by digital reactive hyperemia peripheral arterial tonometry (RH-PAT). Peripheral blood samples were collected, and the self-reported smoking and alcohol consumption status, age, body mass index, heart rate, blood pressure and drug administrations were recorded.RH-PAT indexes were attenuated in both male and female hypertensive patients [1.60 (1.38-2.02) vs. 1.63 (1.44-1.98)]. Multivariate logistic regression analysis identified plasma creatinine (p < 0.001), total cholesterol (p = 0.001), homocysteine (p = 0.002) and smoking (p < 0.001) as the independent factors correlated with gender . Multivariate linear regression analysis further identified homocysteine as the factor that is significantly and independently correlated with the decrease in the RH-PAT indexes in female patients . However, none of these four factors were correlated with the RH-PAT indexes in male patients.There are gender-related differences in the risk factors for endothelial dysfunction in Chinese hypertensive patients. Homocysteine is an independent factor for endothelial dysfunction in female hypertensive patients. The vascular endothelium plays a vital role in regulating the cardiovascular system and maintaining vascular health . EndotheEndothelial dysfunction occurs in response to vascular risk factors. The traditional risk factors for CVD are overall similar in men and women . HoweverWe evaluated 229 consecutive hypertensive patients who underwent peripheral endothelial function measurements at the Second Affiliated Hospital of Nanchang University from June 2013 to July 2014. Primary hypertension was defined as being treated with anti-hypertensive drugs or having a systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg. Hyperhomocysteinemia was defined as a total plasma homocysteine concentration ≥ 10 μmol/l. Exclusion criteria were secondary hypertension; previous diagnosis of diabetes mellitus; Parkinson’s disease; acute myocardial infarction; pulseless disease; severe systemic diseases, including systemic lupus erythematosus (SLE), or severe liver or renal disease; or any other situation that makes them unsuitable for participating in this study. We excluded 16 patients who met the exclusion criteria. Our final study sample included 113 male hypertensive patients and 100 female hypertensive patients.The study was conducted according to the guidelines of the Declaration of Helsinki and was approved by the Medical Research Ethics Committee of Second Affiliated Hospital of Nanchang University, and we obtained a signed informed consent from each patient before participation.A standardized medical history and accurate physical examination were obtained from all subjects. The self-reported smoking and alcohol consumption statuses were recorded. Height and weight were measured in a standing position without shoes. The body mass index (BMI) was calculated as the weight (in kilograms) divided by the height (in meters squared). After a 12-h fast , a peripheral blood sample was collected. The levels of creatinine, uric acid, fasting plasma glucose, total cholesterol (TC), triglyceride (TG), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol and Hcy were measured with a standard assays for all subjects. The estimated glomerular filtration rate (eGFR) was calculated according to the modified glomerular filtration rate estimating equation for Chinese patients with chronic kidney disease . The serPeripheral endothelial function was assessed using an Endo-PAT2000 device , as described previously . All tesBefore measurement, patients were asked to rest for 10 min. The peripheral blood pressure was measured three times in the right brachial artery ; the measurements were performed at a 2-min interval, and the average SBP and DBP measurements were used for analysis and further calculation. Briefly, one PAT finger probe was placed on the index finger of the hand undergoing hyperemia testing (right hand), and a second PAT probe was placed on the contralateral index finger (left hand). A blood pressure cuff was placed on one upper arm (right hand) at whichever occlusion pressure would be higher, 220 or 60 mmHg plus systolic blood pressure. This arm was the study arm, whereas the other arm served as a control arm. The signals were measured from each fingertip at the basal state, for 5 minutes; then, the arterial flow was interrupted for 5 minutes. The pulse amplitude was recorded for 10 minutes electronically in both fingers during cuff occlusion and following cuff deflation. Typical tracings are represented in Normally distributed results were expressed as the mean ± standard deviation (SD) values. The values of the RH-PAT index, age, BMI, plasma total Hcy, uric acid, creatinine, eGFR, TC, TG, HDL cholesterol, LDL cholesterol, DBP, and fasting blood glucose were not normally distributed and were expressed as the median value (interquartile range) and were log transformed before Pearson’s correlation and regression analyses. Categorical values were presented as the numbers (percentage) and compared by the chi-square test. Comparisons of continuous variables were analyzed by the independent-samples T-test or Mann-Whitney U-test, as appropriate. To determine the effect of a gender difference on the risk factors, multivariate logistic regression analysis with a Forward-Wald variable selection method was performed. Linear relationships between the RH-PAT index and risk factors were first analyzed by univariate analysis, which was followed by stepwise multivariate linear regression to assess the clinical marker correlated with the RH-PAT index in male and female hypertensive patients, respectively. Two multivariate linear regression analyses for the log RH-PAT were developed; model 1 included the variables that were statistically significant in the univariate analyses and model 2 included the factors that were independently correlated with gender differences. Pearson’s correlation was used for simple linear analysis between the RH-PAT index and plasma Hcy. A 2-sided p-value of < 0.05 was considered significant. All statistical analyses were performed with SPSS software for Windows, version 16.0 .This study reports the first vascular risk factor profile for endothelial dysfunction in male and female Chinese hypertensive patients. There was a gender difference in the association between risk factors and endothelial dysfunction. More importantly, we identified that an elevated Hcy level, a non-traditional risk factor, was significantly correlated with endothelial dysfunction in female patients.Gender-related differences in endothelial dysfunction are supposed to be related to age and hormonal status . CompareConsistent with the previous population-based studies , 20, theThe gender difference of the relationship between the plasma total Hcy and endothelial dysfunction in hypertensive patients may be clinically important. Over the past decade, researchers have made substantial efforts to improve our understanding of the gender differences in CVD and other vascular diseases, such as stroke. With respect to the vital role of endothelial dysfunction in vascular diseases, gender-related differences in endothelial dysfunction could be a potential tool in gender-related cardiovascular diseases . Gender As a novel marker and new vascular risk factor, the total plasma Hcy plasma has been demonstrated to be independently correlated with vascular disease , 26. NotEndothelial function is impaired across the stages of the menopause transition in healthy women. A decline in endothelial function begins during the early stages of menopause (perimenopause) and worsens with the loss of ovarian function and prolonged estrogen deficiency . Long-teLow HDL cholesterol, one of the conventional risk factors for CVD, has been well established as a risk factor for endothelial dysfunction. TraditiThe present study has certain limitations. There is a complete reversal of cardiovascular risk in women pre- vs post-menopause as well as in the years post-menopause ,33–36. HIn conclusion, the present study demonstrates that there are gender-related differences in the risk factors for endothelial dysfunction in Chinese hypertensive patients. An elevated total plasma Hcy level and reduced HDL cholesterol level were identified as risk factors that independently correlate with endothelial dysfunction in female hypertensive patients.S1 FigA and B, pulse amplitude recordings with PAT at baseline, during arterial occlusion , and during reactive hyperemia (after cuff deflation) in the ischemic arm. C, PAT recording from the contralateral finger not undergoing reactive hyperemia testing. A, female hypertensive patients with normal blood homocysteine showing a steady-state PAT signal (baseline) and complete disappearance of the signal during cuff inflation (occlusion), which is followed by an increased PAT signal during recovery (hyperemia) (RH-PAT = 2.60). B, female hypertensive patients with hyperhomocysteinemia showing a blunted finger PAT response during reactive hyperemia (RH-PAT = 0.71). C, PAT recording from the contralateral finger in the same patient with hypertension and hyperhomocysteinemia.(TIFF)Click here for additional data file.