Arterial blood pressure tends to rise with growth and development. Elevated blood pressure (EBP) in children usually occurs during the first two decades of life, and the children with hypertension tend to grow into adulthood with the high level of blood pressure. The prevalence of hypertension in children is increasing, the causes likely to be of different combination of factors. In this study we ascertained the prevalence of EBP in pre-school children in Enugu metropolis, South-East Nigeria and also determined its association with some factors like the Body Mass Index (BMI), urinalysis finding, family history, gender, age and socioeconomic class.A Stratified method of sampling was used to select subjects from registered nursery schools (Pre- elementary school) within Enugu metropolis. Physical examination of the recruited pupils was done with emphasis on arterial blood pressure, anthropometric measurements and urinalysis.Six hundred and thirty children (630) were studied out of which 345 (54.8%) were males and 285 (45.2%) were females. Sustained EBP (mainly systolic) were recorded in 12 pupils (1.9%) giving a prevalence of 1.9% of the pre-school population. The twelve (1.9%) pupils were all 5 years of age  and 11 (1.72%) of them were of under-weight BMI. The prevalence of obesity is 0.5% and that of under-weight is 92% of the studied population. There is no association between EBP and obesity . All the pupils with EBP had protein-free urine and no hematuria.EBP and under-weight malnutrition is common in children in 5 years age group. EBP in preschool children is not influenced by their body mass index, urinalysis finding, gender, family history of hypertension or socioeconomic class. The prevalence of hypertension in children is on the increase, as blooIn children, systemic hypertension is uncommon with only about 1 percent of the childhood population having blood pressure significantly above the normal range. SeveralIn this study we evaluated the usefulness of simply screening for high blood pressure and BMI calculation in early detection of blood pressure disorders in healthy pre-school children in Enugu metropolis in southeast Nigeria, with the objectives of determining the prevalence of pre hypertension and hypertension in these children and to ascertain its relationship with some known risk factors in asymptomatic subjects.This study was carried out in Enugu metropolis, the capital city of Enugu State south-east of Nigeria. The population of the preschool age group in Enugu town was 37,556 . WrittenA Stratified method of sampling was employed to get a sample that represents the population. The three local government areas  were used as the strata. In each stratum  four nursery schools were selected randomly from a constructed sampling frame of 75 Nursery schools.In each of the nursery schools, a sample size of 50–60 pupils was calculated and were selected randomly based on population of the school and were given the proforma with universal sample bottle for urine collection. Thus, the numbers of proforma given per-school depend on the population of the school. Selection of schools was influenced by the cooperation and readiness of the management to participate in the research. Six hundred and thirty (n = 630) subjects gave their informed consent to be part of the study and also met the inclusion criteria of relatively healthy children for the study. Exclusion criteria include subjects with age less than 2 and greater than 5 years old (at the last birthday), presence of symptoms of renal disease like dysuria, increased urinary frequency or urgency, macroscopic hematuria and facial or pedal edema, Presence of fever a week prior to the study, Lack of parental or guardian consent.We carefully made sure that confounding and modifying factors of protenuria and hematuria such as fever, intense activity or exercise, dehydration, emotional stress were ruled out in our study. This was done with thorough history taking and physical examination.2). We used the World Health Organization and Centers for Disease Control to classify BMI into underweight as BMI less than the 5th percentile, healthy weight as BMI of 5th up to the 85th percentile, overweight as BMI of 85th to less than the 95th percentile and obese as BMI equal to or greater than the 95th percentile for age and gender[Physical examinations which included blood pressure, height, weight, pulse rate, and temperature measurements were carried-out on the subjects by trained physicians in the research team coordinated by the principal author in a standardized way. Emphasis of the physical examinations was on Body Mass Index (BMI) and Blood Pressure (BP) measurement. The BMI was calculated by the formular: BMI = Weight (Kg)/height  of urine specimen using Combi 9 test strips by one of the authors. The second aliquot of the urine specimen and urine specimen of subjects with abnormal result (proteinuria and/or haematuria) were then transferred to the 10 ml test tubes, and were serially labeled and sent for microscopy. The specimens were centrifuged at 2000 rpm for 5 minutes. The microscopy was done on the sediments to determine presence of cast, red blood cells, white blood cells and crystals. From the proforma filled by the parents or care givers the family history of hypertension and renal disease was retrieved.The families were assigned socioeconomic classes using the recommended method (modified) by Oyedeji. The parYES for those with history of renal diseases and high blood pressure in their family, and NO for those who have no history of renal diseases and high blood pressure in their family. P value of < 0.05 was considered significant. Data presentation was in tables.Data analysis was done using statistical package for social sciences (S.P.S.S for windows 17.0 output). Frequencies were compared using Chi squared test. Chi square was also used to test for association between differences in proportions of the independent variables  on the dependent variables (Blood Pressure reading). All the continuous variables were re-grouped into categorical forms  also, age has its categories as age two, age three, age four and five. Sex was grouped as Male and female, other categorical variables include family history of blood pressure and family history of renal diseases grouped as A total of 630 subjects were studied comprising of 345 males (54.8%) and 285 females (45.2%), giving a male: female ratio of 1: 0.8. Of the 345 male subjects, 66 (19.1 percent) were aged 2 years; 85 (24.7%) 3 years; 95 (27%) 4 years and 99 (28.7%) 5 years. On the other hand, of 285 female subjects, 55 (17.5%) were aged 2 years; 84 (29.5%) aged 3 years; 68 (23.9%) aged 4 years and 83 (29.1%) aged 5 years. Sustained elevated BP were recorded in 12 (1.9%) of the studied population nine (1.4%) of which had pre -hypertension and 3 (0.5%) hypertension (Table There is positive family of hypertension in 71 11.3%) of the subjects out of which only 2 (0.3%) had elevated BP (Table % of the All the subjects with elevated BP had protein-free urine and no hematuria. Hypertension was observed in all the social classes of the studied population.There are several technical challenges in comparing various prevalence studies on elevated arterial BP in children because of the dissimilarity in the studied population and criteria used in defining the condition. In this study, we employed the definition of elevated BP based on the 2004 National High Blood Pressure Education Program Working Group in Children and Adolescent to evaluate and classify our subjects. Our stuThe prevalence of obesity and overweight were 0.5% and 0.3% respectively and there were no association between these and elevated BP. Several studies in the general population in Nigeria have documented prevalence rate of obesity in children and adolescents to range from 0.3 – 18%-23 and RIn this study, no association was observed between hypertension, proteinuria or hematuria which are surrogate markers for renal disease. The distribution of proteinuria and hypertension in this study had no significant preponderance for any particular socioeconomic group, although some of the renal disorders in Africa are related to infection and infestation which are commoner in the lower social class. There were also no signification association between EBP and positive family history of hypertension or renal disease in the subjects. Several studies had reported positive family history of hypertension, renal disease, change in dietary habits, decrease physical activities and increasing stress as affected by the socioeconomic status as risk factors for development of EBP in children,18,19.There is a significant association between EBP and pupils in 5 years age group while obesity, urinalysis finding, gender, family history and socioeconomic class do not affect BP.Pre-admission health examination should be introduced at primary school level and should include BP and BMI measurement in order to identify those with EBP. All cases of elevated blood pressure with or without abnormal BMI detected during this screening should be referred to Pediatric Nephrologists for proper evaluation and follow-up.BMI: Body mass index; EBP: Elevated blood pressure.The authors declare that they have no competing interests.OIO, EEN, JMC and OUE envision the study, participated in its design, data collection and coordination of the study and drafted the manuscript. HUO, JMC, OAO and UE contributed substantially to data collection, analysis and interpretation and revision of the manuscript. OIO, EEN, OAO, HUO, JMC, UE and OUE did the final revision of the manuscript. All authors read and approved the final manuscript for publication.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2431/14/64/prepub


Even though renal function decline is considered relentless in chronic kidney disease (CKD), improvement has been shown in patients with hypertensive nephropathy. Whether this can occur in any type of nephropathy and at any stage is unknown as are the features of patients who improve.51Cr-EDTA clearance at least 3 times during at least 2 years of follow-up. Individual examination of mGFR trajectories by 4 independent nephrologists classified patients as improvers, defined as those showing a sustained mGFR increase, or nonimprovers. Twelve patients with erratic trajectories were excluded. Baseline data were compared between improvers and nonimprovers, as was the number of recommended therapeutic targets achieved over time .We identified 406 patients in the NephroTest cohort with glomerular filtration rates (mGFR) measured by Measured GFR improved over time in 62 patients (15.3%). Their median mGFR slope was +1.88 ml/min/year; it was −2.23 for the 332 nonimprovers. Improvers had various nephropathies, but not diabetic glomerulopathy or polycystic kidney disease. They did not differ from nonimprovers for age, sex, cardiovascular history, or CKD stage, but their urinary albumin excretion rate was lower. Improvers achieved significantly more recommended therapeutic targets (2.74±0.87) than nonimprovers . They also had fewer CKD-related metabolic complications and a lower prevalence of 25OH-vitamin-D deficiency.GFR improvement is possible in CKD patients at any CKD stage through stage 4–5. It is noteworthy that this GFR improvement is associated with a decrease in the number of metabolic complications over time. Chronic kidney disease (CKD), which is associated with an increased risk of morbidity and mortality, is becoming increasingly common. Once CKD has developed, the glomerular filtration rate (GFR) declines at a rate that is considered inexorable albeit highly variable. Furthermore, patients whose GFR declines rapidly are at a particularly high risk of adverse cardiovascular disease events et al reported improvement in kidney function among a subset of patients with hypertensive CKD Although most CKD patients progressively lose renal function, a few studies have reported a significant proportion of patients with stable or improved renal function over time. Investigators for the REIN Follow-Up study showed that prolonged ACE inhibition can induce remission even in patients with severe disease Our aim in this study was to identify patients in the NephroTest cohort whose repeated GFR measurements over time showed an improvement in renal function over time and to describe their characteristics. This ongoing prospective cohort includes patients with various nephropathies and all stages of CKD except dialysis. We compared this subgroup with the rest of the cohort to identify factors associated with better prognosis.The NephroTest study is an ongoing prospective hospital-based cohort, enrolling patients with any diagnosis of CKD stages 1 through 5. Two nephrology departments recruited these patients, who undergo extensive annual work-ups, including measured GFR (mGFR), in the hospitals’ physiology departments 51Cr-EDTA renal clearance As reported elsewhere, all patients had GFR measured by Data recorded during annual 5-h visits to one of the two hospital physiology departments included demographics, primary renal diagnosis, medical history, height and weight, resting blood pressure (BP), and medications. Diabetes was either self-reported or defined as fasting glycemia>7 mmol/L or antidiabetic drug treatment. Smoking was self-reported. Cardiovascular disease history was defined as a history of stroke, ischemic heart disease , or heart failure. The causes and courses of nephropathies were verified from each patient’s original medical file.51Cr-EDTA renal clearance as previously described 51Cr-EDTA  was injected intravenously as a single bolus. Average renal 51Cr-EDTA clearance was then determined over 5 to 6 consecutive 30-min clearance periods. The coefficient of variation was 8.4% ±5.0 (n = 22). GFR was also estimated by the MDRD and CKD-EPI equations, with IDMS-traceable plasma creatinine values. We measured parathyroid hormone (PTH) concentration by a second-generation two-site immunoradiometric assay (ELSA-PTH kit from Cisbio Bioassays), plasma phosphate concentration by colorimetry (phosphomolybdate assay), calcium serum levels by flame photometry (Perkin Elmer 3300 atomic absorption spectrometer), potassium serum levels and venous total CO2 (tCO2) with a specific electrode (ABL 815 from Radiometer and Beckman SX9), and albuminemia by immunonephelometry. We measured urinary protein by colorimetry  and expressed the results as the urinary protein-creatinine ratio (UPCR) mg/mmol creatinine. Urinary albumin was measured with solid-phase fluorescent immunoassays and expressed as the urinary albumin-creatinine ratio (UACR). Plasma 25(OH)D concentration was measured by a radioimmunological method that recognized both 25OHvitamin D2 and D3. Normal values range from 10 to 40 pg/ml.The mGFR was assessed by 2 value <22 mmol/l, hyperkalemia as serum potassium >5 mmol/l, and 25(OH)D deficiency as <15 ng/ml.Thresholds used to define metabolic complications were based on current international guidelines whenever available. We used K/DOQI criteria to define anemia, that is, Hb concentration <110 g/l. We also calculated anemia prevalence estimates based on WHO gender-specific thresholds: Hb concentration <130 g/l for men and <120 g/l for women. Hyperparathyroidism was defined as an intact PTH concentration >60 pg/ml , hyperphosphatemia as a plasma phosphate value >4.3 mg/dl (or 1.38 mmol/L), metabolic acidosis as a tCOWe studied four therapeutic targets: systolic and diastolic blood pressure: <130 mm Hg and <80 mm Hg respectively, albuminuria <3 mg/mmol of creatinine or proteinuria <20 mg/mmol, and use of renin angiotensin system blocker. We assigned 1 point if the therapeutic target was achieved, 0 if it was not achieved.The Kappa statistic estimating agreement among the four nephrologists was computed withthe SAS macro %MAGREE  or medians  reported, as appropriate. We compared baseline clinical and laboratory data and cardiovascular and CKD risk factors between improvers and nonimprovers. The sample size for each variable is specified in the tables. Continuous variables were compared with the Wilcoxon test and categorical variables with the chi2 or Fisher’s exact test. Linear or logistic regression allowed us to test whether adjustment for mGFR affected any significant crude differences found between the groups.We compared improvers and nonimprovers for the number of therapeutic targets achieved at baseline and at study end and for the mean over time. We then performed a logistic regression analysis to estimate of kidney function improvement according to the number of therapeutic targets achieved at baseline or during follow up, adjusted for baseline or mean mGFR, center, age, gender, BMI, African origin, and diabetes. We studied mGFR improvement according to proteinuria and BP considered continuously  or as categorical variables (at baseline), adjusting for the same covariates and use of renin angiotensin system blocker.2 <22 mmol/L), hyperkalemia (potassium >5 mmol/L) at baseline and during follow-up between the two groups. Statistical analyses were performed with SAS 9.2  and R .Finally, we compared the type and number of antihypertensive medications, as well as the prevalence andnumber of CKD metabolic complications including hyperparathyroidism (PTH >60 ng/mL), anemia (Hb <110 g/L), hyperphosphatemia (phosphate >1.38 mmol/L), acidosis (venous tCOSixty-two (15.3%) patients were classified as improvers, and 332 as nonimprovers. The median(IQR) mGFR slope for the improvers was 1.74 ml/min/year and for the nonimprovers, −2.31, both significantly different from zero . It is wThe initial nephropathy among the 62 improvers was glomerular disease for 19, tubulo-interstitial nephropathy for 16, vascular nephropathy for 17 (15 nephroangiosclerosis and 2 thomboticmicroangiopathy) including diabetes for 9, nephron reduction for 6 , and undetermined for 4. Most patients with glomerular disease had had a renal biopsy (16/19). Interestingly, no improver had either diabetic glomerulopathy or polycystic kidney disease, diseases that affected 12.7% and 4.5% of the nonimprovers.At baseline, the two groups did not differ significantly for age, sex ratio, ethnicity or BMI. Around 10% the patients had African ancestry. Both MDRD and CKD-EPI eGFR were significantly higher in improvers than nonimprovers, but the difference in median mGFR value was on the borderline of significance . Of noteImprovers had diabetes mellitus less often than nonimprovers . The proImprovers had lower systolic, diastolic, mean, and pulsed arterial BP than nonimprovers. Moreover, improvers had high BP, whether defined as >140/90 mmHg or 130/80 mmHg, less often than nonimprovers. At baseline, the proportion of patients receiving antihypertensive therapy, higher than 90%, did not differ between the two groups, nor did the mean number or type of medications. However, at the last visit, improvers used ACEi or ARBs and diuretic loops significantly less often, as well as significantly fewer types of different antihypertensive medications than nonimprovers . The daily protein intake, estimated from urinary excretion of urea nitrogen per kilogram of body weight, was similar between groups, as was the proportion treated with anti-platelet agents (aspirin or clopidogrel).Improvers had less urinary protein excretion than nonimprovers  accordinCompared with nonimprovers, improvers achieved more therapeutic targets at both first and last visits  and had The proportion of patients with anemia, hyperkalemia, acidosis, or hypocalcemia did not differ between groups . HyperphInterestingly, at the first visit, improvers had already developed fewer metabolic complications than nonimprovers: 0.7±0.6 and 1.0±1.0, p = 0.02, respectively. They also developed fewer complications during follow-up: 0.5±0.6 and 1.2±0.8, p<0.0001. The prevalence of two or more metabolic complications at the first visit was 6.5% in improvers and 25.0% in nonimprovers (p = 0.0012); at the last visit, these percentages were 4.8% and 38.8% (p<0.001) respectively .51Cr-EDTA renal clearance, a gold standard method to assess renal function In this study, we demonstrate that renal function can improve sustainably over time in a subgroup of patients followed and treated for CKD. Given the reputedly relentless nature of CKD, the existence of our group of improvers may appear surprising, but the methods we used attest to its reality. First, we measured GFR in all patients, using 2 per year 2/year in 55% of patients, including those with an improving slope. Others have emphasised the beneficial effect of nephrology referral and reported a positive slope for eGFR (more than +1 ml/min/1.73 m2/year) in 18% of patients in stages 2 and 3 of CKD and in 24% of those in stage 4 The 15.3% prevalence of GFR improvement observed in this cohort is consistent with the few reports previously published. In the 2-year follow-up of the MDRD study, GFR remained stable in 19% of patients and improved in 11% A second important finding is that this favourable disease course occurred in patients with various initial nephropathies. The notable exceptions were diabetic and polycystic kidney diseases, not seen in any improvers. Both those nephropathies are well known for their relatively poorer prognosis. Polycystic kidney disease has been reported to be resistant to ACE inhibitor treatment and to progress relentlessly even after inhibition of cyst development Surprisingly, GFR also improved in some patients with advanced CKD: 24.2% of the improvers had advanced CKD, in stage 4 or 5. Our results suggest that the ability to heal persists in some conditions in advanced CKD. This is consistent with previous evidence from the REIN study demonstrating that the tertile with the lowest GFR at inclusion had the most ESRD events prevented We assessed the number of achieved recommended treatment targets, based on the main established modifiable risk factors for CKD, including systolic and diastolic blood pressure, proteinuria or albuminuria, and use of angiotensin blockers. We observed a higher number of achieved targets in improvers than in nonimprovers at all visits, despite a lower need for antihypertensive and antiproteinuric treatments. The use of a higher number of treatments in nonimprovers may clearly reflect indication bias. However, it is important to note that the number of achieved targets was significantly associated with mGFR improvement independent of baseline or mean mGFR and of progression risk factors. Thus our results confirm the value of achieving recommended therapeutic targets to preserve renal function. Improvers also differed from nonimprovers in their CKD metabolic complications. This finding underlines the possible deleterious role of metabolic complications on GFR progression. We considered CKD metabolic complications to include hyperphosphatemia, metabolic acidosis, anemia, hyperkalemia, and elevated parathormone, as previously reported Metabolic acidosis is another risk factor for renal disease progression, and its correction with sodium bicarbonate slows renal function decline in stage 2–5 CKD We found that native vitamin D deficiency was less prevalent in improvers than nonimprovers. This result is important because vitamin D deficiency is very common in CKD patients, and its prevalence increases as GFR declines Major strengths of this study include the quality of the patient phenotype, including repeated GFR measures with a reference method, and the variety of nephropathy types. Its principal limitation is that data could be confounded by a regression to the mean (RTM) phenomenon. RTM is indeed a concern when the outcome is the evolution of a continuous variable over time. However, it is considerably reduced when the evolution is studied with several measurements, which we did by selecting patients with at least 3 measurements. Moreover, we performed several sensitivity analyses and found RTM was limited. In addition, our classification of patients was not based on mGFR slopes estimated from linear regression, but on the examination of mGFR trajectories by four independent nephrologists. While we cannot rule that this qualitative method may have slightly overestimated the number of improvers, it is outweighted by strong agreement between nephrologists in their evaluation. Another limitation is that this is an observational study, and observed associations cannot be presumed to be causal relations. Moreover, as with all studies of change in GFR, our study is subject to potential survival bias, which may result in overestimating the prevalence of mGFR improvement. Finally, despite careful data collection, we cannot exclude unrecognized therapeutic modifications for some patients that could be responsible for bias.In conclusion, our data show that renal function can improve over time in a significant proportion of CKD patients, even at a severe stage. It is noteworthy that the observed GFR increase is associated with a decrease in the number of metabolic complications over time, thus demonstrating true renal function improvement. Achievement of the current targets of nephroprotection is essential for preserving renal function. Our results also suggest that treating metabolic complications and 25(OH)D deficiency more effectively could promote improvement in renal function. Prospective replication of these findings during intervention trials is now required.File S1Combined file of supporting figures and tables.(DOC)Click here for additional data file.


Racial disparities in prevalence and control of high blood pressure are well-documented. We studied blood pressure control and interventions received during the course of a year in a sample of black and white Medicaid recipients with high blood pressure and examined patient, provider, and treatment characteristics as potential explanatory factors for racial disparities in blood pressure control.We retrospectively reviewed the charts of 2,078 black and 1,436 white North Carolina Medicaid recipients who had high blood pressure managed in primary care practices from July 2005 through June 2006. Documented provider responses to high blood pressure during office visits during the prior year were reviewed.P = .001). Blacks above goal were more likely than whites above goal to have been prescribed 4 or more antihypertensive drug classes ; to have had medication adjusted during the prior year ; and to have a documented provider response to high blood pressure during office visits . Many blacks (28.0%) and whites (34.3%) with blood pressure above goal had fewer than 2 antihypertensive drug classes prescribed.Blacks were less likely than whites to have blood pressure at goal (43.6% compared with 50.9%, In this population with Medicaid coverage and access to primary care, blacks were less likely than whites to have their blood pressure controlled. Blacks received more frequent intervention and had greater use of combination antihypertensive therapy. Care patterns observed in the usual management of high blood pressure were not sufficient to achieve treatment goals or eliminate disparities. Racial and ethnic health disparities have become a prominent issue in the national debate about health care in the United States and have been particularly well-documented in cardiovascular disease (CVD), including stroke, coronary heart disease, heart failure, and high blood pressure -3. DeathA number of factors are important in achieving adequate control of high blood pressure, including biological, cultural, social, and health care provider and system factors .Although access to health care has dominated the national debate about the inadequacies of the US health care system, racial and ethnic disparities among patients with similar access to care and similar socioeconomic status are known to exist . PreviouMedicaid is the largest provider of health insurance for low-income and minority populations in the United States, and Medicaid patients have a disproportionate share of cardiovascular risk factor prevalence, uncontrolled blood pressure, and associated illness and death ,11. We rWe used Medicaid administrative data to select a representative sample of North Carolina Medicaid recipients aged 21 years or older with high blood pressure managed in the primary care setting. Recipients were enrolled with Medicaid for at least 11 months from July 1, 2005, through June 30, 2006, and had an office visit with a diagnosis of high blood pressure (ICD9 401xx), excluding pregnancy-induced high blood pressure. We excluded patients who had any office visits with a cardiologist or endocrinologist during this time and those receiving dialysis services for end-stage renal disease. This study was performed as a quality improvement activity of the North Carolina Division of Medical Assistance and was exempted from review by the University of North Carolina Office of Human Research Ethics.North Carolina had a traditional fee-for-service (FFS) program for Medicaid recipients and 2 managed-care programs during the study period: Carolina ACCESS (CA-I), in which recipients are assigned to a primary care provider (PCP), and ACCESS II (CA-II), which additionally incorporates community-based care management and quality improvement initiatives. PCPs were identified according to administrative assignment for eligible patients in the CA-I and CA-II systems. For FFS patients, the PCP was identified by examining professional services claims submitted during the eligibility year with the following specialty type: general or family medicine, internal medicine, obstetrics and gynecology, pediatrics, federally qualified health center, rural health center, nurse practitioner, or health department. The provider who had submitted the most claims (or the most recent claim in case of a tie) was identified as that patient's PCP. In Medicaid administrative data, "provider" refers to a single physician or a larger practice organization.To ensure a representative statewide sample and adequate sampling from 8 counties planning a high blood pressure initiative for CA-II enrollees, we used a stratified cluster sampling design and randomly selected PCPs within 4 sampling strata . We excluded providers with fewer than 5 eligible patients. A total of 4,046 charts were reviewed from March through July 2007. Of these, we excluded 224 patients from analysis because there was no high blood pressure diagnosis in the chart; 60 patients because they had no office visit after June 30, 2005; and 20 patients because no blood pressure measurement was documented. We limited our analyses to patients identified as black or white in the medical record, or if not available in the record, according to self-reported race in Medicaid enrollment data. We could not determine patient race for 3.5% of charts reviewed. The final sample included data for 2,078 black and 1,436 white patients from a total of 160 providers.We abstracted medical record data from the offices of selected PCPs by using an electronic clinical abstraction tool developed by Michigan Peer Review Organization and the North Carolina Division of Medical Assistance. Q Mark Inc  provided trained nurses for the chart abstractions who passed interrater reliability and consistency tests. Reviewers followed systematic guidelines and read all summary documents in the chart as well as clinic notes and correspondence for a 12-month look-back period from the most recent visit. Each chart was reviewed by a single reviewer.PCP specialty was determined by self-identification of the billing practice as recorded in Medicaid administrative data. Length of time with PCP was calculated on the basis of the earliest service date and the most recent service date documented in the chart. Providers located in a county with a population density of more than 200 people per square mile, according to US Census 2000 data, were classified as urban; all others were classified as rural.2 and was calculated by using the isotope dilution mass spectrometry (IDMS)-traceable Modification of Diet in Renal Disease (MDRD) Study equation from the most recent serum creatinine level documented in the medical record. Body mass index (BMI) was calculated from most recent weight and height documented in the medical record, when available. If no height was recorded in the medical record, the sex-specific median height of the study population was used to calculate BMI. Tobacco use status, creatinine, and weight were not available for 31%, 9%, and 2% of patients, respectively. Antihypertensive agents listed on the patient's medication regimen at the time of abstraction were recorded. Combination therapy was defined as the use of 2 or more of the following antihypertensive drug class categories: angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers, beta blockers, calcium channel blockers, thiazide diuretics, other diuretics, vasodilators, and antiadrenergic agents.All study analyses were based on medical record documentation. The goal for blood pressure treatment was defined as less than 130/80 mm Hg for patients with diabetes and less than 140/90 mm Hg for all others, in accordance with the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) . A comprP value less than .10 were included in the final model. In step 2, we added provider characteristics, including PCP specialty, rural versus urban location, number of years of care with current PCP, and number of visits to PCP during the prior year. Covariates associated with blood pressure control with a P value less than .10 were included in the final step 2 model.We used the most recent blood pressure measurement available from the patient's medical chart to assess the prevalence of above-goal blood pressure in blacks compared with whites. Next, we examined the bivariate relationships between race and patient and provider characteristics that may influence blood pressure control. To assess potential explanations for racial disparities in blood pressure control, we used logistic regression to calculate odds ratios (ORs) for the association between blood pressure control and race (black vs white) and expected covariates. First, in the step 1 full model, we tested for contributions of patient characteristic variables in predicting blood pressure control, including sex, age, comorbidities, and number of medications. Covariates associated with blood pressure control with a To examine the hypothesis that differential treatment patterns may contribute to observed differences in blood pressure control, we analyzed treatment characteristics for the subset of black and white patients with blood pressure above goal. Treatment characteristics included discussion of medication adherence, diet, weight reduction, exercise, sodium restriction, and moderation of alcohol; change in antihypertensive medication regimen in the prior year; and number of antihypertensive drug classes prescribed in combination.We additionally examined provider response to high blood pressure during office visits within the year before the most recent office visit, up to 5 visits per patient . For visits with blood pressure above goal, we examined the likelihood that patients had the following care components: 1) documentation of a lifestyle recommendation , 2) change in antihypertensive medication regimen, and 3) a documented plan for follow-up care.F-adjusted Rao-Scott χ2 square and Wald χ2 square tests were used.To analyze data, we used SAS versions 9.1 and 9.2 . Weights were applied to correct for the unequal chance of being selected for patient clusters within providers in the 4 sampling strata, and for unit nonresponse. Analyses accounted for the clustering of patients within providers and for stratification. For significance testing, the P = .001) (P < .01), and age distribution was similar. Although the presence of most comorbidities was similar, blacks were less likely to have hyperlipidemia, chronic kidney disease, chronic obstructive pulmonary disease, asthma, or reactive airway disease, and were less likely to smoke. Whites were more likely than blacks to have 8 or more total active medications (56.6% vs 46.6%). Looking specifically at antihypertensive medications, however, nearly half (46.7%) of blacks were on 3 or more antihypertensive drug classes compared with a third (31.3%) of whites. Geographic location, length of time with current PCP, and number of office visits in the prior year did not differ by race.The proportion of patients who had met their blood pressure goal was significantly lower among black patients than white patients  . A greatP = .009). Inclusion of provider characteristics to the model in step 2 had little additional effect on the association between race and blood pressure control , and the relationship remained significant. In addition to race, diabetes, weight status, and PCP specialty other than family practice or internal medicine were associated with poor blood pressure control in the final model.In step 1 of the logistic regression modeling , when coP = .006), whereas other types of lifestyle recommendations  did not differ significantly by race. Only 47.4% of black and 47.2% of white patients with blood pressure above goal had any documentation of lifestyle recommendations during the prior year. Use of combination antihypertensive therapy was more common among blacks (P < .001). Blacks were more likely than whites to have had a change of antihypertensive medication regimen during the prior year .Among patients who had not achieved their blood pressure goal  , blacks P = .002) and more likely to have any documented intervention (medication change or lifestyle recommendation) . There was no significant difference between races in the likelihood of antihypertensive medication change. A follow-up care plan was noted during 64.3% of above-goal visits for blacks and 69.1% of above-goal visits for whites (P = .08). Planned follow-up within 4 weeks was noted for only 27% of these visits for both races.A total of 14,583 office visits were reviewed. Blood pressure was elevated during 4,812 (57.2%) office visits during the prior year for blacks, and 2,931 (49.4%) office visits for whites . During In this statewide sample of Medicaid patients with high blood pressure managed in the primary care setting, blacks were less likely than whites to have their blood pressure controlled. We found that adjusting for observed patient and provider characteristics slightly attenuated the relationship between race and blood pressure control but did not completely explain racial differences.One strength of this study is that the sample is representative of a statewide Medicaid population with high blood pressure, spanning multiple systems of care and treatment localities. Medicaid recipients are characterized by many factors known to be associated with poor blood pressure control or poor health outcomes, including low socioeconomic status and higher prevalence of multiple comorbidities ,14. Our Provider characteristics, and quality and intensity of care have been shown to be significant causes of health disparities . DiffereLack of appropriately aggressive care, or clinical inertia, has been cited as a cause for suboptimal control of chronic disease risk factors across much of the US health care system . We confWe were unable to explore many characteristics of patients, health systems, and environments that may contribute to racial disparities in blood pressure control, including health literacy, medication adherence, and barriers to following therapeutic lifestyle recommendations . Racial This study had several limitations. We may have overestimated blood pressure control in this population because all patients sampled were receiving primary care services, and patients with more complicated disease  were excluded. Our study population had a lower proportion of patients older than 65 years than the source Medicaid population, probably because of these exclusions. Generalizability to other populations is also limited. Medicaid eligibility requires meeting state-specific thresholds of low income and assets, in addition to categorical requirements of being elderly, disabled, or pregnant, or having dependent children. Our analyses were limited to information obtainable in the medical record and relied on the accuracy of clinic blood pressure measurements and completeness of chart documentation, which may be particularly unreliable in assessing the extent of therapeutic lifestyle counseling. We counted as evidence of counseling any mention of lifestyle factors or medication adherence in the visit note.In summary, the gap between current care and ideal care for both black and white Medicaid recipients with high blood pressure is substantial, even among patients with frequent access to primary care. Racial disparities in blood pressure control are not readily explained by socioeconomic, demographic, or comorbidity differences or by provider characteristics or treatment patterns. Current care patterns are not sufficient to eliminate racial disparities in blood pressure control or to achieve desired treatment goals. The consequences of ineffective health care for high blood pressure, in terms of avoidable cardiovascular illness, death, and health care costs, disproportionately affect blacks. Emerging models of high blood pressure care, incorporating patient-centered care teams and planned, longitudinal stepped care approaches, show promise for improving outcomes across all patient populations -30. It c


Cardiovascular disease is the most prevalent disease mainly in the Western society and becoming the leading cause of death worldwide. Standard methods by which healthcare providers screen for cardiovascular disease have only minimally reduced the burden of disease while exponentially increasing costs. As such, more specific and individualized methods for functionally assessing cardiovascular threats are needed to identify properly those at greatest risk, and appropriately treat these patients so as to avoid a fate such as heart attack, stroke, or death. Currently, endothelial function testing—in both the coronary and peripheral circulation—is well established as being associated with the disease process and future cardiovascular events. Improving such testing can lead to a reduction in the risk of future events. Combining this functional assessment of vascular fitness with other, more personalized, testing methods should serve to identify those at the greatest risk of cardiovascular disease earlier and subsequently reduce the affliction of such diseases worldwide. One of the goals of personalized medicine is to identify patients at risk for future cardiovascular events. Methods such as genomics, proteomics, metabolics, and transcriptomics are used to discern a marker or a set of markers that will identify the people who are at risk and also identify the optimal treatment for each individual. However, in certain areas, such as heart diseases, the predictability of these methods is lacking.About 1.4 million heart attacks ) occur in the United States every year. The most common screening for heart disease is done by taking a history and conducting minimally invasive blood tests at the doctor’s office. These tests provide certain parameters such as blood pressure, cholesterol glucose, and C-reactive protein levels, which, as shown in the Framingham study,Although this stepwise strategy is aimed at identifying those most likely to have significant coronary or arterial diseases, in reality the picture is quite different. One study has shown that of 136,905 people presenting with coronary diseases, 77% had normal low-density lipoprotein (LDL) levels.Four separate studies have shown that there is a relationship between stressful events such as earthquakes, missile attacks, stock market fluctuations, and even soccer matches and the incidence of acute coronary syndrome.Acute coronary syndrome and sudden death is a dynamic process. The process occurs at the interface between the vascular wall and the circulating blood. Thus, it is important to develop a test that measures vascular function, not one that just measures cholesterol levels or takes images of the arteries. If an intact blood vessel is put into a glass vessel and acetylcholine is added to the buffer, a relaxation of the blood vessel will occur. However, if there is an injury to the endothelial layer of cells or the blood vessel, this reaction will not happen. The main molecule that mediates this reaction is nitric oxide (NO).Not all vessels or blood vessel segments react in a similar fashion. People whose blood vessels display abnormal endothelial-dependent reactivity have an increased risk for coronary diseases. Abnormal blood vessel reactivity was first measured in an experiment conducted 25 years ago. In that experiment, acetylcholine was infused into the left anterior descending artery. In some patients, the reaction to acetylcholine was normal, and the resulting effect was vasodilation. In other patients, the reaction to acetylcholine was abnormal, and the resulting effect was vasorestriction.19The endothelial layer responsible for the response to NO is also responsible for the body’s reaction to exercise and mental stress. In both these situations, the normal response of the arteries is endothelial deposit vasodilation, which increases blood flow to the myocardium. However, when vessels react abnormally, the blood flow to the myocardium is restricted, and the result is reduced oxygen supply.reactive hyperemia. In this test, blood flow is temporarily cut off using a blood pressure cuff. After the pressure is released, blood flow returns to normal after a short period of time. In normal people, a measurable dilation of the brachial diameter occurs at roughly 30 seconds following pressure release and tapers off at roughly 90 seconds. This response is not seen in people who have an endothelial layer dysfunction. The response of large blood vessels can be measured using ultrasound, and the response of smaller vessels, such as those in the finger, can be measured using an EndoPAT device .The abnormally reacting endothelial layer is not limited to the coronary arteries but is a body-wide systemic reaction. This dysfunction is associated with other diseases such as stroke, vascular dementia, sleep apnea, and erectile dysfunction. However, the fact that this disorder is systemic can be advantageous because it allows detection through non-invasive diagnostic tests. If the endothelium reacts abnormally in the arm, finger, or leg, it can be used to identify a cardiac at-risk patient. Such a test was developed around 10 years ago and is based on the endothelium test to Several studies have shown the predictability and efficacy of the endothelial function test. One study confirmed that endothelial dysfunction is associated with a higher rate of coronary adverse effects during a follow-up period.20Mental stress is also mediated by endothelin. A difference in vascular response was seen between men and women who were put under mental stress.apical ballooning, or takotsubo cardiomyopathy, that affects mainly postmenopausal women. A study on women who had experienced stress-induced heart attacks showed that exposing them to mental stress caused their blood vessels to constrict instead of expand.17An example of stress-induced heart attacks can be seen in a syndrome called In addition to the endothelial function test being a predictive parameter for coronary disease onset, it can also predict the effectiveness of a treatment given to patients with cardiovascular disease. One study followed a group of hypertensive women with no significant heart disease.Wall Street Journal article ,According to a recent Novel imaging modalities have demonstrated that the arterial wall is not a homogeneous structure. There are areas that have no plaques, areas that have unstable plaque, and areas with stable plaque. In addition, not all blockages and lesions are created equally. Some lesions block the blood flow and others do not.It is very important to differentiate between these stable types of plaque so that patients receive optimal care. The COURAGE trial  involved 2,287 patients who had stable coronary artery disease.A subsequent study examined the COURAGE results and measured the fractional flow reserve (FFR) to differentiate between coronary lesions causing ischemia, and blockages not causing ischemia.In the 1960s, a relatively small number of patients was sufficient to see a significant difference on cardiovascular events between treated and untreated groups. Today, however, since patients are getting better medical care and improved treatments, the delta between study groups is much smaller, thus necessitating studies of at least 20,000 patients in order to see significant differences between treatment groups. Therefore, it is of utmost importance to find ways to treat individual patients based on parameters such as individual functional tests so that true differences will be apparent without the need for very large and highly expensive mega-studies.In conclusion, functional tests have been found to be essential in predicting both at-risk populations and treatment outcomes. Using functional risk assessment tests can bring about an improvement in the individual’s health care outcome along with a reduction in health care costs. It is therefore just as important, and sometimes more important, to look at the functionomics of the individual patient and not only at the other four classical individualized healthcare parameters of genomics, proteomics, metabolics, and transcriptomics.


Heart failure is a very common disease, with severe morbidity and mortality, and a frequent reason of hospitalization. Anemia and a concurrent renal impairment are two major risk factors contributing to the severity of the outcome and consist of the cardio renal anemia syndrome. Anemia in heart failure is complex and multifactorial. Hemodilution, absolute or functional iron deficiency, activation of the inflammatory cascade, and impaired erythropoietin production and activity are some pathophysiological mechanisms involved in anemia of the heart failure. Furthermore other concomitant causes of anemia, such as myelodysplastic syndrome and chemotherapy, may worsen the outcome. Based on the pathophysiology of cardiac anemia, there are several therapeutic options that may improve hemoglobin levels, tissues' oxygenation, and probably the outcome. These include administration of iron, erythropoiesis-stimulating agents, and blood transfusions but still the evidence provided for their use remains limited. Cardiovascular diseases are among the most frequent causes of death worldwide , 2. HearIn the last 19 years the role of several immunological, metabolic, and neurohormonal abnormalities has been recognized in the pathophysiology and progression of the congestive heart failure (CHF) , 5. AmonUsing the historical definition by the World Health Organization, anemia is defined when Hb concentration is less than 13 g/dL for men or less than 12 g/dL for women . HoweverAnemia is prevalent in patients with CHF but the exact rates vary widely . A recen−1/1.72 m−2). CHF and CKD share some common causes , features , and risk factors . In a meta-analysis of 16 studies, it was found that 63% of 80,098 patients with CHF had some degree of concomitant impaired renal function and 29% of them had severe CKD. This is associated with an increased risk of adverse outcome [One of the most frequent comorbid conditions in patients with CHF is CKD (as defined by an estimated glomerular filtration rate (eGFR) <90 mL/min outcome , being p outcome . In larg outcome , 18. Thi outcome .Anemia exacerbates symptoms of heart failure. There is an impaired mechanism in which tissue hypoxia and release of nitric oxide (NO) cause decreased arteriolar resistance and peripheral vasodilatation. These in turn lead to decreased blood pressure, increased sympathetic activation, renal vasoconstriction, reduced renal function, and activation of renin-angiotensin aldosterone system. The results are production of antidiuretic hormone, fluid retention, left ventricular (LV) hypertrophy and dilation, worsening of heart failure, release of brain natriuretic peptide (BNP), and signs from stress on myocardium. The final outcome, completing the vicious circle, is further anemia. This, however, implies that in the presence of volume overload there might be a decrease in Hb concentration and also oxygen content, although red cell mass remains stable . The patFinally, most studies indicate that the prevalence of anemia is increased in patients with CHF who also have co-morbid kidney disease, advanced age, and more severe symptoms when compared to less symptomatic ambulatory populations .The major factors contributing to CHF-related anemia involve CKD, renin-angiotensin system, hematinic abnormalities, mainly iron deficiency, chronic inflammation, and hemodilution . A major factor contributing to anemia of CHF is kidney dysfunction, being associated with the cardiac disorder. The renal damage in the CHF is mainly hypoxic, due to reduced renal flow, caused by the reduced cardiac output , 24. HypThe renin-angiotensin system seems also to be involved in the control of erythropoiesis. Angiotensin II reduces renal blood flow, increases the oxygen demands, and thereby stimulates EPO production . It alsoIron deficiency is common in patients with CHF especially when accompanied by CKD , whereasThere are many causes of absolute iron deficiency associated with CHF, especially in coexistence with CKD. These includelow iron intake (due to low protein diets and anorexia),gastrointestinal blood loss ,iron malabsorption , removal of blood for tests.α (TNF-α), and less frequently interleukin-18 (IL-18) seem to be the most important, whereas IL-6-induced hepcidin expression also participates in the phenomenon [κB, and impaired response to bone marrow erythroblasts. It also causes hepcidin-induced blockade of iron absorption from the gut and iron trapping in reticuloendothelial system's stores. Hepcidin is an acute phase antibacterial protein, induced by IL-6, through JAK/Stat3 pathway, released from the liver and excreted from the urine. Therefore, in CHF with a concomitant CKD, there is a reduced hepcidin removal from the kidney, implying a further increase of its levels. Hepcidin inhibits ferroportin, a protein expressed on intestinal cells, macrophages, and hepatocytes that releases the iron from those cells into the blood. Hepcidin-induced inhibition of ferroportin causes decreased iron absorption from the gut and blockade of iron release from its stores, in hepatocytes and macrophages, into the blood. This implies inadequate iron delivery to the bone marrow erythroblasts, although the total stores may be adequate, causing a functional iron deficiency. Furthermore hepcidin seems to exert a direct inhibitory effect on erythroblast proliferation and survival [In CHF the functional iron deficiency is related to iron disuse, resembling anemia of chronic disease, as evidenced by iron acquisition by the reticuloendothelial system . In patienomenon , 38, 39.survival .α serum levels and worsening of molecular signaling pathways. Those defects may participate in the transition from adaptive cardiac hypertrophy to permanent cardiac impairment in chronic iron deficiency [α and free radicals, as expressed by total peroxides, and higher levels of anti-inflammatory interleukin-4) compared to patients receiving EPO alone [Iron metabolism is crucial for energy production in the body and most importantly for cells with high energy demands, such as cardiomyocytes . Iron plficiency . On the PO alone . FurtherPO alone  and has PO alone . In a rePO alone . Another effect of iron deficiency on CHF patients is the consequent thrombocytosis. CHF is a hypercoagulable state , where tα levels [α neutralising antibodies [Except iron disuse, inflammatory cytokines may cause EPO resistance in anemic CHF patients. It has been suggested that there is a diminished responsiveness of erythroid cells to EPO, being accompanied by increased levels of inflammatory cytokines, such as IL-6, soluble TNF receptor 2, and TNF-α levels , 53. Theα levels . This istibodies .α, impair hematopoiesis in CHF following myocardial infraction [Another factor contributing to anemia of CHF patients is NO. Endothelial dysfunction associated with heart failure may alter endothelial NO synthase activity, hence further augmenting myocardial dysfunction due to increased oxidative stress . Parallefraction .A recent study suggests that vitamin D deficiency is independently associated with anemia in end-stage heart failure, based on the fact that vitamin D may stimulate erythropoiesis. On this study circulating 1,25-dihydroxyvitamin D was a better predictor of anemia than circulating 25-hydroxyvitamin D. Prospective randomized studies with administration of vitamin D will have to clarify if the association of vitamin D deficiency with anemia is causal .In conclusion anemia in CHF is multifactorial. Two major factors contributing and exacerbating to its appearance are kidney dysfunction and iron deficiency. In 2003 this abnormality was described as cardio renal anemia syndrome (CRAS) , whereasCHF is not just a hemodynamic disorder. It is the final common pathway of other conditions, where renal failure and anemia contribute to the progression to a more severe disease status. They also could be potential targets for intervention. Since the two major components of CHF anemia are iron deficiency and reduced EPO activity , the main goals of intervention would be to increase their levels. Anemia treatment strategies in heart failure patients include erythropoiesis-stimulating agents (ESAs) and red blood cell transfusions. Iron replacement in iron-deficient patients with or without anemia has also been investigated. Before starting any treatment for anemia in CHF, it is necessary to exclude and treat, if possible, any other causes of anemia, such as active bleeding, hemolysis, vitamin B12 or folate deficiency, or even more chronic situations such as myelodysplastic syndromes and other malignancies. Health Services Research & Development Service's Evidence-based Synthesis Program has collected the literature from 1949 until November 2010 and published a review regarding the treatment of anemia in CHF and coronary heart disease patients . DespiteIt has been suggested that a small reduction of Hb levels may worsen the outcomes and symptoms of CHF, whereas the correction of anemia may improve NYHA classification, LVEF, LVH, and diuretic response –63. TreaThere are many data supporting that iron deficiency may contribute to the increased mortality in CHF patients. It has also been shown that correction of iron deficiency could improve symptoms and status of the syndrome. Nevertheless, this has not been adequately confirmed . There aε isoform signalling, to directly affect both calcium release dynamics and myofilament function [Regarding ESAs, there are only pilot studies for their use in the treatment of anemia of CHF. Uncontrolled hypertension and iron deficiency are contraindications. They are commonly used with simultaneous administration of IV iron, giving promising results in ameliorating symptoms and improving cardiac function, but only with very limited evidence , 78. Morfunction . TherefoRecently, there have been many studies of anemia in CHF patients with an effort to improve Hb levels. There have been used ESA and oral or IV iron and even IV iron without ESA, that have shown a positive effect on hospitalization, NYHA functional class, cardiac and renal function, quality of life, exercise capacity, and reduced BNP, without any increase in cardiovascular damage related to the therapy. However, adequately powered long-term placebo-controlled studies of ESA and IV iron in CHF are still needed and are currently being carried out . NeverthRecent studies have recognized that dilutional anemia is highly prevalent in CHF patients. In this regard, arginine vasopressin antagonists might be an attractive treatment option, by increasing aquaresis. Until now, there is only indirect evidence supporting a rationale for their use. Therefore, future clinical research should explore the role of arginine vasopressin pathway activation in determining dilutional anemia and, ultimately, assess it as a therapeutic target .Anemia is common in patients with heart disease. The evidence base to date does not convincingly support a role for ESAs for anemia correction. On the other hand, iron treatment may help ameliorate symptoms over the short term in patients with symptomatic heart failure. The role of blood transfusions remains understudied and unclear .It seems that anemia exacerbates CHF, causing a vicious circle, where renal dysfunction and neurohormonal and proinflammatory cytokine activation participate in the development of anemia. On the other hand, anemia increases myocardial workload and worsens cardiac dysfunction. So, it is important to recognize any possible causes of anemia. It would also be beneficial to treat them, if possible. Administration of iron and ESAs seems to be promising, since they can both also improve factors other than anemia, but still there are many questions to be answered. These mainly concern their safety, the goals in Hb elevation, and probably their cost. Further studies are required to understand the association of anemia with CHF outcomes, to recognize the impact of anemia improvement, to asses when to initiate and when to cease the treatment, and finally to estimate the safety of these interventions.


The relationship between hypertension and kidney disease is complicated. Clinical trials found intense blood pressure control was not associated with alterations in glomerular filtration rate (GFR) in all patients but did slow the rate of GFR decline among those with a higher baseline proteinuria. However, the underlying mechanism has been unclear.We tested the hypothesis that the association between high blood pressure and renal function is modified by albuminuria status by conducting analyses in a cross-sectional study with 12,440 adult participants without known kidney diseases, diabetes or cardiovascular diseases, participating in the National Health and Nutrition Examination Survey (NHANES) 1999–2006.P for trend<0.0001); on the other hand, the prevalence of undiagnosed hypertension was also significantly higher among subjects with moderate-severe renal insufficiency than those with mild renal insufficiency , supporting an association between hypertension and renal function damage. In contrast, no association between hypertension and renal insufficiency was observed among those without albuminuria in this population. Similar findings were observed when the CKD-EPI equation was used.1226 out of 12440 were found to have unknown high blood pressure and 4494 were found to have reduced renal function. Overall, a moderate association was found between high blood pressure and renal function insufficiency in all participants analyzed. However, among participants with albuminuria, the prevalence of moderate-severe renal insufficiency substantially and progressively increased from normal subjects to prehypertensive and undiagnosed hypertensive subjects (1.43%, 3.44%, 10.96%, respectively, The association between high blood pressure and reduced renal function could be dependent upon the albuminuria status. This finding may provide a possible explanation for results observed in clinical trials of intensive blood pressure control. Further studies are warranted to confirm our findings. Participants with abnormal BP (prehypertension or hypertension) were more likely to be older, non-Hispanic, obese (BMI≥30 kg/m2) and to have lower educational attainment. In addition, those individuals with hypertension were less likely to be current smokers or current drinkers, more likely to be former smokers, and were more likely to have a lower income and lower energy intake.Among the 12,440 participants who had no known cardiovascular diseases or CKD, 4,717(37.9%) of them had normal blood pressure, 3,326 (26.7%) had prehypertension, 1,226 (9.9%) had undiagnosed hypertension, and 3171(25.5%) had diagnosed hypertension. Participant characteristics by blood pressure (BP) status are shown in MDRD <90 mL/min/1.73 m2 was 63.2%, with prevalence of 54.07%, 2.35% and 0.06% for mild (eGFR 60–89 mL/min/m2), moderate (eGFR 30–59 mL/min/m2) and severe (eGFR<30 mL/min/m2) renal insufficiency, respectively. We found prevalence of mild renal insufficiency was not significantly associated with blood pressure status, whereas the prevalence of moderate-severe renal insufficiency moderately increased from normal subjects to prehypertensive, undiagnosed hypertensive and diagnosed hypertensive subjects . In the stratified analyses by level of albuminuria, we found among participants with ACR≥30 mg/g, the prevalence of moderate-severe renal insufficiency substantially and progressively increased from normal subjects to subjects with prehypertension, undiagnosed hypertension and diagnosed hypertension . The prevalence of normal kidney function and mild renal insufficiency did not significantly differ by blood pressure status. On the other hand, there were no such trends among those with ACR<30 mg/g. We found very similar association patterns when the CKD-EPI equation was used (data not shown).Shown in MDRD≥90 mL/min/1.73 m2, 60–89 mL/min/1.73 m2, and <60 mL/min/1.73 m2). In stratified analyses by ACR, we found the prevalence of undiagnosed hypertension was much higher in those with albuminuria compared to those without albuminuria , whereas the prevalence of prehypertension was similar. Again, similar findings were observed when the CKD-EPI equation was used (data not shown).We also did stratified analyses of age-standardized prevalence of different blood pressure status  by albuminuria (data not shown). The overall prevalence of prehypertension, undiagnosed hypertension and diagnosed hypertension was 26.74%, 9.86% and 25.49%, respectively, and remained similar among the 3 GFR stages  control has been considered the basis of therapy for slowing renal deterioration The association between high blood pressure and renal insufficiency is complex and multifactorial. It is believed hypertension and CKD may mutually be both the cause and consequence of each other We found the association between high blood pressure and moderate-severe renal insufficiency only appeared statistically significant among those with albuminuria (ACR≥30 mg/g), but not among those with ACR<30 mg/g. This finding suggests kidney function may be associated with elevations in blood pressure only when albuminuria is present. This might provide a possible explanation for the renal-protective effects of more aggressive BP control only occurring among participants with albuminuria in previous large-scale clinical trial studies The current study has several strengths and implications. This is a population-based study with nationally representative samples. Using eight years of NHANES data provides a large sample and precise estimates of undetected chronic conditions. Participation rates for the interview and medical examination center during 1999–2006 NHANES were high, which may minimize potential selection biases. We have excluded participants with self-reported kidney diseases,diabetes or cardiovascular diseases in the analyses to minimize the influence of diet change or medication use on blood pressure, urinary albumin excretion or renal function. We have also examined the associations using both the MDRD and CKD-EPI equations and found similar results. However, as with all cross-sectional studies, one major concern is that the temporal sequence may not be clear. It is possible that our results could be due to reverse causation. Findings of this study should be considered preliminary. Thus, future prospective studies are necessary to further replicate our findings. It is possible that albuminuria underlies the association between high blood pressure and renal dysfunction In conclusion, our cross-sectional study found the association between high blood pressure and reduced renal function was modified by the albuminuria status among participants without diabetes, CKD or cardiovascular disease, excluding interference from medication use or dietary changes. Furthermore, our findings suggest this also could be true among those with a mildly reduced or normal kidney function. Further studies are warranted to confirm our findings and explore this promising possibility.The NHANES consists of cross-sectional, multistage, stratified, clustered probability samples of the civilian non-institutionalized US population Our study was limited to adult participants from 1999–2006 NHANES, who were 20 years or older  and were not pregnant or lactating . Because the presence of chronic diseases may affect renal function, we excluded those with self-reported kidney disease (18421), or cardiovascular diseases (16207), or diabetes, . Also excluded were those with missing values for blood pressure, urine protein excretion, or serum creatinine concentration. As a result, 12,440 adult participants were included in the final analyses.A standardized protocol for measurements of auscultatory blood pressure (BP) was executed during the examination center visit by a trained physician using a mercury sphygmomanometer with appropriate cuff sizes. Recorded systolic BP (SBP) and diastolic BP (DBP) were the means of three (sometimes four) measurements separated by 30 seconds after a 5-minute rest period Self-reported information on demographics , socioeconomic status , and lifestyle factors  were obtained during the interview portions of the surveys. Height and weight were measured at the examination center. Random spot urine samples were obtained. Urine albumin was measured using solid-phase fluorescence immunoassay. For those with albuminuria measurement lower than the assay’s detection limit, 0.2 µg/ml was assigned We classified the participants into the following four BP categories: 1) self-reported hypertension are those who answered ‘yes’ to the question ‘Have you ever been told by a doctor or other health professional that you have hypertension, also called high blood pressure?’. Among those who answered ‘no’ to that question, we defined them based on their measured averaged systolic or diastolic blood pressure: 2) participants who had undiagnosed hypertension are those who had either measured SBP≥140 mm Hg or DBP≥90 mm Hg; 3) participants who had prehypertension are those whose SBP ranged from 120–139 mmHg or DBP ranged from 80–89 mmHg; and 4) participants who had normotension are those who had SBP<120 mmHg and DBP<80 mmHg, according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) 2) = 175.0× (SCr)−1.154×age−0.203×0.742  ×1.212 (if African American), where age was expressed in years and SCr was standardized serum creatinine level in milligrams per deciliter 2; 2) mildly decreased renal function with eGFR 60–89 mL/min/m2; and 3)moderately to severely decreased renal function with eGFR<60 mL/min/m2To appropriately estimate glomerular filtration rate (GFR), all serum creatinine measurements were re-calibrated to standardized creatinine measurements obtained at the Cleveland Clinic Research Laboratory following National Kidney Disease Education Program (NKDEP) Urinary albumin-to-creatinine ratio (ACR) was computed in milligrams per gram. Albuminuria was defined as ACR≥30 mg/g, consistent with the position statement of the National Kidney Foundation and the National Institute of Diabetes and Digestive and Kidney Diseases We performed statistical analyses using the Survey procedure in SAS 9.2 software  to estimate variance after incorporating the weights for the sample population, which took into account unequal selection probabilities and planned oversampling of certain subgroups resulting from the complex NHANES multistage stratified cluster sample design


There were 173 (28.3%) deaths due to pre-eclampsia, and 38 (6.1%) associated with chronic hypertension. Cerebral complications were the final cause of death in 283 (45.5%), while cardiac failure and respiratory failure were the final causes in 142 (22.8%) and 158 (25.4%), respectively.From 2005–2007, there were 622 deaths associated with hypertensive disorders of pregnancy. Eclampsia was the major cause of death  and delay in seeking help  were major patient-related factors. Communication problems  and lack of facilities  were health administration issues. Health worker-avoidable factors included problem recognition, delay in referral and management at an inappropriate level of healthcare.Major problems were identified in all areas of assessment. Non-attendance for antenatal care (Compared to the previous report of 2002–2004, there was a reduction in deaths due to hypertension. In the United Kingdom, despite the fact that maternal deaths are uncommon, hypertensive deaths are the second commonest cause after thrombo-embolism.All maternal deaths in South Africa are notifiable to the Department of Health and are reported in a structured data form called the Maternal Death Notification Form, which contains demographic data and clinical details surrounding the primary and secondary causes of death. This form, together with a copy of the hospital records, is sent to the provincial Maternal, Women and Child Cluster who in turn, get an experienced maternal health specialist and a midwife (trained assessors) to formulate a confidential opinion on any substandard care based on patient-related, administrative, and health personnel-related factors. All assessments are collated every three years and published as the Saving Mothers report. Recommendations to reduce maternal deaths are also included in this report.The primary causes of deaths in the various sub-categories of hypertensive disorders are shown in There was a small decline in the number of deaths from cerebral complications, from 316 (2002–2004) to 283 patients. Nonetheless, deaths from cerebrovascular events are a serious concern. Guidelines for the treatment of hypertension associated with severe pre-eclampsia and eclampsia are provided by the National Health Department. Deaths from intracranial haemorrhage probably indicate inadequate treatment of severe hypertension or patient delay in seeking help. In the latest Why Women Die ,n = 90; 17.8%), 2002–2004 , and 2005–2007 .There was an increase in the number of deaths from cardiac failure as shown in Patient-orientated problems show slight improvements The patient, a 27-year-old parity 3, had high blood pressure during her antenatal visits. She had had a previous caesarian (C/S) and had three antenatal visits at a tertiary-care centre.4) was prescribed and a C/S was performed ‘under platelet cover’. Post-operatively, there was difficulty in controlling her high blood pressure; she had HELLP with jaundice and demised at 12:00 the next day.At her last visit, her blood pressure was 170/110 mmHg, she was admitted at 11:00 and methyl dopa was prescribed. She had a seizure at 23:00 on the day of admission. Magnesium sulphate  high blood pressure values and continuing antihypertensive therapy.It is of obvious concern that large numbers of deaths still occur from pre-eclampsia and eclampsia in South Africa. These pregnancy-specific hypertensive conditions are treatable and most are preventable by early detection, adequate treatment and timely delivery. The present report indicates that 304 cases were clearly avoidable.4 and the lack of clinical protocols of management are significant issues associated with maternal deaths due to pre-eclampsia.4 is widely available and is on the essential drug list for use at all health facilities. Further, clinical guidelines for the management of hypertension and, in particular, the management of obstetric emergencies have been widely distributed to all hospitals and clinics . It does appear though that these guidelines might not be reaching all health professionals. Face-to-face teaching and emergency drills on the labour ward floor, on a regular basis, may improve the situation.A recent articleIntracranial haemorrhage remains the commonest final cause of death in hypertensive disorders of pregnancy. Although, the exact mechanisms that are associated with hypertension and intracranial haemorrhage are not clearly understood, it would appear that both systolic and diastolic hypertension play a role. It is generally accepted that diastolic blood pressures of ≥ 110 mmHg are linked with intracranial pathology but recently sustained systolic hypertension has also been found to play a significant role. A systolic blood pressure value above which urgent antihypertensive treatment should be given has been identified as 155–160 mmHg.1Clinical experience indicates that in young women with an abrupt onset of severe hypertension, the blood pressure levels are often labile, therefore not only should blood pressure measurements be performed more frequently, but early treatment of hypertension considered. Treatment of very high blood pressure is an essential component of the immediate management of severe hypertension, impending eclampsia and eclampsia, and serious consideration must be given to the use of rapid-acting antihypertensive agents. In South Africa, oral nifedipine, dihydrallazine in some institutions, and intravenous labetalol are available for this purpose.The commonly used antihypertensive medications for lowering very high blood pressure in pregnancy in South Africa are labetalol, dihydrallazine and nifedipine. These drugs are recommended in the Guidelines for maternity care for clinics and district hospitals.08The latest Saving Mothers report (2005–2007) indicates a number of women developed eclampsia/severe hypertension in the postpartum period. This suggests that antihypertensive medications are stopped once delivery of the baby has occurred. In general, high blood pressures may take up to six weeks to normalise. Therefore, antihypertensive medications must be continued postpartum and the dosage reduced in a stepwise manner.Cardiac and renal failure were assigned as the final and contributory causes of maternal deaths in 42.9 and 8% of cases, respectively. The number of cases of death due to renal failure has declined but those from cardiac failure have increased since the 2002–2004 report. In the previous report,1In a recent report on maternal deaths related to hypertension, one of 27 deaths between 2000 and 2004 was due to cardiac failure. The authors point out that postpartum mobilisation of extracellular water and subsequent shift into the intravascular compartment can aggravate hypertension, and that obstetricians should be aware of this.9The categorisation of patients into deaths from renal failure, cardiac failure and respiratory causes of death is to a large extent arbitrary and should not necessarily be viewed as distinct entities. The three entities should be regarded as the same thing, namely fluid overload. Fluid overload should be recognised early and be treated adequately. There is a predominance of deaths from pulmonary oedema in this group of deaths. Therefore, detecting patients at risk by history and examination, early referral and appropriate critical care are essential for this group of patients.In this audit, of the 207 women who had cerebral complications, the average blood pressure values were systolic 177 (103–244 mmHg) and diastolic 115 mmHg (74–162 mmHg). These are extremely high values and do imply that young women with severe pre-eclampsia and eclampsia require lowering of high blood pressure in a controlled and smooth manner to prevent severe hypotension. This is of particular importance as most of the patients are young and the onset of hypertension is usually abrupt.Eighty per cent of the 207 women who had convulsions were primigravidae and their mean age was 27 years (range 13–45). Furthermore, 16 had systolic blood pressure values above 160 mmHg with diastolic blood pressures of less than 110 mmHg. High blood pressure control is of extreme importance and due diligence must be given to use of rapid-acting antihypertensive agents and frequent blood pressure measurements in the acute phase of the condition. Attention should also be given to the use of anticonvulsant therapy to arrest seizure activity. It is likely that the blood pressure rises further during seizure activity and that most cerebrovascular accidents occur at this time, particularly in patients with low platelet counts.Infrequent antenatal attendance continues to be a challenge. In the public hospitals of South Africa, most women ‘book’ for antenatal care but often this is in mid-gestation, and follow-up visits are infrequent. Community education on the benefits of antenatal care was emphasised in the last Saving Mothers report, but it appears that implementation of this recommendation may not have been done. Public health education and involvement of partners and families should, once again, be a priority.In the previous report, the issue of ‘hidden pregnancies’ was highlighted.Maternity care is free of financial cost in South Africa and access to antenatal clinics widely available, therefore other issues, social and cultural factors may be involved. Improvement in education in general, the dissemination of health information on radio, television and the print media may be ways of overcoming this challenge. More specifically, education of antenatal attendees at time of booking and at every visit should be emphasised. Women with chronic hypertension or those pre-eclamptics being treated as outpatients should be informed about the likely complications and steps to take if these symptoms occur.The previous report also highlighted the problems related to emergency management and recommendations were made regarding under-, post-graduate and continuing professional education, short of instituting that all doctors should undergo a course on emergency resuscitation prior to registering as general practitioners. Hands-on courses on mannequins done at frequent intervals are also recommended. The National Committee on Confidential Enquiries into Maternal Deaths is promoting a training programme on obstetric emergencies called Essential Steps in the Management of Obstetric Emergencies (ESMOE). This involves trainers visiting all health districts and carrying out face-to-face training for doctors on mannequins and other visual aids on the emergency management of common conditions causing maternal deaths.Deaths from hypertensive disorders of pregnancy remain the commonest direct cause of maternal death and most of the deaths had avoidable factors and substandard care. There is a continuing need for better education of women, families, communities and professionals concerning the danger signs of the complications of hypertension. The need for early and regular attendance of antenatal care should also be emphasised. In addition, health professionals need to be educated about women at risk and be aware of factors associated with complications associated with pregnancy hypertension


Aspergillus, Penicillium and Candida albicans allergens in the severe group were significantly higher compared with those in the moderate and mild groups ; those of the moderate group were significantly higher compared with those of the mild group (P<0.05). No significant difference was observed for the levels of sIgE to Alternaria alternata among the three groups. sIgE to Cladosporium herbarum was not present for all three groups. No significant difference was observed for the levels of sIgE to non-fungal allergens among the three groups. Fungal allergens are closely correlated with the severity of asthma, whereas non-fungal allergens are not.Fungal sensitisation is closely associated with asthma; however, the correlation between fungi and asthma severity remains unclear. The aim of this study was to investigate the severity of asthma in 100 patients with asthma due to fungal and non-fungal allergens. A total of 100 outpatients and inpatients with asthma were selected from 2010 to 2011 and were divided into three groups  according to their clinical manifestations, lung function results and treatment situations. Enzyme-linked immunosorbent assay (ELISA) was used to detect the levels of specific immunoglobulin E (sIgE) to five fungal allergens and seven non-fungal allergens in the serum of all patients. The levels of sIgE to  Alternaria alternata, Penicillium, Aspergillus and Cladosporium, are common allergens of patients with asthma  to various fungal and non-fungal allergens and investigate the correlation of fungal sensitisation with asthma severity in the local region. This study is likely to be significant in the prevention and treatment of severe asthma.A total of 100 cases of outpatients and inpatients diagnosed with bronchial asthma were selected from 2010 to 2011. All patients complied with the diagnostic criteria in the Prevention and Treatment Guideline of Bronchial Asthma prepared by the Asthma Study Group under the Respiratory Disease Branch of the Chinese Medical Association in 2008. According to the clinical manifestations of the patients, lung function prior to treatment and treatment modes for maintaining asthma control, the asthma severity of the patients was classified into mild severity (grades 1 and 2), moderate severity (grade 3) and severe severity (grade 4) . Patientμl standard solution was added. In the test sample well, 10 μl test sample solution was initially added (five times the test sample dilution solution). No solution was added to the blank control well. Then, the plate was incubated in an incubator at 37°C for 30 min. The liquid in each well was removed and the plate was dried with bibulous paper. Subsequently, each well was filled with washing solution. After standing for 1 min, the washing solution was removed, the plate was dried with bibulous paper and the plate was washed repeatedly four times. Approximately 50 μl enzyme working fluid was added to each well, with the exception of the blank control well. The plate was incubated at 37°C for 30 min. The liquid in each well was then removed and the plate was dried with bibulous paper. Subsequently, each well was filled with washing solution. After standing for 1 min, the washing solution was removed, the plate was dried with bibulous paper and the plate was washed repeatedly four times. Approximately 50 μl chromogenic agent liquid A was placed into each well and then 50 μl chromogenic agent liquid B was added. After the plate had been agitated on the flat mixing device for 30 sec, development was conducted at 37°C for 15 min in the dark. Then, the enzyme-linked immunosorbent assay (ELISA) plate was removed and 50 μl termination solution was added to each well to terminate the reaction. Zone adjustment was conducted in the blank well. The absorbance values [optical density (OD)] of the various wells were measured at 450 nm within 15 min of the termination of the reaction. The linear regression equation of the standard curve was calculated according to the standard concentrations and corresponding OD values. The corresponding sample concentration was calculated based on the sample OD value using the linear regression equation. The final concentration is calculated as the product of the measured concentration multiplied by the dilution factor.A refrigerated sIgE kit  was used and maintained at room temperature for 30 min. The concentrated washing solution (20 times) was diluted with distilled water for repeated use. An adequate number of enzyme-encapsulated plates was fixed onto the frame. The standard, test sample and blank control wells were set up and the positions of the various wells were recorded. In the standard well, 50 SPSS 17.0  was used for statistical analysis. Measurement data are expressed as mean ± standard deviation. One-factor analysis of variance was used for comparison of means among multiple groups, whereas the Chi-square test was used for comparison of classification data. P<0.05 was considered to indicate a statistically significant difference.For the clinical features of the three groups of patients with asthma, patients in the mild group and the moderate group were significantly younger compared with those in the severe group . No significant differences among the various groups were observed in terms of gender, asthma onset age < 40 years old, smoking, allergic rhinitis disease history and positive family history of asthma. In the clinical examinations, no significant difference was noted for tIgE, eosinophil percentage, forced expiratory volume in 1 sec (FEV1) and FEV1/forced vital capacity (FVC) among the three groups .Penicillium, Aspergillus and C. albicans, was significantly higher in the severe group than in the moderate and mild groups; the percentage in the moderate group was significantly higher compared with that in the mild group (P<0.05). For A. alternata-sensitised patients, no significant difference was observed in the percentages among the three groups. Patients with asthma caused by C. herbarum were not observed in the three groups. The percentage of patients sensitised by any of the five fungi was significantly higher in the severe group than in the moderate and mild groups; the percentage in the moderate group was significantly higher compared with that in the mild group (P<0.001). In the severe group, almost half of the patients with asthma were sensitised by any of the fungi. For patients simultaneously sensitised by multiple fungi, no significant difference was observed in the percentages among the three groups.The percentage of patients with asthma sensitised by fungal allergens, including Dermatophagoides pteronyssinus, house dust, cat hair, dog hair, Artemisia argyi and a tree combination (maple/birch/beech/oak/Chinese parasol/poplar), no significant difference was noted in the percentages among the three groups. For patients sensitised by any of the seven non-fungal allergens, no significant difference existed in the percentages among the three groups. Moreover, no significant difference was observed in the percentage of patients simultaneously sensitised by multiple non-fungal allergens among the three groups. The percentage of patients sensitised by combined fungal and non-fungal allergens was significantly higher in the severe group than in the moderate and the mild groups; the percentage in the moderate group was significantly higher compared with that in the mild group . Regarding the level of sIgE to A. alternata, no significant difference was observed among the three groups of patients with asthma. sIgE to C. herbarum among the three groups was not present. Regarding the levels of sIgE to seven non-fungal allergens, no significant difference was noted among the three groups of patients with asthma  reached 54%. However, the percentage of patients sensitised by fungi in the other group of patients with asthma who were not admitted in the ICU was only 30% (A. alternata sensitisation is a risk factor for the development of severe asthma (The results of the current study demonstrated that fungal sensitisation is common in patients with severe asthma and fungal allergens, including herbarum . The suronly 30% . An addie asthma .A. alternata sensitisation is not correlated with asthma severity, in opposition to the results of previous reports. Asthma patients sensitised by C. herbarum were not observed in the three groups. Given the different geographical environments, climates and vegetations, greater differences exist in the distribution of allergenic fungi between regions (Penicillium and Paecilomyces variotii were the dominant colonies of fungi distributed in the air in Beijing, which was in line with the distribution of fungi in the environment, wherein Aspergillus yeast and A. alternata were the dominant colonies. In the literature, A. alternata is not reported to be the dominant fungus in the air in Beijing. In the literature, A. alternata is not reported to be the dominant fungus in the air in Beijing. Moreover, the data demonstrated that the distribution of C. herbarum is not detected in Beijing (A. alternata. Given that C. herbarum content is undetectable in the air, the possibility of C. herbarum sensitisation is extremely minimal.The results of the current study indicate that common  regions . A study Beijing . These fThe results of studies concerning the correlation of non-fungal allergens with disease severity in patients with asthma are inconsistent. A number of studies suggested that certain non-fungal allergens, including dog hair, are associated with asthma severity, whereas other studies suggested that no correlation existed between these components ,16. In tC. herbarum, A. alternata and Aspergillus. Fungal and non-fungal allergens, including D. pteronyssinus, dog hair and pollen, are protein allergens. However, fungal allergens have unique features; they constantly germinate and infect the host or implant in the respiratory tract of the host. Therefore, fungi generate non-allergenic toxins and enzymes to pathogenic bacteria by stimulating the defense system of the host. These substances have an auxiliary role in sensitisation stimulation and cause a greater impact on the host.The difference between fungal and non-fungal allergens lies in the complex fungal allergen components. Fungal allergens include proteases, glycosidases, protein product components, oxidative stress-related proteins and enzymes involved in glyconeogenesis or the pentose phosphate pathway. Proteases and glycosidases directly affect the host, whereas the other three components function in the metabolism process of spore germination. Therefore, the exposure to fungal spores is equivalent to the exposure to all fungal allergens and not just the exposure to simple allergens, including non-fungal allergen pollen protein or animal pelage. In addition, fungi are common in the environment; therefore, the human respiratory tract is often exposed to fungal spores in the air. The most common airborne fungi include C. albicans and Tracheophyta, are common colonisation fungi of the skin or gastrointestinal tract. Although C. albicans is not an airborne fungus, reports have indicated that ∼10% of patients with mild asthma and almost 33% of patients with severe asthma are sensitised by this fungus (C. albicans, which is significantly correlated with asthma severity.Fungi, including s fungus . Trichops fungus . TherefoAspergillus-allergenic patients with severe asthma who failed to comply with the diagnostic criteria of allergenic bronchopulmonary Aspergillus was evidently reduced following treatment with itraconazole for several months. However, no change was observed in the tIgE and sIgE levels (Tracheophyta-sensitised patients with severe asthma. Fluconazole reduced the bronchial hyper-reactivity of patients to inspiratory Tracheophyta, reduced the hormone requirement and increased the PEF value (The effect of antifungal therapy on severe asthma remains controversial and relevant studies are rare. In a retrospective study, the hospitalisation rate and glucocorticoid treatment course of E levels . In anotEF value . MoreoveEF value . These sThe limitation of this study is the small number of patients with asthma; thus, confirmation from large-scale clinical trial data is required.This study demonstrated that fungal sensitisation is closely correlated with disease severity in patients with asthma by detecting the levels to sIgE to different fungi in patients. Non-fungal allergens are not correlated with the disease severity of patients with asthma. Moreover, this study demonstrated that fungi have an important role in the disease severity of patients with asthma. Therefore, this study is significant for the future prevention and treatment of severe asthma.