Abnormalities in postprandial lipemia (PPL), particularly those related to triglyceride-rich lipoproteins, are considered an independent cardiovascular risk factor. As diet is known to be one of the main modulators of PPL, the aim of this review was to summarize and discuss current knowledge on the impact of diet and its components on PPL in humans; specifically, the impact of weight loss, different nutrients , alcohol and other bioactive dietary components , as well as the effect of different dietary patterns. The possible mechanisms behind the metabolic effects of each dietary component were also discussed. For many years, abnormalities in postprandial lipemia (PPL), particularly those related to triglyceride-rich lipoproteins (TRL), have been considered an independent cardiovascular risk factor, even more important than altered fasting triglyceride (TAG) metabolism .PPL may be influenced by different factors, but among these, diet and its respective components represent the main modulators. However, there are few human intervention studies focusing on this topic, and these have yielded very different results. This heterogeneity depends on several factors, including type of study population , genetic background, type and composition of test meals used to evaluate PPL response, methods used to study PPL , and type of nutritional intervention . This multitude of factors makes it difficult to draw direct comparisons between the studies, and it is still more difficult to translate this scientific data into recommendations and practical implementations.Therefore, in this review, we tried to clarify some of the more intricate aspects of this topic, focusing on chronic (short/medium and long-term) intervention studies carried out in humans, to evaluate the real impact of dietary habits on PPL. Acute studies were considered when chronic studies were not available, or to highlight possible mechanisms of action.After a chapter providing insight into the possible mechanisms, available evidence on the impact of weight loss, as well as different nutrients , alcohol, and other bioactive dietary components  on PPL was reviewed, excluding intervention studies with supplements. Moreover, we looked at the effect of different dietary patterns and tried to consider, wherever possible, the confounding factors reported above.Postprandial lipemia consists of changes in plasma lipid concentrations and composition occurring after a meal. The main constituents of these changes are the triglyceride-rich lipoproteins (TRLs). TRLs have both intestinal (chylomicrons) and hepatic  origin. Chylomicrons are characterized by the presence of one molecule of apolipoprotein B48 (ApoB48), while the lipoproteins of hepatic origin instead contain one molecule of apolipoprotein B100 (ApoB100). Postprandial variations in lipoprotein concentration/composition depend on 1) uptake of dietary fat by the gut and secretion rate of chylomicrons, 2) intra-vascular clearance of TRLs and hepatic re-uptake of remnants, and 3) hepatic lipid metabolism and secretion rate of VLDL. Balance between these different pathways is finely regulated by insulin. In conditions related to insulin resistance , lipolysis in adipose tissue is increased, making more substrate available for the synthesis of hepatic triglycerides. This, along with reduced inhibition of liver catabolic pathways, induces a more pronounced secretion of VLDL. At the intestinal level, insulin resistance favors intracellular apo B48 stability and promotes activity in microsomal triglyceride transfer protein, leading to an increase in chylomicron production  and chylomicron secretion, through the rapid mobilization of intracellular lipid droplets and preformed chylomicrons. Conversely, at the intestinal level, dietary fibers may exert a triglyceride-lowering effect by disrupting the micellization process, altering gut motility, physically impeding fat absorption through the formation of a water barrier between nutrients and intestinal mucosa, and by altering gut microbiota . Changes in cholesteryl ester transfer protein (CETP) activity have been suggested as another possible pathway through which alcohol may influence postprandial lipid response, particularly in terms of lipoprotein composition. However, the few studies reporting data on postprandial lipemia do not substantiate this hypothesis  after a medium-term intervention, from 6 to 16 weeks, reduces PPL in overweight/obese patients .In fact, in forty overweight/obese individuals with moderately elevated fasting TAG (1.69–5.65 mmol/l) following a 12-week low-calorie low-carbohydrate [12% of total energy intake (TEI)] or low-fat diet (24% of TEI), the postprandial total area under the curve (tAUC) TAG reduction was significantly greater after the very low-carbohydrate diet (−47%) than after the low-fat diet (−15%), and the tAUC normalized for fasting TAG remained significantly lower. Importantly, despite similar calorie reductions, weight loss in the low-carbohydrate group was greater than that in the low-fat control group (−10.5 vs. −5.5%), and this difference may explain the greater reduction in TAG response observed in the low-calorie-low-carbohydrate diet . Aside fMoreover, a 16% reduction in TEI for 16 weeks in abdominally obese men with moderately elevated TAG, leading to a weight loss of 10 kg on average, reduced fasting (−17.5%) TAG and improved insulin sensitivity, without changes in incremental area under the curve (iAUC) and tAUC for ApoB48, but with a significant decrease in retinyl palmitate tAUC, suggesting that weight loss might not affect the number of chylomicrons but instead their lipid composition .In addition to the different extents of weight reduction, is the type of hypocaloric diet important in influencing PPL?This point is strictly related to the use of a very low-carbohydrate diet, namely a ketogenic diet . In thisAnother relevant question is related to the possibility that the energy restriction model may have different effects on the PPL beyond body weight reduction and the magnitude of energy restriction. Only one study reporting data on PPL has dealt with this issue: an intermittent energy restriction  reduced by 40% incremental postprandial TAG, without changes in fasting TAG compared with a continuous low-calorie model with the same level of body weight reduction (−5%), achieved on days 59 and 73 in the two groups  Table 2Table 2. From the available data, it seems that weight loss may improve PPL in overweight/obese individuals with and without lipid abnormalities. This effect seems to be, at least in part, independent of the effect on fasting TAG, and in relation to the magnitude of weight loss. Moreover, a low-calorie regimen very low in carbohydrate intake seems more effective, although not all the studies are concordant; furthermore, it is important to underline that the duration of trials performed was short (4–16 weeks), and whether these effects are lost with time—as generally happens for fasting TAG in long-term studies (24 months of follow-up)—is still unknown .In relation to the possible mechanisms, the few intervention studies carried out in humans seem to confirm the role of improved insulin resistance with a consequent positive impact on TRL clearance and VLDL production, as discussed previously , 11, 33 Carbohydrates and fats account for the main proportions of macronutrient intake across different cultural backgrounds and are the principal inducers of PPL. Postprandial increase in plasma TAG is linearly related to the amount of ingested fats, as shown in acute studies in which proteins and carbohydrates were kept constant, and fats were gradually added to different test-meals. This relationship, independent of the type of fat used, was consistent with a wide range of fat intake with a lower threshold at 15 g of fat –36.Carbohydrates, when added to a fat load, also increase postprandial TAG. However, this effect differs according to the type of carbohydrate added. For simple sugars, while the addition of glucose (50–100 g) inconsistently determined an increase in postprandial TAG in different studies , 37, 75 Hence, both fats and carbohydrates were able to elicit a PPL response in experimental settings where these nutrients were added, increasing the energy content of the meals. This differs from real-life conditions where carbohydrates and fats substitute each other in different relative amounts; therefore, both their respective proportions may influence PPL. A recent meta-analysis  evaluateNo similar analysis is available for non-acute studies, although several papers report the effects of short/medium-term trials comparing low-fat/high-carbohydrate (LF-HCHO) diets with high-fat/low-carbohydrate diets (HF-LCHO) . In the Of relevance, in all studies showing more powerful lipemic effects for LF-HCHO, simple sugars represented a relevant proportion (20–30 % of TEI) of carbohydrates , 52, 53.Interestingly, in 3-day, 70% carbohydrate dietary interventions differing in the relative amount of simple sugars (sucrose) and starchy foods, Culling et al.  showed tCarbohydrate quality may depend on different factors such as the type of carbohydrate  and the amount and type of dietary fibers.Evaluating the impact of the type of simple sugars on PPL mainly entails, in particular, a comparison between glucose and fructose.ad libitum food intake, a mixed-meal test resulted in an earlier rise in postprandial TAG, with a significantly greater postprandial TAG tAUC. The increase in postprandial TAG corresponded to higher ApoB48 concentrations and increased liver fat content  but also, and perhaps more importantly, to other characteristics such as their fermentability .per se.All the results reported above suggest that the effect of carbohydrates on PPL is strictly related to the type and quality of carbohydrates. In fact, different foods with the same amount of carbohydrates could have different nutritional and structural properties that impact on PPL more than carbohydrates Overall, the evidence described above would suggest that a diet with a moderate amount of carbohydrates from starchy foods rich in fiber would be preferable to a diet moderately high in fats for preventing an increase in postprandial TAG.Several studies –17, 60 hIn all studies, this early increase in plasma TAG was consistent with an increased TAG in lipoproteins of intestinal origin. However, not all studies consistently showed an increase in the number of chylomicrons , with soVery few studies comparing the TAG-rising effects of diets rich in SFA or n-6 and/or n-3-PUFA from natural foods have led to conflicting results. Two trials have yielded particularly relevant insights, since they were designed to specifically distinguish acute and chronic postprandial effects from these types of fats. Bergeron et al.  found thAs the effects of supplements fall outside the aims of this review, we only mention, for the sake of completeness, that extensive literature is also available regarding the effects of supplementation with n-3 PUFA. Overall, evidence is in favor of a reduction of PPL by n-3 supplementation, partly linked to the effects on fasting TAG . NonetheAmong other dietary components that might affect PPL, it is worth mentioning proteins, polyphenols, and alcohol.Protein quantity and quality have shown a pivotal role in the reduction of TAG response, at least in acute settings and with protein supplements. Overall, no significant differences in fasting TAG were detected in all studies investigating protein quality or quantity, suggesting that the possible effect is related to the postprandial period. As for PPL, the addition of casein (45–50 g) during an 8-h high fat meal challenge (80 g of fat) significantly reduced the TAG response  in healthy volunteers and in individuals with type 2 diabetes , 64. HowAs for protein quality, most of the studies have focused on the effect of whey protein against casein on PPL within an isocaloric meal –73. InteAs for the addition of other protein sources –74, thatIn recent years, polyphenols have received much attention due to their association with lower cardiovascular risk in observational studies. Among cardiovascular risk factors, the effect of polyphenols on PPL has been poorly explored, at least in medium- and long-term human studies . To the Conversely, there is ample evidence that alcohol has detrimental effects on fasting TAG, especially if consumed in moderate to high doses and in individuals with high cardiovascular risk .The effects of alcohol consumption on postprandial TAG response have been evaluated in different acute (hours or 1 day) settings , 80, andLooking at the short/medium term effect of alcohol intake on PPL, van der Gaag et al.  investigper se and is not modifiable by other components such as polyphenols  and mineral water on postprandial TAG have been evaluated in healthy men in a 3-week study. Postprandial TAG tAUC measured after dinner reached a peak at 5 h and decreased to fasting values in the next morning, with higher post-dinner concentrations vs. mineral water and without difference between beer, wine, and spirits. This suggests that the effect on PPL is linked to alcohol intake yphenols .In conclusion, there have been too few trials investigating the chronic effect of alcohol on PPL, limited by short durations and small sample sizes, to provide conclusive evidence.Moreover, a significant component of the effect of alcohol on PPL is linked to its negative effects on the overall homeostasis of TAG.As discussed previously, different dietary components may influence PPL. However, individuals do not eat single nutrients or dietary components, but rather foods combined in different eating models based on a social-cultural background. The quantity, variety, or combination of different foods and beverage in a diet and the frequency with which they are habitually consumed, is defined as dietary patterns. Thus, from a clinical point of view, it is important to know the possible effects of dietary patterns on PPL.Very few clinical trials have addressed this issue. Among the dietary patterns, the Mediterranean diet has attracted much interest in recent decades for the prevention and treatment of cardiometabolic risk factors, and some evidence of its beneficial effects on PPL is available .Perez-Martinez et al.  evaluateAPOE polymorphism and the type of diet was found. In fact, T-allele carriers of APOE in the Mediterranean intervention group showed a more significant decrease in postprandial TAG and large TRL compared with CC subjects , and a more remarkable difference in ApoB48 , suggesting a beneficial effect of the Mediterranean diet in reducing the number of ApoB48 particles in the postprandial state . Data frsubjects .The Mediterranean diet is characterized by a combination of different components  that could beneficially affect PPL through different mechanisms, as discussed previously. These different components could also act synergistically to determine their effect on PPL .Although PPL is a well-known independent cardiovascular risk factor, human intervention studies evaluating the impact of dietary habits on PPL are rather scarce, and some of them contain notable weaknesses to be considered when drawing conclusions. In fact, some intervention studies were carried out on relatively small numbers, making the results difficult to transfer to other and broader contexts; the general (sex and age) and metabolic  characteristics of participants in different studies are quite variable and, therefore, again, the results are difficult to generalize. Another point to be considered is the type of challenge used to elicit postprandial response, varying from different oral fat tolerance tests to test meals resembling real life. Additionally, there is a shortage of long-term studies. All these factors make the comparison between studies very difficult. To overcome some of the above problems, long-term controlled studies in large samples of different populations, well-characterized for their metabolic status, are needed. In addition, mechanistic studies looking in more depth at the effect on PPL are warranted, and should focus on different lipoproteins and their subfractions, as well as on the possible mechanisms, using the new technologies available.However, from a careful analysis of the current evidence and with great caution, it is possible to conclude that :Weight loss seems to have independent beneficial effects on PPL, which is strictly linked to the magnitude of weight reduction. In the short/medium term, very low carbohydrate diets seem to be more effective, but long-term studies are needed.Studies evaluating the impact of carbohydrates and fat both in terms of amount and quality are the most numerous, although the results are not always concordant and are, in some cases, very intricate. In any case, we could attempt to summarize the available evidence as follows: (a) carbohydrate quality is more important than amount in modulating PPL or, at least, its influence is in part independent of quantity; (b) in relation to carbohydrate quality/type, simple sugars, particularly fructose, increase PPL, whereas dietary fiber and fiber-rich diets decrease PPL; (c) the amount of dietary fat seems to be more important than the different types of fat in regulating PPL.As for proteins, polyphenols and alcohol, the available studies are too few for any conclusions to be drawn. Moreover, most of these studies have been performed using supplements and in an acute setting. In particular, acute studies seem to indicate positive effects of polyphenols on PPL and, therefore, chronic intervention studies should be carried out to confirm these results and those derived from the only chronic intervention trial performed with a polyphenol-rich diet.Among dietary patterns, the Mediterranean diet seems to induce positive effects on PPL, more by virtue of the diet as a whole than of its single components.Thus, based on what we know so far, for PPL, as for the other cardiovascular risk factors and the prevention of cardiovascular disease, the dietary model to be proposed should be characterized by a high intake of fiber-rich foods, whole grain cereals, vegetables, fruit, and non-alcoholic drinks such as coffee and tea—rich in polyphenol—and fish, as well as a low intake of foodstuff rich in saturated fatty acids and simple sugars.LB and AR conceptualized the manuscript and drafted the section regarding background. LB drafted the section regarding carbohydrate and fat. GD drafted the sections regarding weight loss and dietary patterns. CV drafted the section regarding protein and polyphenol. All authors reviewed and revised the manuscript and approved the final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Remaining pharmaceutical compounds cause environmental pollution. Therefore, refining these compounds has become a major challenge. In this study, the function of eliminating Cefixime (CFX) using rice starch was evaluated under controlled conditions.mg/L), CFX initial concentration (0–16 mg/L) and time (20–120 min) was investigated on CFX removal.Response Surface Methodology (RSM) was used to design, analyze, and optimize experiments, and the interaction between four variables including pH (3–9), rice starch dose .The optimum pH, starch dose, initial concentration and time were 4.5, 225 Rice starch has been successful in removing CFX from the aqueous solution. Therefore, it is recommended to utilize this process to remove CFX from aqueous solutions. One of the most important groups of pharmaceuticals are antibiotics that are used to prevent and treat infections of farms, cattles and human 2. Water pollution is the result of uncontrolled use and a serious environmental threat, which may lead to creation of antibiotic-resistant microbes and pose a serious threat to all humanity in coming years 3. Also, these compounds are toxic for aquatic organisms even at low concentrations 4. The excretion of active and unchanged compounds has been proven in many antibiotics 5. Since removing these compounds entirely is not feasible in conventional wastewater treatment plants, these compounds enter into surface water, groundwater, and water treatment plants ultimately, and as a result of not being removed from treatment plant, they enter drinking water 6.In recent years, pharmaceutical compounds have been considered as the most serious water pollutants Escherichia coli, Streptococcus, fever and chills, and throat infections 8. Studies show this compound has been one of the most widely consumed drugs in Europe in recent years 9. The molecular structure of Cefixime is demonstrated in 10.One of the most important antibiotics utilized to treat infection is cefixime. Cefixime is a semi-synthetic antibiotic from the third generation of cephalosporins. Cefixime can be consumed against a variety of bacterial organisms and infections including Staphylococci, Influenza, Hemophilia, 11 based on advanced oxidation, ion exchange and adsorption with activated carbon, reverse osmosis and biological treatment are applied among which biological treatment is not very effective in removing antibiotics 7. The adsorption process is extensively used to remove organic contaminants. This method has an advantage over other chemical methods due to the lack of metabolite production. The adsorption process has received much attention compared to other purification techniques regarding initial cost, reuse of effluent, simplicity, and flexibility in design, easy operation and non-sensitivity to pollutants and toxic compounds. Studies have proven that adsorption process is advantageous for removing antibiotics from aqueous environments 12. In many studies, rice starch has been described as a highly efficient adsorbent to remove heavy metals such as zinc, lead, copper, and cadmium 13. The average size of rice starch granules is 3–8 μl and they are angular and polyhedral. Amylopectin is the dominant component in rice starch and plays a significant role in its physico-chemical properties. Rice starch has more priorities than other starches due to its characteristics such as high stability, high acid resistance and wide range of amylase to amylopectin ratio 14. Owing to water hygiene protection and human protection against severe health consequences of antibiotics, these compounds must be effectively and appropriately removed from sewage and water resources. The use of natural materials is of great importance in eliminating pollutants such as antibiotic compounds from an environmental point of view.Due to persistent incapability of conventional waste-water treatment methods to eliminate or diminish the number of undesired antibiotics, several more efficient treatment methods 15. The objective of using RSM is to identify optimal operating conditions or to enhance operating conditions 16. In this study, four independent variables including CFX initial concentration, pH, starch dose and time were selected and evaluated at five levels . Design Expert software version 12 was used to design the experiment.Studies have shown that the process of removing cefixime from water sources with rice starch has not been investigated so far. In this study, removal of cefixime with rice starch was performed through Response Surface Methodology (RSM). RSM is a statistical method for designing experiments that is used to optimize, evaluate the interaction of independent factors and reduce the number of experiments in chemical and biochemical processes 16H15N5O7S2 and a purity of 0.98% from Sigma-Aldrich. Rice starch, HCL and NaOH were prepared from Merck. 1 g/L CFX stock was made and intended concentrations were obtained from it. In this study, 3% starch solution was prepared using deionized water. To prevent hydration of starch solution during experiments, the solution was freshly prepared. Stoke solution with suitable dilution ratio was used to make other concentrations used in this study. Evaluating CFX removal function by rice starch was the experiment design which was modeled and optimized using Design Expert software (Version 12). The Central Composite Design (CCD) based on RSM was used to find the optimal conditions, the effect of parameters and their interaction in CFX removal by starch. In this study, CCD with four variables including pH, starch dose, CFX initial concentration and time, at five levels  was chosen. According to the equation 2k+2k+C, total number of experiments designed was 30 runs which K as the number of factors and C as the number of central points 17. 2, adjusted R2 and predicted R218.All the chemicals used in this study had a laboratory grade. Cefixime (CFX) was prepared with chemical formula of Cml Erlenmeyer flasks at initial CFX concentrations, and pH, starch dose and retention time were designed by Design Expert. To separate starch from solution, the samples were centrifuged at 4000 rpm for 10 min. The pH of the samples was adjusted using 0.1 N solutions of either HCl or NaOH and measured by pH meter . CFX concentration was determined using spectrophotometer (Cecil 7250 Model) at a wavelength of 288.5 nm. Finally, the removal efficiency of CFX was calculated by mg/L), respectively.To determine relationship between four independent factors of pH (A), starch dose (B), initial CFX concentration (C) and retention time (D) in CFX removal by rice starch, CCD was used. The experiments were performed in 30 2 were significant (p< 0.05). The results obtained for the analysis of cefixime removal are presented in 2) and adjusted regression coefficient (Adj. R2) for the predicted quadratic model were 0.954 and 0.911, respectively.Based on statistical analysis , one-way2) was also equal to 0.758 which indicates experimental values were consistent with predicted value of the model. The value of Adeq precision in predicted quadratic model was 20.7 which is a value greater than 4, indicating the accuracy of the predicted model. According to The regression coefficient predicted by the model (Pred. R3D contours and perturbation plot were evaluated to assess the effect of variables on CFX removal efficiency using rice starch. As mg/L, the rate of CFX removal increased and then it slowed down. By reducing the pH from 7.5 to 4.5, the amount of pollutant removal increased. As min to 45 min.3D contours in 19. In the present study, the results showed that with acidification of experimental environment, CFX removal was better performed. Mostafaloo et al6 obtained similar results in the study of CFX removal by BiFeO3 photo catalyst.According to 6. In a study by Dehghani et al20 at concentrations of 0.47–0.79 mμ of sulfadiazine, increasing antibiotic initial concentration reduced efficacy. The same results were obtained in the study of Yoousefian et al21, and Ouaissa et al22.Reducing efficiency of removal at higher CFX concentrations  can be a23. Fakhri 24 in a study on efficacy of CFX removal with MGO nanoparticles, found that increasing the adsorbent dose to 0.45 g/L increases the efficacy of CFX removal and then the upward trend greatly slows down. Therefore, 0.45 g/L was selected as the optimal dose of MGO. Similar conclusions were made in the study of Elmolla 25 and Mostafaloo et al6.According to the results, with increasing starch dose, the amount of pollutant removal has been increased. Therefore, it can be said increasing adsorption mass is associated with an increase in surface and more active sites for pollutant adsorption 27. This result is in good agreement with Homem et al28 and Mostafaloo et al's29 investigations.In this study, the CFX removal rate decreased with increasing time. Rapid adsorption at first contact time is due to large number of active sites on the adsorbent surface, which improves diffusion of cefixime to adsorbent surface 2=0.9544, R2 adjusted=0.9118, R2 predicted=0.7582.In this study, CFX removal was performed using rice starch. The response surface methodology and CCD were used to design, analyze and optimize experiments. ANOVA showed the proposed regression model was consistent with statistical analysis: Rmg/L, initial CFX concentration=7.9 mg/L and time=95 min.The optimal values in this study were obtained as follows: maximum CFX removal efficiency, 70.22% with desirability=0.936, optimal pH=4.5, starch dose=225 Due to proper removal of CFX with starch, it is recommended to use the sewage of industries that contain starch in pre-treatment of pharmaceutical industry wastewater.


Patients whose donors had AKI who received using low dose (1.5 mg/kg for three days) rabbit anti-thymocyte globulin (r-ATG) as the induction agent had significantly superior death-censored graft survival compared with patients in that group who received basiliximab (p = 0.039). AKI in DBD donors did not affect long-term death-censored graft survival. Low-dose r-ATG may be considered as an induction immunosuppression in recipients receiving kidneys with AKI because it showed better graft survival than basiliximab.The use of kidneys from donation after brain death (DBD) donors with acute kidney injury (AKI) is a strategy to expand the donor pool. The aim of this study was to evaluate how kidney transplantation (KT) from a donor with AKI affects long-term graft survival in various situations. All patients who underwent KT from DBD donors between June 2003 and April 2016 were retrospectively reviewed. The KDIGO  criteria were used to classify donor AKI. The cohort included 376 donors . Death-censored graft survival was similar according to the presence of AKI, AKI severity, and the AKI trend ( However, there is a huge gap between the demand for and supply of donor organs. The Korea Network for Organ Sharing (KONOS) reported that 2293 patients underwent kidney transplantation (KT) during 2019 in Korea, with one third of the recipients receiving grafts from donation after brain death (DBD) donors; 23,427 patients were still waiting for suitable organs in May 20192.Kidney transplantation is the optimal choice for treating end-stage renal disease (ESRD) because it improves prognosis and quality of life compared with dialysis3. However, some recent studies reported comparable long-term graft survival in recipients who received kidneys from ECDs and SCDs, contrary to expectations5.In an attempt to increase the donor pool for kidney transplantation, the American United Network for Organ Sharing suggested the use of expanded criteria donors (ECDs) in 2002, even though those donors have 1.7-fold higher graft failure compared with standard criteria donors (SCDs)6. Kwon et al.7 reported that delayed graft function (DGF) occurred more often when recipients received a kidney from a donor with AKI than from one without AKI. In addition, the rate of DGF tended to increase with the AKI stage9. Domagala et al.10 reported finding no difference in the rate of biopsy-proven acute rejection (BPAR) episodes between donors with and without AKI in the first year post-transplantation. Those reports thus found no relationship between donors with AKI and graft survival10. Nonetheless, debate continues regarding the use of donors with AKI. Several studies reported a significant difference in graft survival when using donors with AKI12. In addition, Yu et al.13 reported that the AKI trend is associated with graft survival rather than AKI severity. Park et al. reported that DBD donor KT recipients who received kidneys from ECDs with AKI showed worse long-term graft survival than other KT recipients14.The use of kidneys from DBD donors who experienced acute kidney injury (AKI) at the time of death is another strategy to expand the donor poolTherefore, in this study, we evaluated the effects of donor AKI on long-term graft survival after KT in various situations. In addition, we compared clinical outcomes, including the DGF rate, estimated glomerular filtration rate (eGFR), and rejection rate.p = 0.025); in particular, the stage 1 AKI group had significantly older donors than the other two groups (p = 0.002). The history of HTN and proportion of ECDs did not differ significantly between the No AKI and AKI groups. However, donors with stage 1 AKI were more likely than other AKI donors to have HTN and be ECDs (p = 0.018). BMI differed significantly between the groups (p = 0.001), increasing with AKI stage. A cerebrovascular accident (CVA) caused brain death in the majority of the AKI group (p = 0.013), with stage 1 and 2 AKI having a higher proportion of CVA than the other groups (p = 0.011). KDRI and KDPI were significantly higher in the AKI group, with stage 1 AKI having significantly higher values than the other groups (p < 0.001). In addition, donor creatinine level (p < 0.001) was significantly higher in the AKI group (p < 0.001), and increased with AKI stage.117  were included in the no AKI group, and 259 donors  were included in the AKI group. 102 , 71 , and 86  patients had an AKI classified as KDIGO stage 1, 2, and 3, respectively. The KDIGO stage 3 group included 35  donors who received renal replacement therapy before procurement. The comparison of donor characteristics according to the presence of AKI and AKI stage is shown in Table p < 0.001); in particular, low dose r-ATG was used much more than basiliximab in recipients with stage 3 donors. The combination of tacrolimus, MMF, and MPD was used more in recipients from the AKI group for maintenance immunosuppression (p = 0.006)  Table .Table 2Cp = 0.929)      and AKI groups  and tended to increase with the AKI stage  (Table p = 0.126) (Table The DGF rate was significantly higher in recipients with donors in the AKI group (6) Table .Table 3Cp = 0.049). However, this value did not differ significantly based on AKI severity (p = 0.265). The nadir SCr seemed to affect death-censored graft survival in the univariate analysis (p = 0.001); however, it was not significant in the multivariate analysis (p = 0.476)  , but it was significantly higher in the groups with stage 1 and 2 AKI (p = 0.018). Acute cellular rejection (ACR) composed a large portion of the rejection cases. Rejection-free graft survival was similar between the No AKI and AKI groups (p = 0.145)   Fig. .p = 0.040, < 0.001, and < 0.001). The use of low dose r-ATG as an induction agent had a positive effect on death-censored graft survival (p = 0.003) . The use of low dose r-ATG as an induction agent had a positive effect on death-censored graft survival (p = 0.039)  and reduce the incidence of DGF21. DGF is a risk factor for the development of early acute rejection22. However, previous studies reported that the acute rejection rate was not significantly higher among patients whose donors had AKI than among other KT recipients15. We also observed that donor AKI did not affect the acute rejection rate or rejection-free survival. However, when we compared the recipients receiving No AKI kidneys and recipients receiving AKI kidneys of KDIGO stage 1 and 2 only, the rejection free graft survival was significantly superior in the former group. We speculate that this may be because twice as much of the recipients who received AKI kidneys of KDIGO stage 3 used low dose r-ATG  compared to those who received KDIGO stage 1  or 2 kidneys .Many studies reported that DBD donors with AKI were not associated with graft failure24, although some studies have shown otherwise12. Our results show that long-term death-censored graft survival in patients with a DBD donor with AKI was not inferior to that in patients with a DBD donor without AKI. The 10-year death-censored graft survival was 76.1% in the AKI group and 75.1% in the No AKI group. In addition, long-term graft function and the eGFR trend were similar between the two groups.Previous studies showed that donors with AKI were associated with a higher rate of DGF14 reported that the graft survival of kidneys from ECDs with AKI was significantly worse than that in other groups . On the other hand, Ko et al.25 found no significant difference in the graft survival rate among those four groups. In our cohort, long-term death-censored graft survival was similar between ECDs with and without AKI. Similarly, long-term death-censored graft survival did not differ significantly between high KDPI (≥ 80) donors with and without AKI.Park et al.11 reported that the presence and severity of AKI, especially in kidneys from donors with AKIN stage 3 injury, led to inferior graft survival. Yu et al.13 reported that the AKI trend, specifically DBD donors with worsening AKI, led to inferior graft survival. However, we found that the AKI trend and severity did not affect death-censored graft survival. On the contrary, although this finding was not statistically significant, graft survival tended to be superior in recipients receiving KDIGO stage 3 kidneys than in recipients receiving No AKI, KDIGO stage 1 or 2 kidneys. In the case of KDIGO stage 1 kidneys, graft survival tended to be inferior because of more ECD and higher KDPI. However, ECD was similar in the rest of the groups except for KDIGO stage 1 kidneys, and even KDPI was lower in the No AKI group. Among the four groups, there was a significant difference in the choice of induction immunosuppressive agents. Compared with the other groups, more recipients receiving KDIGO stage 3 kidneys received low dose r-ATG for induction therapy. We speculate that the difference in induction agents might have affected graft survival.Boffa et al.p = 0.025) and significantly superior when using low dose r-ATG , even though donor age and the proportions of ECD, KDRI, and KDPI donors were significantly higher in the low dose r-ATG group (p < 0.001)  Table . Lee et 2. Given the increased proportion of ECDs and high KDPI donors, our finding that donor AKI does not affect graft survival could decrease the number of discarded organs and increase the number of KT recipients.In Korea, only 10% of the patients waiting for suitable organs receive KT, and one third of the donors are DBD donors. Donation of patients deceased due to brain death has reduced since 2016. The proportion of donors of age older than 50 years has increased from 52.1% in 2014 to 61.5% in 2019This study has some limitations. This is a retrospective, single-center cohort study and the period of this cohort is 13 years which is quite long. During this period, selection biases were inevitable due to the evolution of donor selection criteria, changes in the immunosuppression protocol, and the accumulation of experience of clinicians. For this reason, the low dose r-ATG was used later than the high dose r-ATG. Thus, the follow-up period using the low dose r-ATG was shorter and the average age of the donor was higher. Also, the follow-up period was shorter in AKI group than No AKI group. Transplanted kidneys with AKI were clinically chosen instead of being discarded. Thus, we might have underestimated the effect of AKI by discarding kidneys due to poor expected outcomes. In addition, the AKI stages might be not correct because we used the KDIGO definition without considering urine output when classifying donor AKI stage.In conclusion, AKI in DBD donors negatively affected the DGF rate. However, it did not affect long-term graft function or death-censored graft survival. The use of high dose-r-ATG as an induction agent, KDRI, and rejection episodes had a negative effect on death-censored graft survival. Low dose r-ATG may be considered as an induction immunosuppression in recipients receiving kidneys with AKI because it produced better graft survival than basiliximab.This retrospective study was approved by the Institutional Review Board of Samsung Medical Center (IRB No. 2020-03-170), and the need for informed consent was waived. All methods were carried out in accordance with Declaration of Helsinki.We retrospectively reviewed all patients who underwent KT from DBD donors at Samsung Medical Center in Seoul, Korea, between June 2003 and April 2016. Figure The immunosuppressive induction agents used were basiliximab and high and low dose r-ATG. We usually use basiliximab for patients who receive SCD kidneys and r-ATG for patients who receive ECD kidneys. However, we gave induction agents considering individual situations, including immunologic risks and physical conditions. The recipients who received 20 mg of basiliximab as an induction agent were injected intravenously twice on the operative day and on postoperative day 4. We used high dose r-ATG (1.5 mg/kg for more than five days) before July 2011 and low dose r-ATG (1.5 mg/kg for 3 days) after that time. r-ATG was initiated on the operative day and administered daily. 500 mg of intravenous methylprednisolone (MPD) was also used for two days starting on the operative day and tapering as scheduled.Maintenance immunosuppression was achieved with a triple immunosuppressive regimen consisting of calcineurin inhibitors (CNIs), mycophenolate mofetil (MMF) and MPD. Each patient received MMF and MPD and then either cyclosporine or tacrolimus.2); history of diabetes mellitus (DM), hypertension (HTN), and hepatitis C virus (HCV); cause of death; ECD status; Kidney Donor Risk Index (KDRI); Kidney Donor Profile Index (KDPI); and the initial, peak, and terminal serum creatinine (SCr) according to AKI stage. We calculated the KDRI and KDPI by using the Organ Procurement and Transplantation Network calculator31. We received all serial SCr values between the donor’s hospitalization and organ procurement from KONOS.We retrospectively analyzed the donor and recipient data. Donors were compared based on their age; sex; body mass index (BMI)  mismatches, induction immunosuppressant type, and maintenance immunosuppression agents.32. According to the KDIGO criteria, stage 1 is any of the following: increase in SCr by ≥ 0.3 mg/dL within 48 h (h), increase in SCr to ≥ 1.5 times baseline that is known or presumed to have occurred within 7 days, or a reduction in urine output (< 0.5 mL/kg/h for 6 h). Stage 2 is an increase in SCr to 2.0–2.9 times baseline or a reduction in urine output to < 0.5 mL/kg/h for 12 h. Stage 3 is an increase in SCr to 3.0 times baseline or ≥ 4.0 mg/dL or receipt of renal replacement therapy (RRT); in patients < 18 years, it is defined as a decrease in eGFR to < 35 ml/min per 1.73 m2 or a reduction in urine output (< 0.3 mL/kg/h for 24 h or anuria for 12 h)33. We used the KDIGO criteria without urine output because that information was not consistently documented in the records for brain-dead donors from other hospitals. The AKI trend was defined using the differences between the peak and terminal SCr levels during the donor management period. When the terminal SCr was lower than the peak SCr, it was defined as improving AKI, and when the terminal SCr equaled the peak SCr, it was defined as worsening AKI13. However, donors who received renal replacement therapy were excluded from the AKI trend analysis. We used the Revised Bedside Schwartz Formula to estimate GFR for patients less than 18 years old and the Modification of Diet in Renal Disease equation to estimate GFR for patients over 18. BPAR was defined and classified according to the Banff 2013 classification.We used the KDIGO criteria to classify donor AKI stage because a previous report showed that the KDIGO criteria are more useful for predicting DGF in KT recipients than the AKIN (AKI Network) criteriaKidneys were discarded if they were grossly discolored or atrophied or if the donor's SCr had elevated for more than 7 days without renal replacement therapy.The primary outcome was the effect of donor AKI, AKI severity, and the AKI trend on death-censored allograft survival, as well as the effect of AKI on death-censored graft survival for KTs using kidneys from ECDs and high KDPI donors. The secondary outcomes were the incidence of DGF, nadir SCr, time to nadir SCr over 3 months, changes in allograft function based on Cr and eGFR, and the rejection rate. We also investigated whether graft survival was influenced by the type of induction immunosuppression.p < 0.05) and clinically significant factors that were not statistically significant in the univariate analysis. All tests were two-tailed, and statistical significance was defined as p < 0.05. All statistical analyses were done using SPSS version 25.0 .Continuous variables are presented as means ± standard deviations and were compared using the student’s t-test and one-way analysis of variance or as medians with interquartile ranges, which were compared using the Kruskal–Wallis test. Categorical variables are presented as numbers and percentages and were compared by chi-square tests. Graft failure was defined as restarting dialysis or re-transplantation. The trends of postoperative SCr and eGFR were compared using linear mixed models. Graft survival was estimated using the Kaplan–Meier method and compared using the log-rank test. Cox proportional hazards model analyses were used to predict graft survival. The multivariate analysis was performed using the factors from the univariate analysis that were statistically significant (Supplementary Information 1.Supplementary Information 2.


Uterus transplantation has proved to be a feasible treatment for uterine factor infertility. Herein, we report on recipient outcome in the robotic uterus transplantation trial of 2017–2019. The eight recipients had congenital uterine aplasia. The donors were six mothers, one sister, and one family friend. Donor surgery was by robotic-assisted laparoscopy. Recipient surgery was by laparotomy and vascular anastomoses to the external iliacs. The duration (median (ranges)) of recipient surgery, blood loss, measured (left/right) uterine artery blood flow after reperfusion, and length of hospital stay were 5.15 h (4.5–6.6), 300 mL (150–600), 43.5 mL/min (20–125)/37.5 mL/min (10–98), and 6 days (5–9), respectively. Postoperative uterine perfusion evaluated by color Doppler showed open anastomoses but restricted blood distribution in two cases. Repeated cervical biopsies in these two cases initially showed ischemia and, later, necrosis. Endometrial growth was not seen, and hysterectomy was later performed, with pathology showing partly viable myometrium and fibrosis but necrosis towards the cavity. The other six patients acquired regular menstrual cyclicity. Surgery was performed in two patients to correct vaginal stenosis. Reversible rejection episodes were seen in two patients. In conclusion, the rate of viable uterine grafts during the initial 6-months of the present study (75%) leaves room for improvement in the inclusion/exclusion criteria of donors and in surgical techniques. Initial low blood flow may indicate subsequent graft failure. Uterus transplantation (UTx), as a treatment for absolute uterine factor infertility (AUFI), proved its feasibility by the first live birth after UTx in 2014 ,4 and deAll initial live-donor UTx trials were with the laparotomy technique of the donor. The main difficulty of the laparotomy technique in donor hysterectomy is the dissection of the distal ureters and the deep uterine veins. These anatomical structures are firmly attached to the para-vaginal/cervical tissue, and the venous outflow from the deep uterine veins often includes an extensive network of venous branches riding over and under the ureter. It has been proposed that minimally invasive surgery, especially by robotic-assisted laparoscopy, may aid in these difficult and fine dissection procedures deep in the pelvis ,8. In 20Along these lines, we performed eight robotic-assisted donor hysterectomies in 2017–2019 and found an obvious evolution of the surgical procedures within the trial . Thus, i) and registered (NCT02987023). The setting was Sahlgrenska University Hospital, a tertiary hospital with a large transplant program and a specialized gyne-oncology division. The collaborative team has extensive experience in robotic surgery and UTx . The study was approved by the Regional Ethics Committee  and 0.25 mg of the gonadotropin-releasing hormone (GnRH) antagonist ganirelix . The eight recipients had uterine agenesis as part of the Mayer-Rokitansky-Kuster-Hauser syndrome (MRKHs). The patients underwent meticulous medical and psychological investigations, including imaging by abdominal/pelvic magnetic resonance imaging (MRI), serology , clinical chemistry, human leukocyte antigen (HLA) typing with assays of donor-specific antibodies (DSAs), psychological tests, and interviews. Gynecological examination of recipients included an evaluation of the vagina and tests for chlamydia, gonorrhea, and high-risk human papillomavirus. In vitro fertilization (IVF) was performed to cryopreserve at least eight embryos. This necessitated 1–3 IVF cycles, using a protocol with a random and simultaneous start of purified human menopausal gonadotropin  tissue-sealing system. In procedure #3–8, the vaginal fascia and mucosa were divided by scissors and with uni- and-bipolar diathermy for hemostasis since we observed significant vaginal stenosis in the initial two cases  and lidocaine (50 mg), followed by perfusion with a minimum of 200 mL of cold histidine-tryptophan-ketoglutarate preservation solution. During the back-table perfusion, the four veins on the graft were assessed for outflow and quality in order to determine the suitability for anastomosis. Leakages from vessels were closed by 7-0 polypropylene sutures, and discarded outflow options were closed. The adjacent segment of the internal iliac vein was trimmed, and minimal dissection of the proximal part of the utero-ovarian vein was performed. ®; Karl Storz, Germany), which is placed inside the vagina and pushed upwards in the direction of the umbilicus. When the vaginal vault is freed from the bladder and the rectum by a sagittal distance of around 5 cm, the dissection is sufficient to permit the subsequent opening and vaginal-vaginal anastomosis. The surgery is then directed towards the dissection of the vessels for the preparation of vascular anastomosis sites. The external iliac arteries and veins are dissected bilaterally, and then fixation sutures , to be used for subsequent uterine fixation, are placed bilaterally into the sacrouterine ligaments, round ligaments, and the bisected uterine rudiment , the vagina of the recipient is opened by a sagittal incision. End-to-end anastomosis is then performed between the vaginal vault of the recipient and the vaginal rim of the graft by a continuous 2-0 resorbable suture. Fixation sutures, placed in the recipient as described above, are then sutured to the respective parts of the graft, and a large bladder peritoneal flap of the graft is sutured on top of the bladder. Prophylaxis against infections and thrombosis was with piperacillin/tazobactam 4 g i.v. (intravenously) every 8 h for 4 days and 5000 IU dalteparin s.c. (subcutaneously) for 6 weeks, plus 75 mg of acetylsalicylic acid until graft removal, respectively. The chilled graft is then placed into its position inside the pelvis, and the vascular anastomoses are completed between the segments of the internal iliac vessels of the graft and the proximal portions of the utero-ovarian veins and external vessels of the recipient by use of continuous 6-0 and 7-0 polypropylene sutures for arteries and veins, respectively B. In som®; Pfizer, USA) and 20 mg basiliximab  just prior to reperfusion, with a second dose of 20 mg basiliximab on day 4. Oral prednisolone  was used at 80 mg on day 2 and then tapered to withdrawal on day 6. Maintenance immunosuppression was by oral administration of tacrolimus  twice daily from the day of surgery. Target trough levels of tacrolimus were 10, 8, and 5–7 ng/mL, during months 1, 2–3, and 4–6, respectively. Additional maintenance immunosuppression was azathioprine .The immunosuppression was an induction protocol with 500 mg i.v. methylprednisolone  during the hospital stay and by gynecological examination (including biopsy) at day 4–5 after UTx. The patients were then, during the initial postoperative month, seen weekly for gynecological examination, including inspection of the cervix, vaginal bacterial culture, and cervical biopsy for rejection diagnosis. Grading of rejection was performed according to our uterine rejection grading system . These gData concerning characteristics of recipients and donors, with the results of their preoperative investigations, are given in The data on the surgeries are summarized in Patient #3 had the longest surgical time (6.6 h) and the longest total graft ischemia time (3.2 h) before completed vascularisation. In this case, the arteries thrombosed spontaneously during the uterine fixation and completion of the vaginal anastomosis. This was discovered during the second routine flow measurement before the closure of the abdomen, with the graft fixed in its position. Both arterial anastomoses had to be opened, and thrombus formations were carefully removed, followed by extensive flushing with heparin solution. The veins remained open, and after the flushing, there was a backflow in the arteries. After completed reanastomosis of both arteries, blood flow in both uterine arteries was confirmed with flow-measurement. The time of warm ischemia during the thrombectomy was around 1.5 h.Two arterial anastomoses B were usDuring the hospital stay, the daily transabdominal color Doppler ultrasound indicated a diminished distribution of blood flow in the central portions of the uteri of two patients  and initial biopsies around day 4–5 showed focal ischemia in the ectocervix of these patients. Data concerning post-transplantation follow-up are given in Two patients had one rejection episode each . The graPatients #1 and #2 showed gradual stenosis over the vaginal-vaginal anastomosis line. When the diameter at the stenosis was less than 10 mm, vaginal surgery by diathermy was performed  to open the stenosis to allow further inspection of the cervix and for biopsies to be taken. No other patients developed vaginal stenosis.The color Doppler ultrasound could only detect blood flow in the major uterine vessels in patients #3 and #8, and the uterine size decreased gradually. Repeated cervical biopsies, starting from the first postoperative biopsy, showed ischemia followed by necrosis, and core biopsies of the myometrium showed patchy necrosis. Hysteroscopy with biopsy was performed around 6 months post-UTx in patient #3, which did not show any viable endometrium. Prior treatment with a high dose (4 mg daily) of estradiol orally for 3 weeks had not shown any visible endometrial lining in repeated transvaginal ultrasound examinations. Hysterectomy was performed soon afterwards. The explanted uterus had a length of 5 cm and was anatomically distorted. Microscopically, no endometrium was found. The myometrium was atrophic, and there were focal infarcts with granulation tissue. Larger arteries were occluded by sclerotic intimal tissue with some foam cells but without active endarteritis.In the uterine graft of patient #8, there was also the development of decreased blood flow, with core biopsies showing ischemic changes in the myometrium and ectocervical biopsies, initially exhibiting ischemia, followed by patchy necrosis. Hysteroscopy at one month after UTx could not detect any endometrium. Based on the experience of patient #3 (see above), hysterectomy was performed shortly after hysteroscopy. The explanted uterus measured 8.5 cm in length. On sectioning, the inner half of the uterus wall and the cervix appeared largely necrotic B. MicrosBoth patients, with graft removal, had uneventful posthysterectomy periods. Uterus transplantation is the first available treatment for AUFI, with previous motherhood options for this group being restricted to adoption or pregnancy in a gestational surrogate carrier. The proof-of-concept of UTx as a fertility treatment came with the first live birth after UTx, which occurred in 2014  outcomesNoteworthy is that UTx has some special features when compared to most other types of solid organ transplantations. Firstly, UTx is a quality-of-life enhancing transplantation rather than a vital type of transplantation . Moreover, UTx is unique as an ephemeral transplantation, with the graft not being intended for life-long use, but rather, for a restricted time until one or two children have been delivered. This transient transplantation period will decrease the time the recipient is exposed to immunosuppression, with its associated side effects. Furthermore, after transplantation of the uterus, there is a long time-interval of at least a year from transplantation until proof of full functionality by a live birth. The major and clinically most important result of the present study is the rate of surgically successful grafts, with resumed menstrual cyclicity of the uterus being a notable sign of functionality. However, pregnancy and delivery of a healthy child is the final proof of a fully functional graft. Our accumulated experience in the UTx field tells us that a graft that shows viability during the initial 6 months will continue to be viable despite rejection episodes or other forms of tissue stress. However, most likely, not all viable grafts will result in a clinical pregnancy and live birth, as illustrated by the first surgically successful deceased donor UTx case from 2011, which presented with early miscarriages but no live birth reported yet . The expIn the present study, we experienced two rejection episodes during the initial six months in the six patients that had functional grafts during the entire follow-up period. This is similar to what we experienced in the initial Swedish trial of 2013, where three out of seven patients with functional grafts had reversible rejection episodes during the corresponding time period . The hisThe 6-month graft survival of the present study was 75%. In comparison, the graft survival rates from the original Swedish study  and the The two graft failures of the present study shared some features. The perioperative perfusion blood flows were lowest in the two patients with graft failures, exhibiting mean (right and left) values of 15 and 24.5 mL/min in patient #3 and #8, respectively. In the six successful grafts, the mean blood flow after reperfusion ranged from 39 to 112 mL/min. Moreover, it is of interest to keep in mind that the early graft failure (because of vascular thrombosis within the first week) of our original study ,15,16. FEven though the uteri of the two graft failures of the present study showed perfusion and blood flow postoperatively, the assessments with color Doppler during the initial weeks showed a clearly impaired distribution of blood to the central parts. Since the blood from the uterine arteries feeds blood to the subserosal part, and then continuation into the smaller spiral arteries ending in the endometrial stroma, this pattern of blood flow is expected at low perfusion. Another indication of insufficient blood flow in uterine areas far from the major branching of the uterine arteries is initial ischemia, followed by patchy necrosis and then confluent necrosis, as seen in repeated cervical biopsies. This observation is in line with the finding of early graft failure of the US study .In the present study, we had a long lag phase from initial signs of irreversible hypoperfusion in case #3 until hysterectomy, but in the second graft failure (last case of the present study), the action to perform a hysterectomy was taken at a much earlier stage. This decision was established on the grounds of the morphology of early core biopsies, as well as hysteroscopy findings. Based on the posthysterectomy histopathology, it is very unlikely that the uterus would have shown functionality later.The duration of recipient surgery in the present study ranged between 4.5 and 6.6 h, which should be compared to 4.2–5.9, 4.0–6.0, 4.5–6.0, 3.5–5, and 4.0–5.0 h in the original Swedish study , the GerThe total ischemic time, from the clamping of vessels in the donor until proper reperfusion in the recipient, varied between 1.7 and 3.2 h in the present study. The longest ischemic time (50 min more than the second-longest ischemia time of the present study) was in the patient with intraoperative arterial thrombosis, followed by thrombectomy. It is not likely that the recorded total ischemia time was the cause of the subsequent graft failure since the ischemic time of the second graft failure was much shorter (2 h). However, the long (1.5 h) warm ischemia, after thrombectomy in patient #3, may have had a negative impact on the outcome. It should be noted that the total ischemic time of the first successful deceased donor UTx procedure was as long as 7.8 h , the CzeOne central observation from the present study is that vaginal stenosis was acquired in two patients, and stenosis was not experienced in any case of our original study . Such stAnother issue that has been a matter of debate in UTx is the venous outflow. In the present study, we used the deep uterine veins on segments of the internal iliac veins in every case, and in addition, one or two proximal parts of the utero-ovarian vein. A publication  of succeIn the present study, two of the successful grafts were from postmenopausal donors. Sequential menopausal hormonal replacement therapy was used for both donors. For the oldest donor (62 years at uterus donation), hormonal therapy had been used for 7 years. It is likely that continuous estrogen therapy since the menopausal age of this donor is of importance for well-preserved uterine arteries. In the other postmenopausal donor (57 years old) with a successful graft, hormonal therapy was merely used to demonstrate functionality in terms of menstruation. It is unlikely that such a short course of hormone therapy would have had any beneficial effect on the uterine arteries, but rather, the relatively short hypo-estrogenic period did not have any major negative effects on the uterine vessels.In conclusion, the present study of a complete study cohort of recipients for UTx shows that the surgical success rate needs to be improved. Low uterine blood flow at transplantation is an important early sign of subsequent graft failure.


Walking speed as one index of gait ability is an important component of physical fitness among older adults. Walking speed-arterial stiffness relationships have been studied, but whether poor walking speed is associated with higher segment-specific arterial stiffness in older adults is unclear. We thus aimed to examine the relationship between walking speed and segmental arterial stiffness among older community dwellers. This study was a cross-sectional study of 492 older Japanese community dwellers . Heart-brachial PWV (hbPWV), brachial-ankle PWV (baPWV), heart-ankle PWV (haPWV), and cardio-ankle vascular index (CAVI) were used as arterial stiffness indices. Walking speed, strength, flexibility, and cognitive function were also assessed. The participants were categorized into low (Slow), middle (Middle), and high (Fast) tertiles according to walking speed. The CAVI and baPWV were significantly lower in Fast than in Slow. Significant decreasing trends in CAVI and baPWV and a tendency toward decreasing trend in haPWV were observed from Slow to Fast, whereas hbPWV did not significantly differ among tertiles and no trend was evident. The results remained significant after normalizing CAVI and PWVs for multicollinearity of arterial stiffness indices and major confounding factors, such as age, gender, body mass index, blood pressure, cognitive function, and each physical fitness. Therefore, these findings suggest that poor walking speed is associated with higher segment-specific arterial stiffness of the central and lower limbs, but not of upper, in older adult community dwellers. Pulse wave velocity (PWV) and cardio-ankle vascular index (CAVI) are widely used as clinical indicators of arterial stiffness . IncreasWalking speed as one index of gait ability is an important component of physical fitness, especially among older adults , is genei.e., placement of transducers) and are significantly associated with aortic arterial stiffness  , heart-brachial PWV (hbPWV), and CAVI are attracting increasing attention . These ptiffness . Howeverve limb) . Indeed,ve limb) . Interesve limb) . Thus, tWith this information as background, we hypothesized that walking slowly reflects site-specific higher arterial stiffness among older adults. Therefore, this cross-sectional study aimed to examine the relationship between walking speed and segmental arterial stiffness among older community dwellers in Japan.n = 14, 2.4%), refusal to cooperate , pain , dementia  , chronic diseases that affected walking , features of peripheral arterial disease  , and technical errors associated with measuring arterial stiffness such as an undetectable pulse wave . Data from 492  older Japanese community dwellers who met the inclusion criteria were analyzed. In accordance with previously reported methods  was calculated as weight divided by height squared . Waist c2] + b, where DBP is diastolic blood pressure, PP is SBP - DBP, ρ is the blood density, and a and b are constants , and heart rate (HR) were measured in the supine position using a VS-1500AE/AN semi-automated device  . Electroonstants . The heaonstants . The meaonstants .Cognitive function was assessed using the CADi2 as described . The CADHandgrip strength was measured in duplicate using a dynamometer  and mean left and right values were analyzed , 2017c. 54⋅ 100 . All dai54⋅ 100 , 2019b.In 338  of limited participants, physical activity (PA) data during one week were assessed by a single-axis activity monitor  under sealed conditions , as previously described , 2018. AP < 0.05.Continuous data were analyzed using one-way ANOVA and MANCOVA. In particular, the analysis of MANCOVA with adjusted model 1 were normalized multicollinearity of arterial stiffness indices and confounding factors such as age, gender, BMI, mean BP (MBP), HR, cognitive function, strength, flexibility, smoking status, exercise status, anti-hypertensive medication, and anti-hyperlipidemic medication. The analysis of MANCOVA with adjusted model 2 were also normalized factors of model 1, moderate PA time, and vigorous PA time. Significant F values were assessed using post hoc tests with the Bonferroni correction to identify significant differences among mean values. Trends were analyzed using linearity tests and weighted P values were adjusted for sample size. Differences in non-parametric variables were analyzed using Kruskal–Wallis tests followed by Schefféì tests. The relationships between walking speed or LRI and each arterial stiffness indices were assessed using univariate regression analyses and forced entry multiple regression analyses. All data were statistically analyzed using SPSS 25.0J . Data are presented as means ± SE. Differences and relationships were considered significant at r = 0.365, P < 0.001), knee extension strength , flexibility , cognitive function , CAVI  and baPWV , but not with haPWV  and hbPWV . In order to determine the physical factors predicting walking speed in older adults, we further performed multiple regression analysis. In addition to BMI, knee extension strength, flexibility, and cognitive function, the analyses identified CAVI and baPWV were significant independent factors that regulate walking speed and haPWV tended to be an independent factor, but hbPWV were not  and baPWV . However, LRI did not correlate with haPWV  and hbPWV .The results of the univariate regression analysis indicate that walking speed correlated especially with handgrip strength . Although total PA can decrease with aging, the reduction in upper limb activity may be relatively less. Furthermore, walking speed is significantly associated especially with lower strength . Further detailed studies are needed to examine variations in arterial stiffness at different sites, especially between the upper and lower limbs. Second, the cross-sectional design limits the ability to determine a cause-and-effect relationship regarding the association between walking speed and arterial stiffness. In terms of longitudinal design, further detailed studies are required to elucidate whether walking slowly actually reduces arterial stiffness.The strengths of our study include the assessment of walking speed and segmental arterial stiffness in approximately 500 older adult community dwellers, but several important limitations require emphasis. First, our device cannot measure cfPWV at the same time of CAVI, haPWV, baPWV, and hbPWV and need to measure cfPWV after making the switch the measurement mode. Thus, the large population study is difficult to measure or quantify cfPWV by using our device, and we did not directly measure only central and leg PWVs (In conclusion, our findings suggest that walking speed is associated with segment-specific arterial stiffness of the central and lower limbs, but not of upper, in older adult community dwellers.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Human Ethics Committee at the Osaka Institute of Technology. The patients/participants provided their written informed consent to participate in this study.MN conceived and designed the study. NO, CN, and MN performed the study. NO and MN analyzed the data and wrote the manuscript. NO, CN, MI, TN, and MN interpreted the data. All authors approved the final version of the article.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Solid-state 13C NMR was used to estimate ordered double-helical structure in the starch. Native starch with 25 % double-helical content was the most resistant to digestion but hydrothermal processing (gelatinisation) resulted in >95 % loss of order and a large increase in starch digestibility. Air-drying of pre-treated flour produced slowly-digestible starch . Refrigeration of gelatinised samples decreased ease of amylolysis coincident with increase in double-helical content. Freezing maintained the same degree of digestibility as freshly gelatinised material and produced negligible retrogradation. Chilling may be exploited to produce ready-meals with a lower glycaemic response.Starch is present in many prepared ‘ready-meals’ that have undergone processing and/or storage in frozen or chilled state. Hydrothermal processing greatly increases starch digestibility and postprandial glycaemia. Effects of different heating/drying and cooling regimes on amylolysis have received little attention. Hence, we examined the effects of different processing treatments on  However, the effects on the digestibility of the constituent starch subjected to freezing, storage and chilling regimes seem to have received scant attention, but the subject is a matter of considerable interest because of concerns over large postprandial glycaemic responses to certain food materials, especially in relation to increased risk of type 2 diabetes  were supplied by AGT Poortman (A. Poortman (London) Ltd., UK) and dry-milled into flour at the VTT Technical Research Centre of Finland Ltd. Whole chickpeas were first crushed with a cutting mill  using a 4 × 4 mm sieve and 700 rpm speed and then ground in a 100UPZ pin disc mill  at 17800 rpm. This resulted in a flour with a unimodal particle size distribution (percentage volume size) with parameters d10, d50, d90 = 7, 19 and 55 μm, respectively, and diameters of particles assumed to be spherical (see OSM 1). The particle size analysis was performed in duplicate using a Beckman Coulter LS 230  with ethanol as a carrier.Whole chickpeas , fatty acid composition was analysed by GC using flame ionisation detection and ash  was determined by combustion in a furnace. Total dietary fibre was determined by AOAC Official Method 991.43 (a gravimetric and enzymic method), and total sugars content was determined by ion-exchange HPLC. The ‘available’ carbohydrate content was calculated ‘by difference’. Energy values were calculated using standard conversion factors. In addition, direct analyses of total starch and moisture content of chickpea flour at the time of the digestibility experiments were performed in-house to provide a more accurate measure of starch content than the ‘by difference’ value. The moisture content of quadruplicate samples was determined gravimetrically by drying overnight in a forced-air (fan) oven  at 103 ± 2 °C. The starch content was determined using the DMSO protocol of the Megazyme Total Starch Method, AOAC 996.11,  with some modifications .2.22. Quality control tests of the PPA described in our previous paper  of high purity (Grade 1-A) was obtained from Sigma-Aldrich Co. Ltd, Poole, Dorset, UK (A6255). The enzyme was supplied as a suspension in 2.9 mol/L NaCl containing 3 mmol/L CaClus paper  showed t2.3An overview of the processing treatments and corresponding sample codes is provided in All samples were prepared from a starting solution of either native (raw) or gelatinised (heated at 90 °C) starches in stock preparations of chickpea flour suspended in PBS (7.5 mg flour/mL PBS), with a starch concentration of 4 mg/mL. For native chickpea flour stock, the raw chickpea flour was weighed directly into a flask and combined with PBS (prepared at room temperature) and then stirred to form a suspension. The chickpea flour suspensions with native starch were either analysed as is (denoted N) or subjected to further processing steps as listed in i)Drying treatments: Native (N) and gelatinised (G) samples were transferred into aluminium pans and heat-processed in either a forced air (fan) oven , at approximately 100 °C for 24 h (samples NO and GO), or in an incubator  at approximately 40 °C for 48 h (samples NI and GI), or left to air dry (samples NA and GA) on a laboratory bench under ambient conditions, ∼22 °C for 72 h. After drying, PBS was added and vortex mixing applied to the dried samples to reconstitute these to the standardised starch concentration (4 mg/mL) required for the amylolysis assay.ii)Cold treatments: The cooled gelatinised (G) samples were transferred into 15 mL Falcon tubes and either immediately refrigerated at 4 °C for 72 h (treatment code F), or frozen at −70 °C and stored at this temperature for 60 h, and then defrosted for 16 h at room temperature (treatment code Z). Samples GF and GZ were then brought to 37 °C and analysed immediately.iii)Treatment Combinations: To assess the effect of reheating cold-stored samples on starch amylolysis, the cold-stored samples denoted GFG and GZG were subjected to the gelatinisation treatment (G) once more after refrigeration or freezer storage (treatments F and Z). These treatments were also applied in combination to examine the effect of including a refrigeration step before (sample GFZG) or after (sample GZFG) the freezing treatment and prior to repeating the gelatinisation treatment.For gelatinisation of the starch in the chickpea flour, the PBS was heated to 90 °C with constant stirring on a magnetic stirrer with a temperature sensor  and then the flour was sprinkled into the vortex of the solution and stirring continued for a further 20 min at the same high temperature and then allowed to cool for 10 min at room temperature (∼22 °C) before further processing. All samples treated in this way were labelled with the treatment code ‘G’. For further processing and storage of the native or gelatinised samples, 4 mL aliquots of the stock suspension were transferred to 15 mL Falcon tubes or to aluminium pans (dependent on further treatment) and then processed in the following ways before use in digestibility assays with PPA:All samples were prepared fresh for analysis and equilibrated to 37 °C prior to amylolysis assay.2.4in vitro digestion method are given in a previous publication  of the supernatant were then transferred to a 96-well microplate for determination of reducing sugars by the Prussian blue assay  and y-intercept (ln [C∞k]), respectively, of the linear plots of LOS versus time of amylolysis. The LOS plot method was previously validated for use in the analysis of first-order kinetic data, not just on pure starches but also starch-containing edible plant tissues (k1 and k2) and end-point starch amylolysis (C1∞ and C2∞) for phases 1 and 2, respectively. In addition, a C90 value, which is the percentage of hydrolysable starch digested at 90 min, was estimated from the first-order kinetic model described previously (in vitro predictor of the GI of foods (The digestibility curves of the starch-containing chickpea flours were subjected to Logarithm of Slope (LOS) analysis of pseudo-first-order kinetics to determine rate constants lsewhere . The val tissues , includieviously  and is aof foods .2.5NMR analysis  was perf13C Cross Polarisation – Magic Angle Spinning (CP-MAS) NMR was performed at 100.61 MHz for 13C and 400.13 MHz for 1H on a Bruker Avance 400. The samples were placed in 4 mm, partially filled rotors and spun at a MAS frequency of 13 KHz with the temperature maintained at 298 K. The contact time was 2 ms and acquisition time was 50 ms. Spectra were externally referenced to adamantane (28.46 and 37.85 ppm). Calculation of molecular order  of the starch was achieved using the method of Flanagan et al. for analysis of the spectra (OSM 2). spectra . Example2.6k and C∞ were estimated from the slope and y-intercept, respectively, of the linear plots of LOS versus time of amylolysis using regression analysis. One-way analysis of variance (ANOVA) was performed on the C90 digestibility data. Statistically significant differences were accepted at the P < 0.05 level. The analysis was performed using IBM SPSS Statistics 20.0. All other analyses were performed using SIGMAPLOT 12.0 (©Systat software 2011) statistical and graphical software.All data are presented as means ± SEM (4 replicates) unless otherwise specified. The values of 33.1The chickpea flour contained  18.6 g protein, 5.2 g lipid, 3.0 g ash, 12.1 g total dietary fibre, 52.5 g available carbohydrate  of which 3.4 g was total sugars and the calculated total energy value was 1500 kJ per 100 g. The lipid content comprised 0.74 g saturated, 1.23 g monounsaturated and 2.99 g polyunsaturated fatty acids. Direct analysis of the starch content in the chickpea flour was found to be 53 ± 2 % (dry weight basis), and the moisture content of the original flour was 9.7 ± 0.3 %.3.2Typical digestibility curves obtained for native and gelatinised starch in the chickpea flour samples subjected to various processing regimes and storage conditions are shown in in vivo  sample relative to freshly gelatinised starch (G).The large differences in amylolysis are illustrated in in vivo . The dif3.3k, the rate constant, and ∞C, the total amount of starch in chickpea flours that can be digested. Native  starch in the chickpea samples that had been incubator- or air-dried generated biphasic LOS plots from which k and ∞C values for each stage were calculated. The resulting kinetic parameters obtained for samples following different processing regimes are summarised in in vitro digestibility (C∞) than the native samples, irrespective of the processing treatment. The exceptions to this were the air-dried gelatinised sample (GA), which had a C∞ value similar to dried native samples . The digestibility constant, k, for gelatinised samples and for those that had been re-treated by hydrothermal processing after refrigeration and freezing, were essentially identical  , the digestibility constants for phase 1 (1k) of native samples closely matched the values for the gelatinised samples. For freely available substrates k values are expected to be virtually identical since this an inherent property of amylase under these assay conditions.Digestibility curves of the type shown in f 0.014) . With th3.413C CP-MAS NMR were used to estimate the proportion of molecular order, specifically the ordered double-helical structure of the starch in the chickpea flour samples  was only 10.7 %. Since the amount digested after 90 min of incubation was less than 11 % of the total starch, it is hardly surprising that there was minimal change in the detectable double-helical content. The double-helical content (ordered structure) decreased to <5 % after starch gelatinisation (sample G) and this had a total amylase digestibility of 74.1 % (dwb). After refrigeration of the gelatinised starch (GF) for 72 h at 4 °C, the helical content increased to 10 % and C∞ was 70.8 % (dwb). Following digestion with amylase the content of ordered material in GF was increased further to 13 %. No increase in double-helical structure was observed for the gelatinised-frozen starch sample (GF) and this remained at <5 %. The C∞ value for amylase digestibility of GF was 83.2 % (dwb). After amylase digestion of GF, the percentage of double-helical order increased to 14 %.Data from solid-state  samples . The amo413C NMR analyses suggest that the marked differences in the rate and extent of amylolysis resulting from the various storage treatments can be attributed to changes in the ordered structure of starch and the number of free α-glucan chains available to amylase.Proximate compositional analysis of the chickpea flour showed that it was rich in starch, protein and dietary fibre at levels consistent with values reported previously . We havee.g. degree of gelatinisation and intactness of cell walls in edible plants) and the presence of protein, lipid and phenolic compounds  and had a high proportion of double-helical order (∼25 %). When hydrothermal processing (for 20 min at 90 °C) was applied to chickpea flour to gelatinise the starch, the double-helical order was lost, which increased the availability of disordered α-glucan chains and thereby greatly increased the susceptibility of the gelatinised sample to amylolysis. These effects are consistent with a plethora of literature reporting substantial increases in the rate and extent of starch digestion following hydrothermal processing due to the loss of ordered structure and an increase in available starch . In a me-amylase .Although the amylolytic process of native and gelatinised starches is reasonably well understood , 2019, w13C NMR data, which revealed that the proportion of double-helical order increased from <5 % for the gelatinised starch to 10 % when the same sample was stored at 4 °C. The effect of this storage in generating slowly-digestible starch in the chickpea flour probably arises from re-association of α-glucan chains during retrogradation. In our previous study, employing LOS plot analysis of digestibility profiles, starches containing retrograded material showed unchanged digestibility rate constant k, but a decrease in C∞ values  relative to freshly-prepared gelatinised starches  seen after the repeated hydrothermal processing of frozen samples also provides evidence of further loss of ordered structure.Interestingly, the digestibility profiles showed that any impaired digestibility as a consequence of storage of the gelatinised sample at 4 °C (sample GF) was reversed by re-heating (sample GFG) and indeed became more digestible than the original gelatinised sample (G). This increase in susceptibility to amylolysis after re-heating refrigerated samples suggests that the re-associated α-glucan chains in the retrograded starch were destabilised by hydrothermal processing. This result is consistent with a recent study showing that starch potato paste, refrigerated for 2 days at 4 °C, was more susceptible to digestion after microwave re-heating compared with freshly made hydrothermally cooked starch . AdditioC∞ and C90 values for the oven and incubator-dried samples showed similar or increased levels of digestion relative to freshly gelatinised material. The biphasic LOS plots obtained for native and air-dried fractions suggest heterogeneity within these samples, with the fraction digested during phase 1 assumed to be readily available surface starch that has exposed flexible polyglucan chains  and it is likely that this drying method potentiated the retrogradation of starch, particularly the amylose fraction . Howevern chains . These mn chains . Thus, sd starch . In the d starch , but it in vivo (e.g. C∞) mentioned above. Furthermore, samples of gelatinised starch that were refrigerated and frozen, irrespective of the order of this cooling/storage treatment, showed a significant increase in starch digestibility following re-heating. With the growing popularity of consumption of convenience foods that are sold by supermarkets in pre-frozen or chilled states, it is important that the digestibility properties of these foods are understood to enable sound dietary advice to be available for consumers. The widely reported increase in levels of obesity, especially in children, is of great concern because of the links of obesity with raised risk factors for cardiovascular disease and type 2 diabetes (The C90 values are particularly useful in providing some indication of the relative differences in glycaemic responses that could be anticipated in vivo , and sugdiabetes . If thisdiabetes , 2019.5Overall, the results of our study have demonstrated marked differences in amylolysis between samples of starch-containing chickpea flour that has been processed and stored under regimes that were selected to simulate conditions occurring during the commercial preparation of ready meals. Hydrothermal processing treatments that gelatinise starch have a profound impact on starch susceptibility to amylase action, and although the rate and extent of amylolysis may be attenuated somewhat by the formation of retrograded starch during refrigeration treatment, these effects were found to be reversed during a second cycle of hydrothermal processing. The air-drying treatment applied to gelatinised starch was found to be particularly effective in lowering the susceptibility of starch to amylolysis. Further work is required to improve mechanistic understanding of the structural changes in starch that occur during processing and storage. This is likely to inform food processing strategies designed to promote the formation or preservation of RS in food products for applications in digestive and cardiometabolic health.CE, PB, PE, and JM designed and supervised the experiments; AV performed the experiments; AV, JM and CE analysed the data; CE, PB and PE wrote the paper and JM and AV contributed to subsequent versions of the manuscript. PE had final responsibility for the manuscript content. All authors read and approved the final version of the manuscript.