Altered blood-brain barrier permeability in rats with prehepatic portal hypertension turns to normal when portal pressure is lowered

AIM： To study the blood-brain barrier integrity in prehepatic portal hypertensive rats induced by partial portal vein ligation, at 14 and 40 dafer ligation when portal pressure is spontaneously normalized. METHODS： Adult male Wistar rats were divided into four groups： Group Ⅰ： Sham14d, sham operated; Group Ⅱ： PHil, portal vein stenosis, （both groups were used 14 days after surgery）; Group Ⅲ： Sham4od, Sham operated and Group Ⅳ： PH4od Portal vein stenosis （Groups Ⅱ and Ⅳ used 40 d afer surgery）. Plasma ammonia, plasma and cerebrospinal fluid protein and liver enzymes concentrations were determined. Trypan and Evans blue dyes, systemically injected, were investigated in hippocampus to study blood-brain barrier integrity. Portal pressure was periodically recorded. RESULTS： Forty days afer stricture, portal pressure was normalized, plasma ammonia was moderately high, and both dyes were absent in central nervous system parenchyma. All other parameters were reestablished. When portal pressure was normalized and ammonia level was lowered, but not normal, the altered integrity of blood-brain barrier becomes reestablished. CONCLUSION： The impairment of blood-brain barrier and subsequent normalization could be a mechanism involved in hepatic encephalopathy reversibility. Hemodynamic changes and ammonia could trigger blood-brain barrier alterations and its reestablishment.

African Americans,hypertension and the renin angiotensin system

African Americans have exceptionally high rates of hypertension and hypertension related complications. It is commonly reported that the blood pressure lowering efficacy of renin angiotensin system(RAS) inhibitors is attenuated in African Americans due to a greater likelihood of having a low renin profile. Therefore these agents are often not recommended as initial therapy in African Americans with hypertension. However, the high prevalence of comorbid conditions, such as diabetes, cardiovascular and chronic kidney disease makes treatment with RAS inhibitors more compelling. Despite lower circulating renin levels and a less significant fall in blood pressure in response to RAS inhibitors in African Americans, numerous clinical trials support the efficacy of RAS inhibitors to improve clinical outcomes in this population, especially in those with hypertension and risk factors for cardiovascular and related diseases. Here, we discuss the rationale of RAS blockade as part of a comprehensive approach to attenuate the high rates of premature morbidity and mortality associated with hypertension among African Americans.

Blood pressure,prevalence of hypertension and hypertension related complications in Nigerian Africans:A review

To review studies on hypertension in Nigeria over the past five decades in terms of prevalence,awareness and treatment and complications.Following our search on Pubmed,African Journals Online and the World Health Organization Global cardiovascular infobase,1060 related references were identified out of which 43 were found to be relevant for this review.The overall prevalence of hypertension in Nigeria ranges from 8%-46.4% depending on the study target population,type of measurement and cut-off value used for defining hypertension.The prevalence is similar in men and women(7.9%-50.2% vs 3.5%-68.8%,respectively) and in the urban(8.1%-42.0%) and rural setting(13.5%-46.4%).The pooled prevalence increased from 8.6% from the only study during the period from 1970-1979 to 22.5%(2000-2011).Awareness,treatment and control of hypertension were generally low with attendant high burden of hypertension related complications.In order to improve outcomes of cardiovascular disease in Africans,public health education to improve awareness of hypertension is required.Further epidemiological studies on hypertension are required to adequately understand and characterize the impact of hypertension in society.

Kidney Volume in Kidney Function Assessment: Determinants and Clinical Correlates in Systemic Hypertension and Chronic Kidney Disease in Southwestern, Nigeria

Background: The kidney volume is a very reliable ultrasound measure, reflecting contributions from all kidney parts. It could be affected by gender, body size and disease conditions. Its use in renal function assessment is based on its correlation with the glomerular filtration rate (GFR). Objectives: To assess the determinants and clinical correlates of kidney volume in hypertension and in chronic kidney disease (CKD). Materials and Methods: The two-center study was carried out at the Federal Medical Centre, Abeokuta (June-December 2017) and Babcock University Teaching Hospital, Ilishan-Remo (August 2019-January 2020). The kidneys of sixty participants who had hypertension without kidney disease (HWKD) and 58 with CKD were scanned from the front and back and their blood samples were taken for electrolytes and hemoglobin concentration. Result: The participants with CKD were significantly older than those with hypertension, P < 0.001. The mean kidney volume of hypertensives, 132.4 ± 18.3, was significantly higher than those with CKD, 63.7 ± 5.9, P < 0.001. The glomerular filtration rate (GFR) and hemoglobin concentration were significantly higher in hypertensives than in CKD, P < 0.001, P < 0.001 respectively. The systolic blood pressure (SBP), creatinine and the albumin creatinine ratio (ACR) were significantly higher in CKD than in hypertension, P < 0.001, P < 0.001 and P < 0.001 respectively. Conclusion: The mean kidney volume was higher in hypertension and in males. The GFR and hemoglobin levels were significantly higher in hypertension than in CKD while blood pressure and ACR were significantly higher in CKD than in hypertension. Kidney volume was positively and negatively correlated with GFR and ACR respectively.

Hyperuricemia in Hypertension and Chronic Kidney Disease: Risk Factors, Prevalence and Clinical Correlates: A Descriptive Comparative Study

Introduction: Uric acid is a product of purine metabolism and elevated serum concentration are very common in, and linked with hypertension and chronic kidney disease, conditions associated with heavy health burden and cardiovascular complications particularly in sub Sahara Africa. An assessment of factors relating hyperuricemia to hypertension and chronic kidney disease would therefore be necessary as way of mitigating the poor quality of life, morbidity and mortality associated with these diseases in low income nations. Methods: A single centre, descriptive comparative study in which the demographic, clinical and laboratory data of hypertensive and non-dialyzed chronic kidney disease (CKD) patients were analyzed. Serum biochemical parameters with uric acid, hematocrit and urine dip strip protein were assessed. Predictors of hyperuricemia were determined using multivariate analysis. Results: One hundred and thirty nine hypertensives and 69 CKD were studied. The mean age of the participants was 54.3 ± 11.7 years, hypertensives (52.9 ± 15.7 years) and CKD (57.3 ± 16.1 years). Both groups had more males, P = 0.8. Majority (78.3%) of the CKD cohorts had stage 4 or 5 (non-dialyzed) disease. The systolic and diastolic blood pressure, creatinine and uric acid were lower in hypertension than in CKD, P = 0.07, P = 0.05, P < 0.001 and P = 0.004 respectively. The hematocrit, albumin and GFR were higher in HTN than CKD, P < 0.001, P < 0.001 and P < 0.001 respectively. The prevalence of hyperuricemia was 56.2%. The mean uric acid was 505.9 ± 23.6 mmol/L, 382 7 ± 10.5 mmol/L for hypertensive and 755.9 ± 14.8 mmol/L for CKD, P < 0.001. The prevalence of systolic HTN, proteinuria, hypoalbuminemia and anemia were 51%, 75%, 46% and 59%, and were higher in males. Hyperuricemia was related to advancing age, proteinuria, elevated creatinine, hypoalbuminemia, anemia and hypertriglyceridemia. Proteinuria (OR—4.66, 95% CI—2.42 - 9.65), elevated creatinine (OR—3.12, 95% CI—2.40 - 6.92), hypoalbuminemia (OR—2.92, 95% CI—1.83 - 5.78) and anemia (OR—4.01, 95% CI—3.78 - 7.99) independently predicted hyperuricemia. Conclusion: Hyperuricemia is commoner in CKD than hypertension and was higher in males and positively correlated with the blood pressure, proteinuria and creatinine, but negatively related to hematocrit, albumin and glomerular filtration rate. Independent predictors of hyperuricemia were proteinuria, elevated creatinine, hypoalbuminemia and anemia. Measures are needed to prevent and treat hyperuricemia to reduce the health burden associated with hypertension and CKD.

Outcome Trials in the Therapeutic Management of Hypertension in East Asians

According to the most recent epidemiological data,the prevalence of hypertension ranged from about 25% in Chinese living either in the mainland or in Taiwan and Koreans,to approximately 40% in Mongolians.The control rate of hypertension was about 35% in Koreans and Japanese,24% in Mongolians,and less than 10%in Chinese.Four placebo-controlled trials in China unequivocally proved that antihypertensive therapy may prevent stroke and other cardiovascular complications in hypertension or patients with a history of stroke or transient ischemic attack.Four actively-controlled trials in Japan did not show signifi cant difference between various classes or combinations of antihypertensive drugs.Two trials that compared intensive with less intensive blood pressure control in elderly Japanese hypertensive patients did not show further benefi t of controlling systolic blood pressure to a level below 140 mmHg in comparison with blood pressure control to a level of 140 mmHg or above.These trials that compared various classes of antihypertensive drugs or intensive with less intensive blood pressure control often had small sample size and hence inadequate power to detect modest or moderate benefi t.There is still a need for high quality outcome trial data in East Asians.

Why is the Chinese hypertension guideline necessary?

The new Chinese hypertension guideline was eventually published.[1] It has been more than seven years since the previous Chinese hypertension guideline was published in 2011.[2] The guideline committee should also be congratulated that this new Chinese hypertension guideline was for the first time published in full length in the English language in this issue of the Journal of Geriatric Cardiology.[3] This is the fourth Chinese hypertension guideline,[3] after the first,second[4] and third[2] in 1999,2005 and 2011,respectively.The first Chinese hypertension guideline was printed in a booklet.The document was not so sophisticated,but nevertheless played a role in improving management of hypertension at that time in China.The treatment rate of hypertension increased substantially from 45.5% in 1991[5] to 81.8% in 2002[6] in patients who were aware of the disease (Table 1).

Endoscopic Ruler for varix size measurement:A multicenter pilot study

BACKGROUND We invented Endoscopic Ruler,a new endoscopic device to measure the size of varices in patients with cirrhosis and portal hypertension.AIM To assess the feasibility and safety of Endoscopic Ruler,and evaluate the agreement on identifying large oesophageal varices(OV)between Endoscopic Ruler and the endoscopists,as well as the interobserver agreement on diagnosing large OV using Endoscopic Ruler.METHODS We prospectively and consecutively enrolled patients with cirrhosis from 11 hospitals,all of whom got esophagogastroduodenoscopy(EGD)with Endoscopic Ruler.The primary study outcome was a successful measurement of the size of varices using Endoscopic Ruler.The secondary outcomes included adverse events,operation time,the agreement of identifying large OV between the objective measurement of Endoscopic Ruler and the empirical reading of endoscopists,together with the interobserver agreement on diagnosing large OV by Endoscopic Ruler.RESULTS From November 2020 to April 2022,a total of 120 eligible patients with cirrhosis were recruited and all of them underwent EGD examinations with Endoscopic Ruler successfully without any adverse event.The median operation time of Endoscopic Ruler was 3.00 min[interquartile range(IQR):3.00 min].The kappa value between Endoscopic Ruler and the endoscopists while detecting large OV was 0.52,demonstrating a moderate agreement.The kappa value for diagnosing large OV using Endoscopic Ruler among the six independent observers was 0.77,demonstrating a substantial agreement.CONCLUSION The data demonstrates that Endoscopic Ruler is feasible and safe for measuring the size of varices in patients with cirrhosis and portal hypertension.Endoscopic Ruler is potential to promote the clinical practice of the two-grade classification system of OV.

Nationwide survey analysis of esophagogastric varices in portal hypertension based on endoscopic management in China

Aims:The endoscopic treatment of esophagogastric varices is challenging,and the nationwide application of endoscopic therapies for various types of esophagogastric varices and different clinical scenarios remains unclear.This study investigated the use of endoscopic therapy for portal hypertension in China.Methods:This study used a questionnaire survey initiated by the Liver Health Consortium in China to investigate the use of endoscopic therapies for portal hypertension.Questionnaires were released online from January 30,2023 to February 28,2023 and filled out by chief physicians or senior instructors responsible for endoscopic therapies in participating hospitals across 31 provinces(autonomous regions and municipalities)in China.Comparisons of guideline adherence between primary and referral medical centers were performed using the chi‐square test or Fisher's exact test.Results:In total,836 hospitals participated in the survey.For primary and secondary prophylaxis of esophagogastric variceal bleeding(EGVB),adherence to the national guidelines was 72.5%(606/836)and 39.2%(328/836),respectively.Significant differences were observed in the rate of adherence between the primary and referral centers for primary(79.9%[111/139]vs.71.0%[495/697],p=0.033)and secondary prophylaxis(27.3%[38/139]vs.41.6%[290/697],p=0.002).Of the hospitals,78.2%(654/836)preferred endoscopic therapies for acute EGVB,and the timing of endoscopy was usually within 12 h(48.5%,317/654)and 12-24 h(36.9%,241/654)after bleeding.Endoscopic therapy was more likely to be the first choice of treatment for acute EGVB in referral centers than in primary centers(82.6%[576/697]vs.56.1%[78/139],p<0.001).Regarding the management of gastroesophageal varices type 2 and isolated gastric varices type 1,the most prevalent procedures were cyanoacrylate injection combined with sclerotherapy(48.2%[403/836]and 29.9%[250/836],respectively);however,substantial hospitals preferred clip-assisted therapies(12.4%[104/836]and 26.4%[221/836],respectively).Nonselective beta‐blockers were routinely used in 73.4%(614/836)of hospitals during the perioperative period of EGVB management,and propranolol(88.8%,545/614)and carvedilol(37.5%,230/614)were the most widely used nonselective beta-blockers.Conclusions:This survey clarified that various endoscopic procedures have been implemented nationwide in China.Participating hospitals have actively performed emergent endoscopy for acute EGVB;however,these hospitals do not adequately follow recommendations regarding primary and secondary prophylaxis of EGVB.In the future,standardizing the selection of endoscopic procedures and improving compliance with guidelines is crucial.

Role of vitamin D in diabetes mellitus and chronic kidney disease

Approximately 30%-50% of people are recognized to have low levels of vitamin D,and insufficiency and deficiency of vitamin D are recognized as global health problems worldwide.Although the presence of hypovitamin D increases the risk of rickets and fractures,low vitamin D levels are also associated with hypertension,cancer,and cardiovascular disease.In addition,diabetes mellitus(DM) and chronic kidney disease(CKD) are also related to vitamin D levels.Vitamin D deficiency has been linked to onset and progression of DM.Although in patients with DM the relationship between vitamin D and insulin secretion,insulin resistance,and β-cell dysfunction are pointed out,evidence regarding vitamin D levels and DM is contradictory,and well controlled studies are needed.In addition,vitamin D influences the renin-angiotensin system,inflammation,and mineral bone disease,which may be associated with the cause and progression CKD.There is increasing evidence that vitamin D deficiency may be a risk factor for DM and CKD;however,it remains uncertain whether vitamin D deficiency also predisposes to death from DM and CKD.Although at this time,supplementation with vitamin D has not been shown to improve glycemic control or prevent incident DM,clinical trials with sufficient sample size,study periods,and optimal doses of vitamin D supplementation are still needed.This review focuses on the mechanism of vitamin D insufficiency and deficiency in DM or CKD,and discusses the current evidence regarding supplementation with vitamin D in patients with these diseases.

Renin-angiotensin system in the pathogenesis of liver fibrosis

Hepatic fibrosis is considered a common response to many chronic hepatic injuries. It is a multifunctional process that involves several cell types, cytokines, chemokines and growth factors leading to a disruption of homeostatic mechanisms that maintain the liver ecosystem. In spite of many studies regarding the development of fibrosis, the understanding of the pathogenesis remains obscure. The hepatic tissue remodeling process is highly complex, resulting from the balance between collagen degradation and synthesis. Among the many mediators that take part in this process, the components of the Renin angiotensin system （RAS） have progressively assumed an important role. Angiotensin （Ang） II acts as a profibrotic mediator and Ang-（1-7）, the newly recognized RAS component, appears to exert a counter-regulatory role in liver tissue. We briefly review the liver fibrosis process and current aspects of the RAS. This review also aims to discuss some experimental evidence regarding the participation of RAS mediators in the pathogenesis of liver fibrosis, focusing on the putative role of the ACE2-Ang-（1-7）- Mas receptor axis.

TET1 is a DNA-binding protein that modulates DNA methylation and gene transcription via hydroxylation of 5-methylcytosine

Dear Editor, DNA methylation, which often occurs at the 5-carbon position of cytosine （5mC） located in CpG dinucleotide, is a key epigenetic hallmark and serves as a major epigenetic mechanism for establishing X-inactivation, parental imprinting and silencing retrotransposable elements during early embryogenesis in mammals. Accumulative evidence also suggests that DNA methylation plays key roles in transcriptional regulation [1].

Elevated Homocysteine and C-reactive Protein Levels Independently Predict Worsening Prognosis after Stroke in Chinese Patients

Increased plasma total homocysteine (tHcy) and high sensitivity C-reactive protein (hsCRP) levels are independent risk factors for cardiovascular disease.However, the predictive value of tHcy in combination with hsCRP in patients with stroke is not known.To determine the relationship between tHcy and hsCRP, we enrolled 291 patients with first-onset stroke (196 ischemic and 95 hemorrhagic).Plasma tHcy and hsCRP levels were measured and subsequent vascular events and deaths were determined over a 5-year period.Using the arbitrary cutoff for tHcy (【18 μmol/L and ≥18 μmol/L) and hsCRP (【1 mg/L, 1-3 mg/L and 】3 mg/L), the patients were divided into 6 groups.Survival analysis showed that the probability of death or new vascular events during a 5-year follow-up increased according to tHcy and hsCRP levels (P【0.01).The relative risk (RR) of death or new vascular events was 4.67 (95% CI, 1.96 to 11.14, P=0.001) in patients with high tHcy (≥18 μmol/L) and hsCRP (】3 mg/L) compared with those with low tHcy (【18 μmol/L) and hsCRP (【1 mg/L).The increased tHcy level (≥18 μmol/L) combined with increased hsCRP level (】3 mg/L) was still significantly associated with the risk of death or new vascular events (RR, 4.10, 95% CI, 1.61 to 10.45, P=0.003) even when adjusted for other risk factors at inclusion.The combination of increased tHcy and hsCRP levels had a stronger predictive value than increased hsCRP alone or increased tHcy level alone.Further studies are required to evaluate the potential decrease in risks associated with lowering both Hcy and hsCRP levels in patients that present with both increased tHcy and hsCRP.

Antioxidant role of heme oxygenase-1 in prehepatic portal hypertensive rats

AIM： To study the effect of bilirubin on the oxidative liver status and the activity and expression of heine oxygenase-1 （HO-1） in rat liver injury induced by prehepatic portal hypertension. METHODS： Wistar male rats, weighing 200-250 g, were divided at random into two groups： one group with prehepatic portal hypertension （PH） induced by regulated prehepatic portal vein ligation （PPVL） and the other group corresponded to sham operated rats. Portal pressure, oxidative stress parameters, antioxidant enzymes, HO-1 activity and expression and hepatic sinusoidal vasodilatation were measured. RESULTS： In PPVL rats oxidative stress was evidenced by a marked increase in thiobarbituric acid reactive substances （TBARS） content and a decrease in reduced glutathione （GSH） levels. The activities of liver antioxidant enzymes, superoxide dismutase （SOD）, catalase （CAT） and glutathione peroxidase （GSH-Px） were also diminished while activity and expression of HO-1 were enhanced. Administration of bilirubin （5μmol/kg body weight） 24 h before the end of the experiment entirely prevented all these effects. Pretreatment with Sn-protoporphyrin IX （Sn-PPIX） （100 μg/kg body weight, i.p.）, a potent inhibitor of HO, completely abolished the oxidative stress and provoked a slight decrease in liver GSH levels as well as an increase in lipid peroxidation. Besides, carbon monoxide, another heme catabolic product, induced a significant increase in sinusoidal hepatic areas in PPVL group. Pretreatment of PPVL rats with Sn-PPIX totally prevented this effect CONCLUSION： These results suggest a beneficial role of HO-1 overexpression in prehepatic portal hypertensive rats.

Preeclampsia from a renal point of view:Insides into disease models,biomarkers and therapy

Proteinuria is a frequently detected symptom,found in 20% of pregnancies.A common reason for proteinuria in pregnancy is preeclampsia.To diagnose preeclampsia clinically and to get new insights into the pathophysiology of the disease it is at first essential to be familiar with conditions in normal pregnancy.Animal models and biomarkers can help to learn more about disease conditions and to find new treatment strategies.In this article we review the changes in kidney function during normal pregnancy and the differential diagnosis of proteinuria in pregnancy.We summarize different pathophysiological theories of preeclampsia with a special focus on the renal facets of the disease.We describe the current animal models and give a broad overview of different biomarkers that were reported to predict preeclampsia or have a prognostic value in preeclampsia cases.We end with a summary of treatment options for preeclampsia related symptoms including the use of plasmapheresis as a rescue therapy for so far refractory preeclampsia.Most of these novel biomarkers for preeclampsia are not yet implemented in clinical use.Therefore,we recommend using proteinuria(measured by UPC ratio) as a screening parameter for preeclampsia.Delivery is the only curative treatment for preeclampsia.In earlypreeclampsia the primary therapy goal is to prolong pregnancy until a state were the child has an acceptable chance of survival after delivery.

Simvastatin Increases the Activity of Endothelial Nitric Oxide Synthase via Enhancing Phosphorylation

3-hydroxy-3-methylgulutaryl-coenzyme A （HMG-CoA） reductase inhibitors or statins are a kind of lipid-lowering agents and have been used for the prevention and treatment of Cardiovascular diseases. Recent studies suggested that statins, besides lowering cholesterol, may protect vessels by enhancing the activity of endothelial nitric oxide synthase （eNOS）. In the present study, we investigated if simvastatin increases eNOS activity through its phosphorylation in 293 cells （293-eNOS） with stable expression of eNOS. The results showed that incubation of 293-eNOS cells with simvastatin （10 μm/L） for 2 h significantly increased in the activity of eNOS as shown by the conversion of L-arginine to L-citrulline （2889.70±201.51 versus 5630.18＋218.75 pmol/min . mg proteins） （P〈0.01）. Western blotting revealed that simvastatin increased phosphorylation of eNOS at 1177 （ser） and also 495 （thr） but did not affect the overall expression of eNOS or inducible NOS. Further study found that simvastatin raised phosphorylation levels of Akt and AMPK, and such effect could be antagonized by Akt inhibitor or AMPK inhibitor. These results suggest that simvastatin could stimulate,the activity of eNOS via its phosphorylation by Akt and AMPK, which provides a new mechanism, other than lipid-lowering effect, for the cardiovascular protection of statins.

Acute abdomen and ascites as presenting features of autosomal dominant polycystic kidney disease

We describe a patient with sudden onset of abdominal pain and ascites,leading to the diagnosis of autosomal dominant polycystic kidney disease(ADPKD).Her presentation was consistent with acute liver cyst rupture as the cause of her acute illness.A review of literature on polycystic liver disease in patients with ADPKD and current management strategies are presented.This case alerts physicians that ADPKD could occasionally present as an acute abdomen;cyst rupture related to ADPKD may be considered in the differential diagnoses of acute abdomen.

Changing organ allocation policy for kidney transplantation in the United States

The new kidney allocation scheme(KAS) in effect since December 4th 2014 was designed to overcome the shortcomings of previous system. A key feature of the new KAS is preferential allocation of best quality organs to wait-list candidates with the longest predictivesurvival in a concept called longevity matching. Highly sensitized recipients would get extra points and enjoy widespread sharing of organs in order to increase accessibility to transplant. Wait-list candidates with blood group B will be offered organs from donors with A2 and A2 B blood type in order to shorten their wait-list time. Time on the wait list will start from day of listing or date of initiation of dialysis whichever comes first which should benefit candidates with limited resources who might be late to get on the transplant list. Pay back system has been eliminated in the new KAS. These changes in organ allocation policy may lead to increase in median half-life of the allograft and increase the number of transplants; thus resulting in better utilization of a scarce resource. There could be unintended negative consequences which may become evident over time.

Associations of renal function with diabetic retinopathy and visual impairment in type 2 diabetes: A multicenter nationwide cross-sectional study

BACKGROUND Diabetic retinopathy(DR) separately has been noted as a major public health problem worldwide as well. Currently, many studies have demonstrated an association between diabetic nephropathy and DR in type 1 diabetes mellitus(T1DM) patients, but this association is less strong in T2DM. The evidence for an association between renal function and DR and visual impairment among T2DM patients is limited, particularly in the Asian population.AIM To assess the association between glomerular filtration rate(GFR) and DR, severe DR, and severe visual impairment among T2DM patients in Thailand.METHODS We conducted a nationwide cross-sectional study based on the DM/HT study of the Medical Research Network of the Consortium of Thai Medical Schools. This study evaluated adult T2DM patients from 831 public hospitals in Thailand in the year 2013. GFR was categorized into ≥ 90, 60-89, 30-59 and < 30 mL/min/1.73 m^2.The association between GFR and DR, severe DR, and severe visual impairment were assessed using multivariate logistic regression.RESULTS A total of 13192 T2DM patients with available GFR were included in the analysis.The mean GFR was 66.9 ± 25.8 mL/min/1.73 m^2. The prevalence of DR,proliferative DR, diabetic macular edema, and severe visual impairment were 12.4%, 1.8%, 0.2%, and 2.1%, respectively. Patients with GFR of 60-89, 30-59 and <30 mL/min/1.73 m^2 were significantly associated with increased DR and severe DR when compared with patients with GFR of ≥ 90 mL/min/1.73 m^2. In addition,increased severe visual impairment was associated with GFR 30-59 and < 30 m L/min/1.73 m^2.CONCLUSION Decreased GFR was independently associated with increased DR, severe DR, and severe visual impairment. GFR should be monitored in diabetic patients for DR awareness and prevention.

Role of steroid maintenance in sensitized kidney transplant recipients

AIM: To evaluate whether there is a threshold sensitization level beyond which benefits of chronic steroid maintenance(CSM) emerge. METHODS: Using Organ Procurement and Transplant Network/United Network of Organ Sharing database, we compared the adjusted graft and patient survivals for CSM vs early steroid withdrawal(ESW) among patients who underwent deceased-donor kidney(DDK) transplantation from 2000 to 2008 who were stratified by peak-panel reactive antibody(peak-PRA) titers(0%-30%, 31%-60% and > 60%). All patients received perioperative induction therapy and maintenance immunosuppression based on calcineurin inhibitor(CNI) and mycophenolate mofetil(MMF).RESULTS: The study included 42851 patients. In the 0%-30% peak-PRA class, adjusted over-all graft-failure(HR 1.11, 95%CI: 1.03-1.20, P = 0.009) and patientdeath(HR 1.29, 95%CI: 1.16-1.43, P < 0.001) risks were higher and death-censored graft-failure risk(HR 1.06, 95%CI: 0.98-1.14, P = 0.16) similar for CSM(n = 25218) vs ESW(n = 7399). Over-all(HR 1.04, 95%CI: 0.85-1.28, P = 0.70) and death-censored(HR 0.97, 95%CI: 0.78-1.21, P = 0.81) graft-failure risks were similar and patient-death risk(HR 1.39, 95%CI: 1.03-1.87, P = 0.03) higher for CSM(n = 3495) vs ESW(n = 850) groups for 31%-60% peak-PRA class. In the > 60% peak-PRA class, adjusted overall graft-failure(HR 0.90, 95%CI: 0.76-1.08, P = 0.25) and patientdeath(HR 0.92, 95%CI: 0.71-1.17, P = 0.47) risks were similar and death-censored graft-failure risk lower(HR 0.84, 95%CI: 0.71-0.99, P = 0.04) for CSM(n = 4966)vs ESW(n = 923).CONCLUSION: In DDK transplant recipients who underwent perioperative induction and CNI/MMF maintenance, CSM appears to be associated with increased risk for death with functioning graft in minimally-sensitized patients and improved death-censored graft survival in highly-sensitized patients.