TBX5 was identified as the only inhibited regulator (z-score = −2.89). F2R and SFRP4 were identified as the activated regulators . Multiple downstream genes regulated by TBX5, F2R, and SFRP4 were involved in ICM-related diseases such as HF and arrhythmia. Overall, our study is the first to perform an RNA-seq meta-analysis for clinical ICM and provides robust candidate genes, including three key transcriptional regulators, for future diagnostic and therapeutic applications in ischemic heart failure.Ischemic cardiomyopathy (ICM), characterized by pre-existing myocardial infarction or severe coronary artery disease, is the major cause of heart failure (HF). Identification of novel transcriptional regulators in ischemic HF can provide important biomarkers for developing new diagnostic and therapeutic strategies. In this study, we used four RNA-seq datasets from four different studies, including 41 ICM and 42 non-failing control (NF) samples of human left ventricle tissues, to perform the first RNA-seq meta-analysis in the field of clinical ICM, in order to identify important transcriptional regulators and their targeted genes involved in ICM. Our meta-analysis identified 911 differentially expressed genes (DEGs) with 582 downregulated and 329 upregulated. Interestingly, 54 new DEGs were detected only by meta-analysis but not in individual datasets. Upstream regulator analysis through Ingenuity Pathway Analysis (IPA) identified three key transcriptional regulators.  Heart failure (HF), leading to considerable mortality and health care costs, is a critical health problem, especially among the people aged ≥65, around the world . CharactDysregulated transcriptional hubs, such as transcription factors, non-coding RNAs and chromatin regulators, and their downstream gene expression signatures are representative of genomic mechanisms underlying disease processes. Therefore, detecting such genomic signatures aids in the development of new diagnostic and therapeutic approaches. A few such independent studies have reported unique gene expression signatures eventually leading to cardiovascular diseases such as HF ,5,6,7.RNA-seq studies play an important role in understanding transcriptional regulation of cardiovascular diseases . Since dFour RNA-seq datasets  differentially expressed genes (DEGs), including 582 downregulated and 329 upregulated genes, were identified in meta-analysis . The topp-value < 0.05). Activation z-score > 2 was considered as significantly activated. Only two pathways, arrhythmia (z-score = 2.81) and failure of heart (z-score = 2.41), were marked with significant activation status. Interactions of these two pathways with their associated DEGs are shown in DES and TNNT2 were among the top 50 DEGs , only four pathways had absolute z-scores more than 2.0 and were marked as significantly inhibited in the ICM group  that were 38 downregulated and 23 upregulated in the ICM group, respectively (TBX5 was marked as a significantly inhibited regulator (z-score = −2.89); only F2R and SFRP4 were significantly activated regulators   . Figure TBX5-targeted genes and the DEGs in toxicity pathways, we found that the dysregulation of TBX5-targeted genes, TNNT2, NPPA, TTN, ATP2A2, DES and SCN5A, contributed to the development of heart failure and arrhythmia , cardiac contractility (decreased), contractility of muscle (decreased) and function of cardiac muscle (decreased) (Integrating the results of the rhythmia A. NKX2-5of heart A. TBX5-trhythmia A. MoreovEGs list . The netdiseases . Inhibit failure . Inhibitcreased) .F2R, as the activated upstream regulator, upregulated PLAT, which was involved in heart failure and arrhythmia  of all four individual datasets to prevent methodological inconsistences in terms of data processing and bioinformatics pipelines among original studies. Our meta-analysis identified a total of 911 differentially expressed genes including 582 downregulated and 329 upregulated genes .OGN and RPL26, were previously reported to be dysregulated in ICM patients [OGN, osteoglycin, has been reported to play a role in collagen maturation and deposition in mouse myocardial infarction tissue [OGN has also been observed in ischemic HF patients experiencing myocardial infarction compared to patients with non-ischemic HF and thus it has been proposed as a biomarker for ischemic HF with pre-existing myocardial infarction [RPL26, ribosomal protein L26, has also been observed in patient with ischemic HF [DES and PTN were also reported in dilated cardiomyopathy (DCM) [PALLD , important for organizing actin cytoskeleton, have been reported to be associated with myocardial infarction [MYH6, TNNT2 and TPM1, have been found to be associated with hypoplastic left heart, cardiac hypertrophy and DCM, respectively [Among the top 50 significant DEGs , severalpatients ,16. Upren tissue . Increasfarction . Moreovehy (DCM) ,18. Intefarction ,20. Geneectively ,22,23.CRMP1 has been demonstrated as a potential candidate for left-sided congenital heart disease [ATP1A1 has been reported in end-stage HF [ATP1A1 was involved in heart failure , CREB3L1 (belongs to CREB family), SMARCA4, NCAM1 and SFRP4 were significant DEGs in our dataset  from our IPA analysis  has been reported to promote cardiomyocyte division in vivo and regulate cardiac function responding to heart failure in a rat myocardial infarction model [TBX5, our study identified F2R and SFRP4 as two important activated transcriptional regulators involved in the development of ICM-related cardiac dysfunctions.ed genes . SFRP4, ignaling . Increas and DCM ,42. Sevediseases ,41,43,44response . Genetic disease ,46. In oCM group B. Activaed CCND1 D, which ed CCND1 . CCND1 . Further, we did not include the datasets if they were not collected using the Illumina sequencing platform or they were collected in patients with any treatment of a specific drug or medically implanted device. The clinical information of ICM patients and their controls has been described in Study_1 [https://www.ebi.ac.uk/ena). Quality control for raw reads and trimmed reads was performed using FastQC [ Study_1 , Study_2 Study_1 , Study_3 Study_1  and Stud Study_1 . RNA-seq Study_1 ,50,52,53 Study_1  and is sg FastQC . Adaptorg FastQC . A pipelg FastQC , Samtoolg FastQC  and HTSeg FastQC  was usedp-values were adjusted by the Benjamini–Hochberg false discovery rate (FDR) method and the adjusted p-values less than 0.05 were considered as statistically significant. Only DEGs with consistent expression directions among the four individual studies were included in the final DEGs list.DESeq2  was usedTo identify enriched canonical pathways, toxicity functions (IPA-Tox) and upstream transcriptional regulators, the Ingenuity Pathway Analysis software   was used


Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines were adopted, which included a 24-point checklist. Articles were stratified according to biofluid. Of articles reporting discriminating metabolites between formula- and human milk-fed infants, 62.5% (5/8) of plasma/serum/dried blood spot, 88% (7/8) of urine and 100% (6/6) of feces related articles reported such discriminating metabolites. Overall, no differences were found between analytical approach used (targeted (n = 9) vs. un-targeted (n = 10)). Current articles are limited by small sample sizes and differing methodological approaches. Of the metabolites reviewed herein, fecal metabolites provided the greatest distinction between diets, which may be indicative of usefulness for future diet metabolite-focused work.Metabolites are generated from exogenous sources such as diet. This scoping review will summarize nascent metabolite literature and discriminating metabolites for formula vs. human- milk-fed infants. Using the PICOS framework  and PRISMA item-reporting protocols, infants less than 12 months old, full-term, and previously healthy were included. Protocol was registered with Open Science Framework (OSF). Publications from 1 January 2009–2019 were selected, for various biofluids, study designs, and techniques (such as high-performance liquid chromatography (HPLC)). From 711 articles, blinded screening of 214 articles using Abstrackr Infant health is strongly correlated to their diet of human milk or infant formula ,2,3. MetBoth human milk and infant formula affect the infant’s resistance to illness within the first months of life ,11. HumaThe aim of this scoping review was two-fold: first, to assess the quality of the literature for review, and secondly, to determine whether any of the studies were able to identify metabolites that were discriminatory between breast- and formula-fed infants . The lathttps://osf.io/registries), followed the PRISMA reporting ; analyzed <3 metabolites (n = 5); dietary exposure unclear (n = 1)). Accordingly, a total of 24 articles were analyzed fully [Authors followed the PRISMA guidelines for item reporting  30]. Al. Al30]. ® . After ted fully ,53,54,55Abstracted data as summarized in the tables included: the PMID, first author, year of publication, diets, ages, sample sizes , assay, targeted vs. un-targeted, whether results were discriminatory, and if so at what age and for which metabolite.Given that one of the weaknesses of scoping reviews is the lack of a quality of reporting assessment , selecteSTROBE is designed for observational studies of which 18 (75%) of 24 papers met this criterion . Two reviewers scored each manuscript following STROBE checklist electronically , and discrepancies were analyzed by a third reviewer (S.S.C). The remaining discrepancies were eliminated through discussions between two of the three reviewers both electronically and verbally , where discrepancies were largely in study design, and sources of bias. Reviewers discussed each case of the remaining discrepancies and came to full agreement. A point was given for each positively evaluated checklist item. From this, the scoring was deemed neutral (16–19) and positive (20–24), no studies were excluded based on their STROBE result.The median age of articles included was 3 years old. International representation of studies included: 7 (29.2%) from Germany, 3 (12.5%) from Japan, 3 (12.5%) from USA, 2 (8.3%) from Italy, 1 (4.2%) from Canada, 1 (4.2%) from Brazil, 1 (4.2%), from Taiwan, 1 (4.2%) from UK, 1 (4.2%) from Poland, 1 (4.2%) from Switzerland, 1 (4.2%) from Netherlands, 1 (4.2%) from Ireland, and 1 (4.2%) from France. In summary, most articles were from Europe , 4 (16.7%) from North America, 1 (4.2%) from South America, and 4 (16.7%) from Asia. Study designs included: 8 (33.3%) cohort, 6 (25%) randomized control trials, 6 (25%) case-controls, 2 (8.3%) mother-baby cohort, 2 (8.3%) cross-sectional. The median age of patients recruited was: 4 months. Biofluids included in analyses were: 10 (40.0%) urine, 7 (28.0%) feces, 3 (12.0%) plasma, 3 (12.0%) serum, 2 (8.0%) DBS. Specific measurement techniques included: 6 (24%) liquid chromatography/mass spectrometry (LC/MS); 4 (16%) NMR; 4 (16%) HPLC, 2 (8%) gas chromatography/mass spectrometry (GC/MS), 2 (8%) enzyme-linked immunosorbent assay (ELISA), 2 (8%) matrix-assisted laser desorption/ionization time-of-flight-mass spectrometry (MALDI-TOF-MS), 1 (4%) electrospray ionization-mass spectrometry/mass spectrometry (ESI-MS/MS), 4 (16%) other (1 (4%) high-performance anion-exchange chromatography with pulsed amperometric detection (HPAEC-PAD); 1 (4%) ultra-high-performance liquid chromatography mass spectrophotometry (UHPLC/MS); 1 (4%) chemical analysis; 1 (4%) urease methods).All initial discrepancies were resolved. STROBE results from two independent reviewers revealed total points of neutral (16–19) and positive (20–24) scored manuscripts. All manuscripts met 12 of the 24 STROBE criteria. For seven of the STROBE criteria, fewer than half of the 24 papers reviewed herein met the criteria. These missing criteria included: addressing potential sources of bias, explaining how study size was arrived at, explaining how missing data were addressed, describing any sensitivity analyses, giving reasons for non-participation/sample exclusion at each stage, indicating the number of participants with missing data for each variable of interest, and translating estimates of relative risk into absolute risk for a meaningful time period. Additionally, fewer than 20 studies but more than 12 studies noted the following: how quantitative variables were handled in the analyses, how loss of samples were accounted for, numbers of individuals at each stage of the study, demographic/clinical or social characteristics of study participants, unadjusted estimates of risk, limitations of the study , as well as the source of funding and role of the funders in the study. Notably, few articles described how they quantified several of the variables included in their analyses. This directly impacted how the authors described their outcome data. Lastly, the point of generalizability was not always implicitly stated in the text but was assumed to be present when the text presented the greater clinical implications of the work. The weakest sections were: reporting of study size, sample size calculation, and explanation of missing data.n = 9) vs. un-targeted (n = 10) analytical approach did not reveal differences. Similarly, the techniques used to qualify metabolites was extremely heterogenous, whereby there was little repetition in any of those reporting for discriminatory markers: fecal ; plasma/serum/DBS ; urine . From this we may state that H1-NMR was more frequently used for fecal metabolite detections, LC-MS for plasma/serum/DBS, and CE-TOF/MS for urine with twice as many times reported. Given the small sample size we are unable to speculate as to which technique is best for each biofluid.Summary tables were generated for the following biofluids: fecal samples , plasma,n = 6 out of 6 such articles), fecal metabolites were discriminatory for dietary exposure.Fecal metabolites were discussed in the following reports ,40,44,45n = 5), no (n = 3), and largely based on the detection of lipids and amino acids. In summary, Acharjee et al. found that an exclusively human milk diet resulted in the presence of distinct lipids species (PC (35:2), SM (36:2), SM (39:1) [The discriminatory ability of the articles was qualified as either yes (M (39:1) . KirchbeM (39:1) . SlupskyM (39:1) . A similM (39:1) . FinallyM (39:1) .In spite of the lack of a comparative group, other observations in this sub-cohort of studies looking at plasma, serum and DBS, from exclusively human milk-fed included those describing serum phospholipids, acylcarnitines, amino acids, and LPC 14:0 . This fin = 236) and many urine samples (n = 587) [n = 636) at six months, where urinary C-peptide: creatinine ratio higher in HP, as compared to LP compared to human milk-fed [N, N-dimethylglycine, sarcosine, and betaine) and l(-)-threonine and l-carnosine excretion at 1 month were statistically significantly higher in human milk-fed infants; 1(-)-threonine and 1-carnosine. Lactic acid was lower in human milk-fed infants at both 1 and 6 months [Dietary-specific urinary markers were found in seven studies ,51,55,62n = 587) . Socha e6 months . A final6 months .One manuscript did not provide discriminatory results. Anderson et al. looked at exclusive human vs. exclusive formula milk in 175 infants and DCA  excretion amounts did not differ between groups . Two addThe current review of the literature describing metabolites in biofluids of healthy infants fed human milk, infant formula or a mixed diet demonstrates wide variability in metabolites but provides evidence that metabolites in fecal samples may be best suited to differentiating human milk-fed from formula-fed infants. Furthermore, it highlights the variety of methods used to profile these metabolites and the failure of much of the literature to report necessary details about study design, participants, and generalizability of reported results. It was beyond the scope of this review to determine if compositional differences within human milks or within formulas can be detected in biofluids from infants consuming those foods. However, one of the manuscripts that was reviewed compared formulas of differing composition (high- and low-protein formulations). That article did not identify differences in infant metabolites by formula composition. Another of the manuscripts (Dotz 2015 ) did ideBased on the STROBE results and to report on the primary objective of the work, we can deduce that the overall quality of the articles is fair to positive. None of the articles were excluded based on their STROBE results and this internal metric should be considered for future reviews, as it is not customary for scoping reviews to screen articles using this metric.This literature review also demonstrates that metabolites are measured using a variety of methods, including targeted (by MS only) or untargeted (by NMR or MS) approaches. Targeted approaches are those which set out to measure specific metabolites whereas untargeted approaches measure all metabolites . TypicalBlood, plasma, and DBS are attractive sources of metabolic differences. It is known that blood reveals metabolic changes reflective of organ function and is commonly used in clinical biochemistry, therefore there is ongoing interest to develop blood markers of interest for this patient population. The use of blood for patient analytics remains at the forefront of current bedside medicine, playing a major role in decision making, deductive reasoning for physicians and how we derive a diagnosis. It has evolved in the field as a common biofluid of interest .nil per os (NPO). In such cases, little fecal matter is produced, making it difficult to use this biofluid for metabolite analyses. Nonetheless, 100% (6/6) of articles describing fecal metabolites reported discriminatory metabolites between formula- and human milk-fed infants. These discriminatory metabolites included the human milk oligosaccharides themselves as well as short-chain fatty acids. Only 62.5% (5/8) of plasma/serum/dried blood spot and 88% (7/8) of urine reports had such discriminating metabolites. Thus, when the goal is to discriminate between human milk- and formula-fed infants, feces may be the preferred biospecimen.There also is a desire in the pediatric community to determine novel ways to run studies using non-invasive practices, of which urine and fecal matter, both constituted as waste-products, have a certain appeal. However, urine has specific challenges ,65,66. FThis review excludes articles published after 31 December 2018. Findings cannot be used to recommend policy/practice. In many cases biomarkers still need to be validated in a separate cohort. Given the limited number of manuscripts, we were not able to further stratify based on technique, which may introduce additional heterogeneity. Studies may not have been adequately powered. We did not differentiate here between human milk-fed to infants at the breast or human milk given to infants via bottle feeding.n = 24). Most are of high quality, but some do not clearly describe the populations from which samples were collected nor the methods used to handle missing data/samples. These articles reported differentiating between human milk- and formula-fed infants based on metabolites in their urine, plasma, serum, blood or feces. Although the studies identified several metabolites that differ between human milk- and formula-fed infants, only some metabolites were reported in more than one study. These are summarized here. Human milk oligosaccharides and short-chain fatty acids were discriminatory in fecal samples. In serum/plasma, amino acids and urea were discriminatory. For urine, myoinositol was discriminatory. It is beyond the scope of this review to state whether sufficient evidence exists; however, if dietary markers are of interest, then the studies listed in this review may serve as reference body of literature. Further work is required. In healthy infants, fecal samples provide the best discriminatory prospect for dietary metabolite differentiation.There are many articles that characterize dietary metabolites in infants, as described here (


Rationale: Up to date, the exploration of clinical features in severe COVID-19 patients were mostly from the same center in Wuhan, China. The clinical data in other centers is limited. This study aims to explore the feasible parameters which could be used in clinical practice to predict the prognosis in hospitalized patients with severe coronavirus disease-19 (COVID-19).Methods: In this case-control study, patients with severe COVID-19 in this newly established isolation center on admission between 27 January 2020 to 19 March 2020 were divided to discharge group and death event group. Clinical information was collected and analyzed for the following objectives: 1. Comparisons of basic characteristics between two groups; 2. Risk factors for death on admission using logistic regression; 3. Dynamic changes of radiographic and laboratory parameters between two groups in the course.Results: 124 patients with severe COVID-19 on admission were included and divided into discharge group (n=35) and death event group (n=89). Sex, SpO2, breath rate, diastolic pressure, neutrophil, lymphocyte, C-reactive protein (CRP), procalcitonin (PCT), lactate dehydrogenase (LDH), and D-dimer were significantly correlated with death events identified using bivariate logistic regression. Further multivariate logistic regression demonstrated a significant model fitting with C-index of 0.845 (p<0.001), in which SpO2≤89%, lymphocyte≤0.64×109/L, CRP>77.35mg/L, PCT>0.20μg/L, and LDH>481U/L were the independent risk factors with the ORs of 2.959, 4.015, 2.852, 3.554, and 3.185, respectively (p<0.04). In the course, persistently lower lymphocyte with higher levels of CRP, PCT, IL-6, neutrophil, LDH, D-dimer, cardiac troponin I (cTnI), brain natriuretic peptide (BNP), and increased CD4+/CD8+ T-lymphocyte ratio and were observed in death events group, while these parameters stayed stable or improved in discharge group.Conclusions: On admission, the levels of SpO2, lymphocyte, CRP, PCT, and LDH could predict the prognosis of severe COVID-19 patients. Systematic inflammation with induced cardiac dysfunction was likely a primary reason for death events in severe COVID-19 except for acute respiratory distress syndrome. Since the outbreak of COVID-19 in Wuhan, it spread rapidly worldwide with a severity spectrum from asymptomatic to critical illness with the overall rate of approximately 3% To date, the clinical studies revealed different clinical and laboratory features between survivors and non-survivors, or between the non-severe and severe patients, and some prognostic risk factors were preliminarily discovered, such as age and D-dimer This study was approved by the Ethics of Committees of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology (No. 2020-0026), and followed the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Only the anonymous data was collected and informed consent for this retrospective study was waived.The consecutive admission records were reviewed retrospectively for the period from 27 January 2020 to 19 March 2020 in this provisional center . Clinical data, including initial symptoms, past medical history, hospitalization date, treatment, and hematological and biochemical blood test results were obtained directly through the institutional electronic patient database. The inclusion criteria included: 1. Confirmed severe COVID-19 on admission as mentioned above Regular bedside chest digital radiographs (DRs) were regularly performed every 1 to 3 days instead of conventional computed tomography (CT) scans after admission owing to the risk during the transfer of severe patients. A conventional semi-quantitative scoring system for DR was used to evaluate the pulmonary involvement area of the abnormalities including air-space and reticular opacities Two groups were divided based on the clinical outcomes: discharge group and death event group. Three objectives were explored in this study: 1. Comparisons of basic characteristics between two groups, including the occurrence of ARDS, which was defined as worsening respiratory symptoms with PaO2/FiO2≤300 mmHg based on the Berlin definition and WHO criteria Statistical analysis was performed using IBM SPSS Statistics Software . Quantitative data were presented as median with inter-quartile range (IQR) and counting data were presented as the percentage of the total unless otherwise specified. The comparisons of the quantitative data were statistically evaluated using the Mann-Whitney U test, according to the non-normal distribution assessed by the Shapiro-Wilk test. The quantitative parameters were stratified into binary variables with the cutoffs of median values. The comparisons of counting data were evaluated using the Chi-square test. The bivariate and multivariate logistic regressions were used to investigate the risk factors for death events involving the stratified clinical, radiographic, and laboratory parameters with significant differences between two groups on admission, and the odds ratio (OR) with 95% confidence interval (95%CI) were calculated. Variables were excluded in the multivariate logistic regression if: 1. The univariate analysis demonstrated no statistical significance (p<0.05); 2. The multivariate analysis demonstrated the probability of p≥0.10 when using forward-LR method; 3. Variable had obvious colinearity with other variables resulting in variance inflation factor (VIF) of more than 5 Figure 1). The basic information of included patients was summarized in Table 1. The median age of patients was 68 yrs (IQR 61-75 yrs), and 68.5% of patients were male. Half of the patients had hypertension history and 11 patients had COPD (GOLD II grade) history which was controlled well after quitting smoking and ipratropium treatment. Fever and cough were the most common initial symptoms . The median interval between the admission and symptom onset was 11 days (IQR 7-15 days). On admission, the median body temperature on admission reached 38.3 °C (IQR: 37.0-39.0°C). The median breath rate was 30/min (IQR: 23-33/min) and median SpO2 was 89% (IQR: 82-92%). In most patients , DRs demonstrated bilateral opacities with the median DR score of 13 (IQR: 7-16). Multiple abnormities of biochemical and hematological parameters were observed as well, including neutrophil, lymphocyte, C-reactive protein (CRP), procalcitonin (PCT), lactate dehydrogenase (LDH), D-dimer, cardiac troponin I (cTnI), and brain natriuretic peptide (BNP), and so on. In the course, 91 patients (73.4%) aggravated to ARDS with the median period of 7 days after admission (IQR 4-11 days), who were transferred to ICU afterwards. Eventually, 89 patients (71.8%) with ARDS complications died who were included in death event group, while 35 patients (28.2%) were recovered and discharged who were included in discharge group.After retrieving the electronic records, 124 patients were eventually included in the further analysis from 211 consecutive records (Table 2). In the course, ARDS was more predominantly occurred in death event group compared with discharge group (89 vs. 2). 10 patients with ARDS in death event group refused endotracheal intubation. The median survival period in death event group was 15 days (IQR 9-22 days), while the median hospitalized period in discharge group was 29 days (IQR 23-35 days) (Table 2). On admission, the bedside DRs showed larger pulmonary opacities in death event group compared with discharge group, but without a significant difference  (Table 2). Besides, more abnormities of biochemical and hematological parameters were observed in death event group compared with discharge group, such as neutrophil, lymphocyte, CRP, PCT, LDH, D-dimer, cTnI, and BNP (Table 2).Compared between the two groups, the patients in death event group had significantly higher male proportion (75.3% vs. 51.4%), lower SpO2 (85% vs. 90%), and higher breath rate (30 vs 25/min) (Table 3). As a result, ten stratified parameters including male sex, SpO2≤89%, breath rate>30/min, diastolic pressure≤80mmHg, neutrophil>6.46×109/L, lymphocyte≤0.64×109/L, CRP>77.35mg/L, PCT>0.20μg/L, LDH>481U/L, and D-dimer>3.06mg/L showed significant risks with death events (Table 3). No obvious multicollinearity was observed with the variance inflation factor (VIF) value of less than 1.6 in each involved variable (Table S1). Further multivariate logistic regression showed a significant model fitting involving stratified SpO2, lymphocyte, CRP, PCT, and LDH. The results demonstrated that SpO2≤89%, lymphocyte≤0.64×109/L, CRP>77.35mg/L, PCT>0.20μg/L, and LDH>481U/L were the independent risk factors with the ORs of 2.959, 4.015, 2.852, 3.554, and 3.185, respectively (p<0.04). The C-index of the predicted probability calculated using this multivariate logistic model was 0.845 (p<0.001) .The bivariate logistic regression was performed on the clinical, radiographic, and laboratory parameters . After 15 days, DR scores slowly declined in discharge group while increasing in death event group . In death event group, the neutrophil gradually increased to more than 10.00×109/L, and lymphocyte stayed at the lower level from 0.47 to 0.56×109/L in the course, with significant differences from discharge group . In discharge group, lymphocyte gradually increased from 0.88×109/L to normal level (≥1.1 ×109/L) after nine days. Besides, it demonstrated the significantly higher levels of CRP, PCT, LDH, and D-dimer in death event group, which gradually decreased or stayed at the relatively lower levels in discharge group . cTnI and BNP demonstrated dramatic fluctuation with significantly higher levels at some time points in death event group compared with discharge group . No obvious abnormalities of total bilirubin (TB), aspartate aminotransferase (AST), and serum creatinine (Scr) in the course were observed in both groups (Table S2).In the course, DR scores increased in death event group with a significant difference between the two groups after 1 to 3 days from admission . Compared with discharge group, IL-6 was significantly elevated in death event group. And IL-10 was significantly increased after 29 days in death event group . CD3+, CD4+, and CD8+ T-lymphocyte ratio stayed in the normal range in both groups, though approaching the upper or lower reference at some time points . CD3+ and CD8+ T-lymphocyte ratios were significantly higher in discharge group at several time points, but the CD4+/CD8+ T-lymphocyte ratio seemed higher in death group compared with discharge group reaching significant difference at the time point of 17-19 days . The quantitative data were summarized in Table S3.Among all 124 patients, 77 patients underwent consecutive cytokine profile and lymphocyte subsets analysis in the course, including 29 patients in charge group and 48 patients in death event group. The levels of IL-2, IL-6, TNF-α, and INF-γ didn't show significant differences between two groups and stayed in the normal reference ranges at most of time  presenting more coexisting illnesses such as hypertension and CVD were more likely to develop severe COVID-19 -75 yrs pBecause the DR demonstrated a good consistency to chest CT which was also capable of estimating the COVID-19 in the follow-up, it was consecutively performed in this cohort in order to reduce the transferring risk of the severe patients and X-ray exposure 9/L, lymphocyte≤0.64×109/L, CRP>77.35mg/L, PCT>0.20μg/L, LDH>481U/L, and D-dimer>3.06mg/L. Further multivariate logistic regression using the forward-LR method resulted in a significant fitting model with good discriminatory power (C-index=0.845). The results revealed SpO2≤89%, lymphocyte≤0.64×109/L, CRP>77.35mg/L, PCT>0.20μg/L, and LDH>481U/L on admission were the independent risk factors, among which the lymphocyte≤0.64×109/L demonstrated the highest OR of 4.015. Moreover, the abnormalities of lymphocyte, CRP, PCT, and LDH stayed or continuously aggravated in death event group but gradually recovered to normal levels in discharge group. Therefore, the dynamic monitoring of these laboratory parameters could estimate the prognosis in clinical practice for severe patients.Up to date, some previous studies already revealed multiple risk factors associated with poor prognosis, such as compromised respiratory status, older age, male sex, lymphocytopenia, high Sequential Organ Failure Assessment score, and elevated levels of CRP, PCT, LDH, and D-dimer In further analysis of the lymphocyte subsets in limited groups, no obvious abnormalities of CD3+, CD4+, and CD8+ T-lymphocyte ratio were found in both groups. However, relatively high CD4+/CD8+ T-lymphocyte ratio above or near the upper normal reference was observed in both groups, while it seemed higher in death event group. Therefore, it indicated no obvious impairment of the immune function, though lymphocyte reduced in severe COVID-19. As an evidence, a previous post-mortem autopsy study of COVID-19, it revealed reduced CD4+ and CD8+ T-lymphocyte in peripheral blood with overactivation of T-lymphocyte manifested by an increase of Th17 and high cytotoxicity of CD8+ T-lymphocytes To date, no confirmed evidence of the viral attack on solid organs other than lung was observed in pathological analysis and autopsy On the other hand, CRP, PCT, IL-6, and BNP as the major indicators of inflammatory severity in intensive care medicine, had significantly increased or stayed at a relatively high level in death event group, corresponding to the aggravated sepsis in these patients which could cause life-threatening organ dysfunction In brief, it was concluded that the systematic inflammation with induced cardiac dysfunction was the leading cause of death events in severe COVID-19 except for ARDS. Thus, the use of corticosteroids should still be considered for critical patients to prevent severe inflammatory response This case-controlled study has limitations. First, the sample size is limited in this study and not all patients underwent sequential cytokine profile and lymphocyte subsets tests. Second, the study was limited by the heterogeneity of treatments based on the disease status with time, which was impossible to summarize in this cohort. Thus, only the speculation was made to explain the fluctuation of some abnormal laboratory parameters in the course. Third, the dynamic changes of vital signs and oxygen saturation were not presented, because they were continuously monitored in the course and sort of affected by the adjusted treatments. At last, some important subsets of lymphocytes including Th17 and Treg were not measured due to the limitation of the laboratory techniques in this provisional isolation center, thus the identification of the immune function was not comprehensive.In summary, this study revealed the clinical course of severe COVID-19 patients from admission with different outcomes. Dynamic monitoring of lymphocyte, CRP, PCT, and LDH could be meaningful to predict the prognosis of severe patients. Besides, the fatal feature of COVID-19 is mostly attributed to severe systematic inflammation with induced cardiac dysfunction except for ARDS.Supplementary figures and tables.Click here for additional data file.


TARDBP, SQSTM1, VCP, FUS, TBK1, CHCHD10, and most importantly, C9orf72 being critical genetic players in these neurological disorders. In this mini-review, we will focus on the molecular mechanisms of these two diseases.Amyotrophic lateral sclerosis (ALS) is a devastating, uniformly lethal progressive degenerative disorder of motor neurons that overlaps with frontotemporal lobar degeneration (FTLD) clinically, morphologically, and genetically. Although many distinct mutations in various genes are known to cause amyotrophic lateral sclerosis, it remains poorly understood how they selectively impact motor neuron biology and whether they converge on common pathways to cause neuronal degeneration. Many of the gene mutations are in proteins that share similar functions. They can be grouped into those associated with cell axon dynamics and those associated with cellular phagocytic machinery, namely protein aggregation and metabolism, apoptosis, and intracellular nucleic acid transport. Analysis of pathways implicated by mutant ALS genes has provided new insights into the pathogenesis of both familial forms of ALS (fALS) and sporadic forms (sALS), although, regrettably, this has not yet yielded definitive treatments. Many genes play an important role, with  Amyotrophic lateral sclerosis (ALS) is a devastating, uniformly lethal progressive degenerative disorder of motor neurons that overlaps with frontotemporal lobar degeneration (FTLD) . ALS is GRN) gene are generally associated with type A TDP-43 pathology, whereas hexanucleotide repeat expansions in C9orf72, which is the most common genetic cause of ALS and FTLD-TDP, most frequently result in the type B pathology [TARDBP (the gene coding protein TDP-43) mutations are rare in ALS and FTD (<1%), the pathological aggregation of TAR DNA-binding protein 43 in affected brain regions and motor neurons is characteristic of the majority of ALS and FTD patients [FTLD and ALS are two related neurodegenerative diseases forming the two ends of a disease spectrum. Behavioral FTLD is a form of dementia clinically characterized by progressive changes in behavior, personality, and language skills . ALS invathology ,30. Althpatients ,31.TARDBP gene) [C9orf72 (chromosome 9 open reading frame 72) has an essential role in stress granule formation, microglial function, and autophagy [C9orf72 expanded repeats contribute to ALS. One of the most frequently found proteins in neuropathological lesions is ubiquitin-binding protein p62 (sequestosome 1). Many experimental and clinical studies have shown that p62 plays a significant role in autophagy, an evolutionarily conserved pathway for the degradation of long-lived proteins and organelles. Dysfunction of the autophagy pathway may contribute to the pathology of various neurodegenerative disorders characterized by abnormal protein accumulation [SOD1) produce an unstable protein deposited in the cytoplasm; oligomerization of unstable SOD1 leads to aggregate formation [FUS) is another RNA binding protein in which mutations can result in cytoplasmic aggregates. It is also a component of stress granules and may form p62 and TDP-43 positive aggregates [SQSTM1), SOD1, optineurin (OPTN), valosin-containing protein (VCP), ubiquitin-2 (UBQLN2), and TANK-binding kinase 1 (TBK1) [The presence of protein and RNA aggregates in the cytoplasm of motor neurons is the hallmark of ALS . The hisBP gene) ; howeverBP gene) ,38, LewyBP gene) ,40, and BP gene) . The relBP gene) . C9orf72utophagy ,44,45. Tutophagy . These amulation ,48. Recemulation . The buimulation . A portimulation . Mutatioormation . Fused igregates . It has gregates . Mutatio1 (TBK1) . The rem1 (TBK1) . An impa1 (TBK1) .2+ homeostasis and increased production of reactive oxygen species (ROS). ROS are associated with oxidative-related damage, including changes in protein carbonylates and tyrosine nitration [SOD1, TDP-43, FUS, and C9orf72, show interactions with mitochondria [CHCHD10 can disrupt mitochondrial cristae and profoundly affect the mitochondrial structure [CHCHD10 gene was described in an FTD-ALS patient whose family was originally from Catalonia (Spain), with affected individuals carrying a missense mutation in the CHCHD10 gene. Functional characterization of the CHCHD10 mutant identified in the family showed fragmentation of the mitochondrial network and the loss of cristae junctions [CHCHD10 is a novel gene responsible for the clinical spectrum of ALS-FTD, which raises the intriguing prospect of an underlying mitochondrial basis for this group of disorders.Mitochondria dysfunction is at least partly responsible for the broad clinical spectrum of ALS and FTD. Mitochondrial dysfunction has been implicated in ALS motor neuron death . Fragmenitration . Mitochoitration ; as suchitration ,63. Moreitration . Many prchondria ,66,67. Dchondria . ALS-asstructure . Mitochotructure . In recetructure . The c.1unctions . CHCHD10TAF15), senataxin (SETX), and RNA-binding protein EWS (EWSR1), have also been linked to impaired DNA damage repair, further implicating the breakdown of this process in ALS pathogenesis [Impair DNA repair is another suggested mechanism that may contribute to ALS pathogenesis. Two of the best-studied ALS-linked proteins, TDP-43 and FUS, function to prevent or repair transcription-associated DNA damage . FUS, inogenesis ,75,76.SOD1-related ALS [DCTN2, caused reduced axonal transport in motor neurons and consequently led to a late-onset progressive motor neuron disease phenotype in the transgenic mice [DCTN1 cause a slowly progressive autosomal dominant distal hereditary motor neuropathy with vocal paresis (HMN7B) and ALS [TUBA4A), which destabilize the microtubule network and diminish its re-polymerization capability, have been identified as possible causes of ALS [Axonal transport defects are a common observation in various neurodegenerative diseases, and mutations in components of the axonal transport machinery have unequivocally shown that impaired axonal transport can cause neurodegeneration . The undated ALS . These iated ALS  mitochonated ALS  pathogenated ALS  protein ated ALS ,80. Therated ALS ; axonal ated ALS . TDP-43 ated ALS . Mutationic mice . This st and ALS ,83,84. O and ALS . The nex and ALS . Microtu and ALS . Severals of ALS . Whethers of ALS .As key regulators of RNA metabolism, RNA-binding proteins (RBP) play a critical role in maintaining the normal function of neuronal systems. RNA-binding proteins are involved in several aspects of RNA metabolism, including splicing, transcription, transport, translation, and storage in stress granules . The aggMutations in genes encoding many RBP are highly associated with ALS. In addition, dysregulation of RBP as a result of compromised nucleocytoplasmic trafficking, posttranslational modification (PTM), aggregation, and sequestration by abnormal RNAs also contribute significantly to disease pathogenesis. This section will briefly discuss the underlying mechanisms resulting in RBP dysregulation in ALS .In response to a variety of stressors such as heat shock and oxidative insult, TDP-43 and FUS translocate from the nucleus and associate with cytoplasmic stress granules (SG), which are dense aggregations of protein-RNA complexes ,97. RBPsLow Complexity sequence Domains (LCD), Nuclear Localization Sequence (NLS). Mutations that occur in these domains (LCD and NLS) can trigger the same pathological cascade, which leads to a deterioration in the dynamics of stress granules .RBM45, an RNA-binding protein, is most likely a causal gene for ALS-FTD. In addition, a novel and evolutionary conserved structural element homo-oligomer assembly (HOA) domain has been identified. It is located within the linker region between RNA-recognition motifs (RRM2 and RRM3), which are essential for the self-association and oligomerization of RBM45 , which is actually common in RBPs; it has a suspicious homo oligomerization domain that, similar to LCD, mediates self-assembly through homo oligomerization and interaction with other proteins .TIA-1 that promotes the assembly of stress granules discrete cytoplasmic inclusions into which stalled translation initiation complexes are dynamically recruited in cells subjected to environmental stress [TIA-1 is a modular protein composed of three RNA recognition motifs and a carboxy-terminal glutamine-rich motif that is structurally related to prion protein (PRD). Overexpressed TIA-1 induces SG formation and represses reporter gene expression, whereas the isolated prion-related domain (PRD) of TIA-1 forms cytoplasmic microaggregates [RBM45.Another RBP is l stress . TIA-1 igregates . These dC9orf72, TBK1, OPTN, SQSTM1, and PGRN [The inflammatory environment associated with ALS changes with disease progression and involves both neurotoxic and neuroprotective aspects. Neuroinflammation associated with neuronal loss is characterized by microglia and astrocyte activation, overproduction of inflammatory cytokines, and infiltration of T lymphocytes . The secand PGRN ,111,112.and PGRN . Microgland PGRN ,115. Genand PGRN ,117,118.and PGRN . Severaland PGRN ,121. WheGRN), microtubule-associated protein tau (MAPT), and C9orf72 [VCP (2004), CHMP2B (2005), TARDBP (2008), FUS (2009), SQSTM1 (2012), CHCHD10 (2014), TBK1 (2015), OPTN (2015), CCNF (2016), and TIA1 (2017). Recent studies have identified TBK1 as probably the fourth most common genetic cause overall of FTD, accounting for between 1% and 2% of all cases  [SOD1), was reported in 1993 [TARDBP) [ANG) [FUS) [OPTN) [C9orf72) [TBK1, CHCHD10, TUBA4A, CCNF, MATR3, NEK1, C21orf2, ANXA11, TIA1) and their potential relevance to the genetic etiology of frontotemporal dementia have also been described [The advent of next-generation sequencing technologies, such as whole-genome sequencing (WGS) and whole-exome sequencing (WES), has led to a wave of novel genes associated with ALS ,123. A r C9orf72 . In receunclear) . The fir in 1993  as well [TARDBP) ,133,134,P) [ANG) , fused iG) [FUS) ,36, opti) [OPTN) , and theC9orf72) ,137. An SOD1 account for the second most common cause of fALS after C9orf72 [SOD1 mutations account for 15–20% of fALS pedigrees [C9orf72, was the most commonly identified gene in ALS. In most families harboring SOD1 gene mutations, disease penetrance is >90% by age 70 yrs [SOD1 gene [C9orf72 is much less common. Although multiple hypotheses have been proposed to explain mutant SOD1-mediated toxicity [SOD1 has been reported to localize to mitochondria under certain conditions [SOD1 proteins are only partially located in the mitochondria, while mutant proteins show an increased propensity to be located in mitochondria, suggesting mitochondria involvement in the ALS etiology [SOD1 is voltage-dependent anion channel 1 (VDAC1), a mitochondrial channel protein. Translocation of ions and proteins between mitochondria and the cytoplasm may be affected by mitochondria-associated misfolded mutant SOD1 [Mutations in  C9orf72 . SOD1 muedigrees ,139 and,e 70 yrs , and morOD1 gene . This litoxicity , the exatoxicity , and a pnditions ,145,146.etiology . Anotherant SOD1 , leadingant SOD1 . Pure upant SOD1 . The A4Tant SOD1 . In contant SOD1 .TARDBP mutations were initially identified [SOD1 mutations and in FTLD-UPS [TARDBP mutation, mutations are rarely found in FTLD and FTD-MND [One consistent pathologic finding in ALS and FTD is the presence of heavily ubiquitinated neuronal cytoplasmic inclusions, which in 2006 were found to contain TDP-4 . TDP-43,entified  as a dirFTLD-UPS ,159. Whe FTD-MND ,160.C9orf72 is mainly related to autophagy, endosomal transport, and immune function. According to statistics, about 40–50% of fALS and 10% of sALS patients carry the C9orf72 expanded alleles. In one study, the C9orf72 expansion accounted for 11.7% of familial FTD [C9orf72 may have hundreds or even thousands of GGGGCC hexanucleotide repeats. A large number of clinical studies have shown that about 700–1600 GGGGCC hexanucleotide repeats are inserted into the intron located between the two untranslated optional exons 1a and 1b of the C9orf72 gene [C9orf72-related ALS is thought to be nearly 100% by the age of 80 yrs. No predictions for individual phenotypes, i.e., ALS, FTD, or ALS/FTD, the exact age at onset, the disease course, and disease duration is currently possible [The protein encoded by lial FTD . The patf72 gene ,162,163.KIF5 genes are expressed in neurons, and transcription products function to transport cargo by binding to distinct adaptor proteins [KIF5A cause disease by disrupting axonal transport. KIF5 is responsible for the axonal transport of neurofilaments [KIF5A knockout mice display abnormal neurofilament transport [KIF5 also contributes to the transport of mitochondria [Kinesins are microtubule-based motor proteins involved in the intracellular transport of organelles within eukaryotic cells. proteins . The cenilaments , and KIFransport . Abnormaransport . KIF5 alchondria , and thechondria ,170,171.TBK1 and OPTN genes encode functionally related proteins that recently gained increased attention from the ALS research community. TBK1 (tumor necrosis factor (TNF) receptor-associated factor NF-κB activator (TANK)-binding kinase 1), also known as NAK or T2K, recently attracted the attention of human geneticists, immunologists, and neurologists alike for its critical role in pathologies of the central nervous system (CNS). TBK1 is involved in the activation of various cellular pathways leading to IFN and pro-inflammatory cytokine production following infection [TBK1 mutations are loss-of-function (LOF), leading to loss of the mutant transcript through nonsense-mediated mRNA decay (NMD) [TBK1 LOF mutations account for 3–4% of ALS-FTD patients [TBK1 and may decrease its expression at both the mRNA and protein level, implying that TBK1 haploinsufficiency contributes to the development of ALS [The nfection , autophanfection ,174, andnfection . The majay (NMD) . TBK1 LOpatients . Nonsenst of ALS ,176.CHCHD10) variants are now known to cause ALS, FTD, and other related degenerative diseases [CHCHD10 G58R and CHCHD10 G66V were identified in mitochondrial myopathy and late-onset spinal muscular atrophy [VCP and Matrin 3 (MATR3), which also exhibit clinical pleiotropy, including myopathy [CHCHD10 expression in patient tissues is unaffected, and CHCHD10 S59L overexpression causes mitochondrial defects similar to those in affected patients [CHCHD10 S59L is a dominant gain-of-function mutation [CHCHD10 variants in pure ALS [Many additional Coiled-coil-helix-coiled-coil-helix domain-containing protein 10 . It has been proposed that it stabilizes certain messenger RNA species . Anothered exons ,187. MATpatients ,189,190, in FTLD .Over the last decade, dysfunction of hnRNPs has become closely linked to neurodegenerative diseases, most prominently amyotrophic lateral sclerosis and frontotemporal dementia, two diseases with significant genetic and pathological overlap . hnRNP ATIA1 harbors several ALS- and ALS/FTD-associated mutations in the low-complexity sequence domain (LCD) [TIA1 is also the site of a mutation that causes Welander distal myopathy, a myopathy characterized by TDP-43-positive inclusions [As a gene that has only recently been associated with ALS, in (LCD) . Notablyclusions  and p62 clusions ,200. TIAclusions .NEK1 encodes a member of the highly conserved NIMA (never in mitosis gene A) kinase family. It is a serine/threonine kinase involved in cell-cycle regulation, ciliogenesis, mitochondrial membrane permeability, and DNA damage repair [NEK1 was shown to interact with C21orf2, which was recently associated with an increased ALS risk [NEK1 and C21orf2 are linked to skeletal disorders and axial spondylometaphyseal dysplasia [C21orf2 may participate in the DNA repair process via interaction with NEK1 [TUBA4A and PFN1 [UNC13A gene, for example, have been associated with susceptibility to ALS and shorter survival times [ATXN1 and ATXN2 genes also increase the risk of disease, particularly for C9orf72 expansion carriers in the case of ATXN1 [EPHA3 gene, in contrast, has been flagged as a potential protective factor for ALS [e repair ,202,203.ALS risk ,205,206 ith NEK1 . Loss ofith NEK1 ,208,209,and PFN1 ,208,210.and PFN1 , the remal times . Intermeof ATXN1 ,214. A c for ALS .Variants in these genes are more likely to have a significant effect, and having the genotype greatly increases the probability of ALS; in other words, these variants show moderate to high penetrance; however, gene variants with low penetrance are also of interest, even though they only modestly increase the risk for any individual . In at lC9orf72-related ALS are being conducted [Our understanding of the biological and genetic basis of ALS, as well as our ability to care for ALS patients, has improved substantially over the last few years. Genetic causes of ALS have been identified in both sporadic and familial patients, and the number of disease-associated genes is still increasing . One migonducted . Besidesonducted . Whether


Introduction: Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) responsible for the COVID-19 pandemic has spread from Wuhan, China in December, 2019 to 216 countries and territories as of September 10, 2020 with 27.74 million cases and 899,911 confirmed deaths. The spectrum of disease is most commonly seen as a viral pneumonia with high grade fevers, shortness of breath, dry cough, and chest pain with radiologic evidence of bilateral, interstitial, ground glass opacities, and peripheral lung consolidation. Liver chemistries are frequently abnormal, with transaminases shown to be one-two times the upper limit of normal in most instances. The full spectrum of gastrointestinal involvement of the SARS-CoV-2 infection has yet to be fully seen.Patient concerns: We present a case of a young woman with SLE who developed severe abdominal pain, nausea and vomiting, rapidly progressing to acute hepatic failure and tested positive for SARS-CoV-2 infection. She had no respiratory symptoms.Diagnosis: A thorough work-up of acute liver failure including liver biopsy confirmed acute hepatitis with viral like changes. Common viral causes of liver failure were ruled out. The patient had no recent travel history.Interventions: The patient was started on hydroxychloroquine due to SLE, treated with N-Acetyl-Cysteine, and methylprednisolone.Outcomes: The patient improved with resolution of encephalopathy and normalization of her liver chemistries without any development of respiratory illness.Conclusion: This case details a unique presentation of likely SARS-CoV-2 infection. Until now, the literature has primarily described a respiratory illness and liver injury with mild transaminase elevations. Significant liver injury progressing to acute liver failure should be considered in those with SARS-CoV-2 infection. One case to date has been reported of a patient with SARS-CoV-2 infection, presenting first with acute hepatitis without respiratory symptoms. A second case of SARS-CoV-2 infection with development of severe liver failure has been published however development of hepatic failure ensued days into the disease course and introduction of antiviral therapy.Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) responsible for the COVID-19 pandemic has spread from Wuhan, China in December 2019 to 216 countries and territories as of September 10, 2020 with 27.74 million cases and 899,911 confirmed deaths.We report a case of SARS-CoV-2 infection likely presenting as acute hepatitis rapidly progressing to fulminant hepatic failure without respiratory symptoms or evidence of drug induced liver injury. Written informed consent was obtained from the patient for publication of this case report and accompanying images.2A 35-year-old woman presented to the emergency department with complaint of severe, diffuse abdominal pain. The pain started 1 day prior to arrival and progressed in severity with nausea, vomiting, and inability to tolerate fluids, prompting her to seek care in the emergency department. She denied cough, sore throat, shortness of breath, chest pain, myalgia, or anosmia. She lives with her husband and newborn child. She denied sick contacts and had not recently traveled. She had a past medical history significant for systemic lupus erythematosus for which she was taking prednisone 5 mg daily. She had previously been on hydroxychloroquine and mycophenolate mofetil which were being held while she was breast feeding. She had delivered a healthy newborn approximately 14 weeks prior to her presentation. Her outpatient medications included prednisone, ferrous sulfate, and etonogestrel implant. She denied the use of any over the counter medications including acetaminophen or non-steroidal anti-inflammatory medications. She did not use alcohol, recreational drugs, or tobacco products. Recent liver chemistries performed in the rheumatology clinic 2 months prior to presentation were normal.oC, she was normotensive, tachycardic, and without hypoxia. She had scleral icterus, jaundice, and epigastric tenderness without evidence of encephalopathy. Her lung exam was unremarkable. Laboratory results on admission were as follows: Alkaline phosphatase 200 IU/L (N: <150), AST 219 IU/L (N: <35) ALT 278 IU/L (N: <55), total bilirubin 7.0 mg/dl (N: 0.2–1.2), direct bilirubin 5.5 mg/dl (N: <0.4), lipase 6 IU/L (N: <80), albumin 3.5 g/dl (N: 3.5–5.0), lactic acid 1.9 mmol/L (N: <2.2), white blood cell count 5.5 K/μl (N: 4.0–11.0) platelet count 55 K/μl (N: 140–400 K/μl), absolute lymphocyte count 0.7 K/μl (N: 0.8-4.1 K/μl), INR 1.5, ferritin 323 ng/dl (N: 5–200), CRP 66.8 mg/L (N: 0.0–8.0). SARS-CoV-2 rapid PCR by nasopharyngeal swab was collected given findings of lymphopenia, coagulopathy, and transaminase elevation which was positive for COVID-19 disease in the emergency department. She was masked and isolated per protocol. Viral causes for acute hepatitis were negative including hepatitis A, B, C, E, EBV, CMV, HSV 1, HSV 2, and HIV. Given the patients history of SLE, ANA was collected and positive. Mitochondrial antibody screen was weakly positive at 0.3 units (N: <0.1). Liver/kidney microsomal antibody and smooth muscle antibody serologies were normal. C3 and C4 were low and anti dsDNA was elevated to 392.2 IU from 58.3 IU 4 months earlier (N: 0.0–29.9). Abdominal ultrasound with Doppler revealed a normal appearing liver with stable hemangiomas and a patent portal and hepatic circulation. Severe gallbladder thickening with pericholecystic fluid without evidence of gallstones and a normal caliber common bile duct measuring 2.1 mm was also noted.On presentation, the patients temperature was 37.4On hospital day 3, the patient developed mental status changes, anorexia, nausea, and vomiting with rising liver chemistries and coagulation studies Fig. . These i3–4,8 The true spectrum of disease, however, is yet to be seen. Transaminase elevations have been noted in many individuals with SARS-CoV-2 infection, usually 1 to 2 times the upper limit of normal. In a cross sectional study of 417 patients who had developed transaminase elevation with SARS-CoV-2 infection, Qingzian et al demonstrated that most patients, >90%, presented with only mild elevations in transaminases, and only 24% progressed to transaminase elevations greater than 3 times the upper limit of normal (6). As our understanding of the breadth of illness in SARS-CoV-2 continues to emerge, we may see more cases with significant liver involvement including fulminant hepatic failure. To the best of our knowledge, this is the likely to be the first case report of acute liver failure associated with PCR confirmed SARS-CoV-2. This diagnosis requires the clinician to have a high level of clinical suspicion. Additionally, close monitoring of liver chemistries, synthetic functions, and mental status is imperative in those with SARS-COV-2. One case report of respiratory illness by SARS-CoV2 progressing to include acute liver failure has been reported in the setting of therapy with lopinavir/ritonavir. Our patient presented with severe hepatitis which rapidly progressed to acute liver failure prior to the onset of respiratory symptoms adding to the spectrum of illness that SARS-CoV-2 is able to cause. The patient did not experience hypoxemia or significant pneumonia, cardiac dysfunction nor have impairment in blood flow to or from the liver. With the exception of SARS-CoV-2, no other infectious etiologies to explain the acute liver failure were found.COVID-19 disease caused by SARS-CoV-2 has been defined as a respiratory illness presenting with dyspnea, fever, cough, anosmia, myalgias, and diarrhea. Severe infections leading to multisystem organ failure, systemic inflammatory conditions, stroke, cardiomyopathies, and rare cases of acute hepatitis have been reported. Several papers suggest evidence of liver injury or liver failure, however, acute liver failure is rare and typically occurs later in the course of COVID-19 disease, and may be influenced certain medications or high positive expiratory pressure as part of lung protective strategy during mechanical ventilation. which has shown affinity for binding to ACE2 receptors like the similar SARS-CoV and Middle Eastern Respiratory Syndrome responsible for the SARS pandemic,7 and the MERS pandemic respectively. ACE2 receptors are known to be found on type 2 alveolar cells, up to 59.7% of cholangiocytes, and less commonly, hepatocytes (2.6%).,7 It is reasonable to consider that SARS-CoV2 can bind to the ACE2 receptors of cholangiocytes inducing direct injury to bile ducts, acute liver injury, and even ALF. There is has been speculation that use of ACE inhibitors may cause upregulation of ACE2 receptors theoretically allowing worse injury by SARS-CoV2. This patient was not on ACE inhibitors.The mechanism of liver injury by SARS CoV-2 is unknown. SARS-CoV-2 is a betacoronavirus Current literature supports the hypothesis that patients with higher transaminase levels on presentation, particularly in the hepatocellular pattern, have a higher likelihood of developing severe disease. This patient was diagnosed with a SLE flare during the hospital course by low C3, C4, and elevated dsDNA levels. The combination of these clinical features may have induced an overwhelming inflammatory response.Patients with SARS-CoV-2 are also experiencing severe inflammatory responses with marked cytokine storm which may induce liver inflammation and induce vascular thrombosis.4This case details a likely unique presentation of SARS-CoV-2 infection. Until now, the literature has primarily described a respiratory illness and liver injury with mild transaminase elevations. Significant liver injury, even progressing to acute liver failure should be considered in those infected with SARS-CoV-2.Conceptualization: Stephanie Melquist, Kayla Estepp, Yauheni Aleksandrovich, Angela Lee, Andrea Beiseker, John Bassett.Funding acquisition: Stephanie Melquist.Resources: Stephanie Melquist, Kayla Estepp, Yauheni Aleksandrovich, Angela Lee, Andrea Beiseker, Farid Saei Hamedani, John Bassett.Visualization: Stephanie Melquist.Writing – original draft: Stephanie Melquist, Kayla Estepp, Yauheni Aleksandrovich, Angela Lee, Andrea Beiseker, Farid Saei Hamedani, John Bassett.Writing – review & editing: Stephanie Melquist, Kayla Estepp, Yauheni Aleksandrovich, Angela Lee, Andrea Beiseker, Farid Saei Hamedani, John Bassett.


In the immune system, calcium signals play a central role in a variety of cellular functions such as proliferation, differentiation, apoptosis, and numerous gene transcriptions. During an immune response, the engagement of T-cell and B-cell antigen receptors induces a decrease in the intracellular Ca2+ store and then activates store-operated Ca2+ entry (SOCE) to raise the intracellular Ca2+ concentration, which is mediated by the Ca2+ release-activated Ca2+ (CRAC) channels. Recently, identification of the two critical regulators of the CRAC channel, stromal interaction molecule (STIM) and Orai1, has broadened our understanding of the regulatory mechanisms of Ca2+ signaling in lymphocytes. Repetitive or prolonged increase in intracellular Ca2+ is required for the calcineurin-mediated dephosphorylation of the nuclear factor of an activated T cell (NFAT). Recent data indicate that Ca2+-calcineurin-NFAT1 to 4 pathways are dysregulated in autoimmune diseases. Therefore, calcineurin inhibitors, cyclosporine and tacrolimus, have been used for the treatment of such autoimmune diseases as systemic lupus erythematosus and rheumatoid arthritis. Here, we review the role of the Ca2+-calcineurin–NFAT signaling pathway in health and diseases, focusing on the STIM and Orai1, and discuss the deregulated calcium-mediated calcineurin-NFAT pathway in autoimmune diseases.Calcium (Ca However, the cytosolic Ca2+ levels are approximately in the range of 100 nM, which is 10,000 times lower than ECF Ca2+ concentrations .Calcium (Cany cells  Table 12+ is a s2+-permeable channels are involved in the influx of extracellular Ca2+: voltage-operated Ca2+ channels (VOCCs), receptor-operated channels (ROCs), store-operated channels (SOCs) like Ca2+ release-activated Ca2+ (CRAC) channels, and second messenger-operated channels (SMOCs)  is mediated by activated CRAC channels (Various Ca (SMOCs) . VOCCs a to them . SOCs ar to them . SOCs archannels .2+ signaling generated by SOCE and CRAC channels play different roles in immune cells. Short-duration functions occur within minutes. Short-duration types of Ca2+ signal transduction are not related to new gene expression, but to motility and the degranulation of T cells  receptor activation , a Ca2+ sensor protein presented in the ER, which is responsible for CRAC channel activation. The second regulator is Orai1, one subunit of CRAC channels. This review focuses on the roles of Ca2+ and the signal pathway upstream and downstream of Ca2+ flow in the immune cells and its involvement in autoimmunity and immunologic diseases.Signaling between the plasma membrane and ER, or between ER and mitochondria, is required for the regulation of a direct Catransfer . It has 2+ influx to the cells. However, their physiological importance or function in immune cells remains unclear.VOCCs are located in electrically excitable cells, and they are activated by membrane depolarization. Usually, VOCCs function as the major passages of Ca2+ channels are mostly non-selective ion channels. Among them, TRP channels consist of six subfamilies according to the amino acid sequence: the TRPC , TRPV (vanilloid), TRPA (ankyrin), TRPM (melastatin), TRPML (mucolipin), and TRPP (polycystin) groups  groups . The TRP) groups . Since tmembrane . Second,ntration . Third, channels .2+ store depletion  screen , there wx factor , and vesx factor . Howeveran cells . Unlike nd STIM2 . Both STER lumen . Mutatio+ stores , 24, sug2+ stores in ER and lead to the activation of SOCE via Orai1. However, RNAi-mediated knockdown of STIM2 selectively decreases baseline levels of Ca2+ cytosolic and ER Ca2+ concentrations. Oh-Hora et al.  in the ER membrane  abrogates Ca2+ influx  , aspartate (D), or glutamine (Q). The mutant proteins were transduced into SCID T cells, and then SOCE was analyzed . IP3 opens IP3 receptors (IP3R) and allows Ca2+ efflux from the ER Ca2+ reservoir  complexes bind to TCR, protein tyrosine kinases are activated. This binding induces the tyrosine phosphorylation and the activation of phospholipase C, gamma 1 (PLC-γ1) . PLC-γ1 2+ influx increases intracellular Ca2+ concentration, intracellular Ca2+ activates other signaling pathway and transcription factors. The pathway known to date is , and , which phosphorylates several effector proteins by transferring phosphates from ATP to serine and threonine residues on the proteins , and  nuclear  complex . This coproteins . Calcineproteins .2+ concentration increases the calmodulin binding to calcineurin, NFAT translocates to the nucleus  and two isoforms of calcineurin B  , 41. Whe nucleus –42 and t nucleus . Periphe nucleus , 45, sugtivation .2+ signal is crucial to a variety of functions of neutrophils as well as lymphocytes. In neutrophils, Ca2+ signaling starts with the binding of various cell surface receptors, including Fc-gamma receptors (FcγRs), G-protein-coupled receptors (GPCRs), and integrins  critically regulates the differentiation of monocytes/macrophages to osteoclasts, the key immune cells involved in bone resorption and destruction. An increasing body of evidence suggests that the Caructures . The Ca2poptosis . Interesg and Li  also havStim1 and Orai1 silencing inhibits RANKL-induced Ca2+ oscillation in RAW264.7 macrophages , systemic lupus erythematosus (SLE), Sjögren's syndrome (SS), and psoriasis, focusing on dysregulated Ca2+ signaling in autoreactive T cells  DR1 and 4 subtypes, smoking, and infectious agents, are thought to contribute to RA etiology and pathogenesis . Most RA+ T cells are thought to be the principal mediators of RA progression, how CD4+ T cells are induced and activated needs clarification. Sakaguchi et al.  within Orai1 were selected for genotyping. As a result, the SNP rs7135617 has a significant correlation with the risk of RA, indicating that genetic polymorphism of Orai1 contributes to the susceptibility to RA.Since RA has a strong genetic background, there is research into whether it is associated with Can et al.  investig2+ is a key regulator of a variety of transcription factors, control of Ca2+ influx is essential for the activation and function of the adaptive immune response. Liu et al.  expressions, suggesting that calcineurin regulates the catabolic and anabolic activities of chondrocytes  , which is caused by a generalized immune cell dysfunction that promotes B cell hyperactivity. Several studies have demonstrated abnormal signaling through BCR, and this modified signaling results in increased Ca signals –94. It hcontrols . Such in(SHIP-1) .2+ signals via the activation of SHIP and hydrolysis of phosphatidyl-inositol-3,4,5-trisphosphate and also by inhibiting CD19-mediated Ca2+ responses (phospholipase Cγ2 (PLCγ2) can lead to severe spontaneous inflammation and systemic autoimmunity  T cells. These double-negative T cells produce more inflammatory cytokines, including IL-17 and IFN-γ  is an animal model of brain inflammation, where autoreactive T and B cells to neuro-antigens, such as myelin basic protein and myelin oligodendrocyte glycoprotein (MOG), play a major role. EAE is a representative Th1 and Th17 cell-mediated central nervous system (CNS) disease  and has 2+ signal pathway is closely related to the development of EAE. For example, decreased levels of STIM1 protein greatly impair the production of neuro-antigen-specific T cell responses (reduced Th1/Th17 responses), and this results in complete protection from EAE  is controlled (2+-calcineurin–NFAT pathway with cyclosporine A and tacrolimus has been the established treatment options of RA, lupus nephritis, and psoriasis patients who show an insufficient response to methotrexate. Therefore, CRAC channels in addition to the calcineurin–NFAT pathway are crucial to the lymphocyte function and development of autoimmunity, perhaps providing a new therapeutic target to treat human autoimmune diseases.In this review, we have discussed recent advances in understanding the role played by the Cantrolled . MoreoveY-JP, S-AY, MK, and W-UK conceptualized the article, reviewed the literature, and wrote the manuscript.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.


The objective of this study was to elucidate the burden, risk factors, and prognosis of serious non-AIDS-defining events among admitted cART-naive AIDS patients in China. The evaluation of the burden, risk factors and prognosis of serious NADEs was carried out among 1309 cART-naive AIDS patients  admitted in Beijing Ditan Hospital between January 2009 and December 2018. Among 1309 patients, 143 patients (10.9%) had at least one serious NADEs, including 49 (3.8%) with cerebrovascular diseases, 37 (2.8%) with non-AIDS-defining cancers, 28 (2.1%) with chronic kidney diseases, 26 (2.0%) with cardiovascular diseases, and 18 (1.4%) with liver cirrhosis. Serious NADEs distributed in different age and CD4 levels, especially with age ≥50 years and CD4 ≤350 cells/ul. Other traditional risk factors, including cigarette smoking , hypertension , chronic HCV infection , and hypercholesterolemia , were also associated with serious NADEs. Seventeen cases (1.3%) with serious NADEs died among hospitalized cART-naive AIDS patients, and severe pneumonia  and AIDS-defining cancers  were identified as risk factors associated with an increased hazard of mortality among these patients with serious NADEs. Serious NADEs also occurred in cART-naive AIDS patients in China with low prevalence. Our results reminded physicians that early screening of serious NADEs, timely intervention of their risk factors, management of severe AIDS-defining events, multi-disciplinary cooperation, and early initiation of cART were essential to reduce the burden of serious NADEs. In spite of updated criteria of starting combination antiretroviral therapy (cART) and widespread coverage of cART in HIV-infected population in China , which rin vivo [Serious NADEs were gradually exacerbated by low-level chronic inflammation and immune activation in HIV-infected patients , which tin vivo . Seriousin vivo , 7, whicin vivo . Besidesin vivo .The co-occurrence of serious NADEs and AIDS-defining events (ADEs), including OIs and ADCs, in cART-naive AIDS patients indicated difficulties of appropriate treatment, increased drug-drug interactions, and affected the prognosis among these patients . The burThis study complied with the principles of Declaration of Helsinki and was approved by Human Science Ethical committee of Beijing Ditan Hospital, Capital Medical University, the largest AIDS referral hospital in China. The Human Science Ethical committee authorized to waive informed consent based on observational nature of this study. The clinical information was abstracted from electronic medical records database and was studied anonymously in Ditan Hospital.One-thousand three hundred and seventy cART-naive AIDS patients admitted in Beijing Ditan Hospital were identified between January 2009 and December 2018, who were unaware of HIV infection until opportunistic infections became the first indicator of their disease. These admitted patients presented unspecific symptoms, including fever with unknown origins, due to severe immunosuppression and etiologic diagnosis, and treatment was required. The patients were cART-naive individuals who were not exposed to any ARV regimens or ART history, had not initiated self-discontinuation, and were without discontinuation for other reasons. Eligible participants included those who were ≥18 years old and were cART-naive. Patients who were aged <18 years, cART-experienced, foreigners, and had incomplete clinical data were excluded. This implied that some admitted patients abandoned further etiologic diagnosis and treatment due to cost constraint , and we Among these cART-naive AIDS patients who were discharged and then readmitted due to immune reconstitution inflammatory syndrome, screening of opportunistic pathogens, biochemical tests, and imaging examination including CT scan were performed for etiologic diagnosis at first admission, including AIDS-defining events (ADEs) and non-AIDS-defining events (NADEs). Prior to initiating cART, we collected these clinical data at first admission but not those at readmission.AIDS patients were defined as anti-HIV (+) patients with CD4 cell counts below 200 cells/ul and/or opportunistic infections or AIDS-defining cancers.Serious NADEs were identified based on ICD-10 diagnostic codes and grouped in this study as: cardiovascular diseases, cerebrovascular diseases, liver cirrhosis, chronic kidney diseases and NADCs.Cardiovascular diseases (CVD) were diagnosed based on medical history, which were further confirmed based on coronary angiography and echocardiography in patients with medical history, as well as signs and symptom of cardiovascular diseases.Brain computerized tomography (CT) scan was conducted in admitted patients, in which patients with abnormal imaging finding or medical history, signs and symptom of cerebrovascular diseases would further receive screening based on magnetic resonance imaging (MRI) of brain or even cerebrovascular CT angiography.Liver cirrhosis was classified as tissue fibrosis and the conversion of normal liver architecture into abnormal nodule due to long-term chronic hepatitis B or C infection with/without portal hypertension was based on imaging examination.2 and/or markers of renal damage for at least 3 months.Chronic kidney diseases (CKD) was diagnosed based on estimated glomerular filtration rate (eGFR) <60 ml/min/1.73mNADCs, excluding non-Hodgkin lymphoma, Kaposi’s sarcoma, and cervical cancer, were defined according to characteristic pathological diagnosis.HIVBOOK published by Christian Hoffmann [The diagnosis and treatment of opportunistic infections were carried out in Ditan Hospital in accordance with guidelines recommended by the National Institute of Health (NIH)of America . The AIDHoffmann .Dyslipidemia was diagnosed based on the following criteria: serum triglyceride (TG) ≥2.3mmol/L was defined as hypertriglyceridemia, total cholesterol (TC) ≥6.2mmol/L as hypercholesterolemia, low density lipoprotein (LDL) ≥3.12 mmol/L and high density lipoprotein (HDL) ≤1 mmol/L respectively, according to guideline on prevention and treatment of dyslipidemia in adults in China .Severe pneumonia was diagnosed as severe infection in respiratory system by co-infections with bacteria, tuberculosis, virus and even fungi accompanied by compatible symptoms and signs .The prognosis was documented either as death or survival among these patients when discharging from hospital.AIDS patients were admitted due to various unspecific symptoms and signs, which may be caused by opportunistic infection, AIDS-defining cancers or even NADEs. Opportunistic pathogens screening, biochemical tests, and imaging examination including CT scan was performed routinely in all admitted patients.The clinical information was abstracted from electronic medical records from January 2009 to December 2018. Demographic data included age and sex, and individual behavior data included cigarette smoking or alcoholic drinking history and HIV transmission routes. The diagnostic criteria of cigarette smoking history was reported smoking one or more cigarettes in the past day . And theThe statistical analysis was carried out using SPSS 24.0 . Categorical variables are presented as percentages and were compared using chi-squared tests, while continuous variables are expressed as median with interquartile ranges (IQR) and were compared using the student t tests for statistical continuous variables.Univariate logistic regression models were first used to determine the association of the common risk factors in clinical work with having serious NADEs, and statistically significant predictors with P<0.1 were included in a subsequent multivariable logistic regression model. Model fit and potential collinearity were also evaluated in the variables.Cox proportional hazard models were used to assess the risk factors of in-hospital mortality of serious NADEs among these patients with serious NADEs.p value <0.05 was treated as statistically significant.Alpha was set to 0.05 with two-side, and Sixty-one of the 1370 cART-naive AIDS patients admitted in Beijing Ditan Hospital between January 2009 and December 2018 were excluded based on the recruitment criteria. The demographic and clinical features of 1309 included patients in this study are available in (27.7%)and 294 cases (22.5%), respectively. Patients with CD4 ≤200cells/ul, 200–350, and >350cells/ul were 998 cases (76.2%), 121 cases (9.2%), and 190 cases (14.6%), respectively.Of 1309 patients analyzed, median age was 38.2 years (18–78 years) and patients aged <50years, 50-65years and ≥65 years were 1078 cases (82.4%), 199 cases (15.2%) and 32 cases (2.4%), respectively. Cigarette smoking and alcohol drinking are presented among 363 casesBesides serious NADEs, AIDS-defining events, including opportunistic infections (74.3%) and AIDS-defining cancers (2.7%), and other complications, including diabetes (2.8%), hypertension (20.5%), syphilis (22.7%), and chronic viral hepatitis B (8.1%) or C (4.5%), were diagnosed among these cART-naive AIDS patients.The prognosis of those with and without serious NADEs was compared and we found that AIDS patients with serious NADEs presented the poorer prognosis compared to those without serious NADEs (p = 0.014) .Of 1309 admitted cART-naive AIDS patients in this study, 143 patients (10.9%) had at least one serious NADEs, which included cerebrovascular diseases in 49 patients (3.8%), non-AIDS-defining cancers in 37 patients (2.8%), CKD in 28 patients (2.1%), cardiovascular diseases in 26 patients (2.0%), and liver cirrhosis in 18 patients (1.4%).The proportion with serious NADEs, stratified by age categories—<50 years, 50–65 years, and ≥65 years—increased with age, which indicated that serious NADEs were prone to occur in older cART-naive AIDS patients, and the burden of serious NADEs gradually increased in these older patients see .The proportion with serious NADEs stratified by CD4 categories, CD4 counts ≤200cells/ul, 200–350, and >350cells/ul, indicated that these serious NADEs were distributed in different CD4 categories see .We found that some cART-naive AIDS patients had one or more serious NADEs; the proportion of patients with multiple serious NADEs stratified by CD4 and age categories are described in In patients with CD4 >350cells/ul, the proportion with 1 serious NADE was 6.3% (12/190 cases), but no one had 2 or 3 serious NADEs. The proportion with 1 and 2 serious NADEs was 14.1%(17/121 cases) and 0.8% (1/121 cases) in patients with CD4 between 200 and 350cells/ul, but no one had 3 serious NADEs, and that with 1, 2 and 3 serious NADEs was 10.1% (101/998 cases),1.0% (10/998 cases) and 0.2% (2/998 cases) respectively in patients with CD4 ≤200cells/ul.In patients aged <50 years, the proportion with 1 and 2 serious NADEs was 7.2% (77/1078 cases) and 0.5% (5/1078 cases), respectively, but no one had 3 serious NADEs; in patients aged 50–65 years, the proportion with 1, 2 and 3 serious NADEs was 19.6% (39/199 cases), 1.5% (3/199 cases) and 0.5% (1/199 cases), respectively, and in patients aged ≥65 years, the proportion with 1, 2 and 3 serious NADEs was 43.7% (14/32), 6.3% (2/32 cases) and 3.1% (1/32 cases), respectively.The prevalence in patients with CD4 ≤ 350 cels/ul and aged ≥ 50 years, CD4 ≤ 350 cels/ul and aged < 50 years, CD4 > 350 cels/ul and aged > 50 years, and with CD4 > 350 cels/ul and aged < 50 years was 27.4%, 8.3%, 1.7%, and 4.4%,m respectively (p<0.001), which indicated that the distribution of multiple serious NADEs was prone to co-occur in patients with CD4 ≤ 350 cels/ul and aged ≥ 50 years and increased complexity of diagnosis and management among cART-naive AIDS patients in China .In cART-naive AIDS patients, univariate logistic regression models were first used to determine the association of the common risk factors for having serious NADEs in clinical work and to identify statistically significant predictors (P<0.1). Age 50–65 years , age ≥ 65 years , cigarette smoking , CD4 within 200–350 cells/ul , CD4 ≤ 200 cells/ul , TC ≥ 6.2 mmol/L , TG ≥ 2.3 mmol/L , HDL ≤ 1.0 mmol/L , invasive fungal infections , AIDS-defining cancers , severe pneumonia , diabetes , hypertension  and chronic HCV infection , were included in a subsequent multivariate logistic regression model, in which age 50–65 years , age ≥ 65 years , cigarette smoking , CD4 within 200–350 cells/ul , CD4 ≤200 cells/ul , TC ≥ 6.2 mmol/L , hypertension  and chronic HCV infection  were predictors of serious NADEs in cART-naive AIDS patients .2 value was 0.164. The variance inflation factor (VIF) value was calculated based on formula: VIF = 1/(1-R2), and result was 1.2; this is less than 5, which indicates that we can ignore VIF to influence parameters’ fit in the model. More importantly, although potential collinearity resulted in increased coefficient’s estimated variance, the predictive ability of the model did not decrease, which indicated the overfitting can be excluded in this model.We also assessed potential collinearity in the variables in multivariate logistic regression model, and we found that the Nagelkerke ROverall, 17 patients (1.3%) with serious NADEs died during hospitalization among the cART-naive AIDS patients, including CKD in 9 patients (0.7%), cerebrovascular diseases in 5 patients (0.3%), CVD in 3 patients (0.2%) and NADC in 1 patient (0.1%), in which included CVD and CKD co-occurred in 1 patient.There were 17 deaths while there were 23 parameters in the multivariable model, which demonstrated overfitting, we chose Univariable COX proportional hazard regression analysis, which demonstrated that severe pneumonia  and AIDS-defining cancers  as risk factors were associated with an increased hazard of mortality. Due to the most common and severe complication in AIDS patients in China , we elucDespite availability of National Free Antiretroviral Treatment Programs (NFATP) in China , 19, somBesides AIDS-defining events, NADEs also occurred among cART-naive AIDS patients due to persistent chronic inflammation, immunosuppression, and viraemia , which iIt was reported that , comparein vivo, and helped increase awareness of healthcare workers to establish appropriate diagnostic and treatment strategies for these patients.This is the first study to evaluate the burden, risk factors, and prognosis of serious NADEs in cART-naive AIDS patients, using electronic medical records database in China. We found that serious NADEs were also another major complications in AIDS patients prior to receiving cART besides AIDS-defining events, and serious NADEs could occur among cART-naive AIDS patients with older age or lower CD4 categories. This finding indicated that cART-naive AIDS patients, especially older patients, experienced serious NADEs earlier. Moreover, this finding demonstrates the importance of earlier initiation of cART, which inhibited viremia, reduced inflammatory cytokines et al. [Hsue et al.  reportedIt was reported that  the burdSome studies reported that CKD occurred in 3.5%-48.5% of HIV-infected population , and oldHIV infection was a risk factor for liver fibrosis  and acceet al. demonstrated that untreated HIV infection was related to an increasing number of non-AIDS-defining events, and immunosuppression and uncontrolled HIV viremia further enhanced the effect [The results in our study revealed that serious NADEs could occur in cART-naive AIDS patients with different CD4 levels, especially with CD4 ≤ 350 cells/ul, which was consistent with results previously found in industrialize countries . Salter e effect . One pose effect , coagulae effect , and ende effect , which wIn general population, serious NADEs were senescence-associated diseases caused by chronic inflammations in elderly patients in vivo , while iIn this study, all patients were HIV-infected patients with end stage of AIDS, who presented unspecific symptoms; prior to initiating cART, diagnosis and treatment of AIDS-defining events (ADEs), including opportunistic infections and AIDS-defining cancers, were first considered. Besides ADEs, we found serious NADEs could occur different CD4 levels and age and increased mortality. We suggest that, in addition to screening for opportunistic pathogens, earlier screening and treatment of serious NADEs among cART-naive AIDS patients after admission and/or prior to initiating cART, but not after taking cART, was beneficial for improving quality of lives of patients.It was reported that, besides liver fibrosis and cirrhosis, extra-hepatic comorbidities including malignancies, cardiovascular diseases, CKD, and neurological diseases were well established in HCV-infected population . ChronicHypertension was reported as a common complication in HIV-infected patients, and we found that the prevalence of hypertension was 20.5% in our cohort, which was similar with results reported in developed countries . It was It was reported that, in HIV-infected patients, lower serum TC and mild increased TG levels were found prior to cART initiated , 37, andIt was reported that lower CD4/CD8 ratio  and chroIt was reported that people living with HIV receiving cART had greater burden of NADEs, who tended to have one or more NADEs . In thisSome literature reported that AIDS-defining illnesses as a significant drivers were associated with pathogenesis of NADEs-related death in spite of unmeasured confounders due to some fatal AIDS-defining illnesses, including Pneumocystis pneumonia, and treatment and prophylaxis of AIDS-defining illnesses and further initiation of cART reduced the mortality of NADEs . In thisThe results in this study revealed burden, risk factors, and prognosis of serious NADEs in cART-naive AIDS patients, in which OIs or ADCs were also common complications in these patients, especially in those with CD4 less than 200 cells/ul, which undoubtedly added complexity to diagnosis and treatment among these patients. Although co-medications were out range of this study, it was not surprising that co-medications , includiThe study about the burden, risk factors, and prognosis of serious NADEs in cART-naive AIDS patients has some strengths. First, serious NADEs were previously reported to occur in cART-experienced AIDS patients , 7, wherThe study had some limitations: First, potential bias inherently existed in retrospective and observational study. Second, only 1309 cART-naive AIDS patients were included in this retrospective and observational cohort, which indicated that it was not a meta-cohort study and the results should be further validated with the increased number of patients. Third, a further limitation of the study was that it was a hospital-based rather than population-based cohort. Patients admitted to hospital were more likely to have a serious NADE, and so the true prevalence of serious NADEs among cART-naïve patients in China may be lower. Despite the limitations, this study provided insight about the burden, risk factors and mortality of serious NADEs in cART-naive AIDS patients in China.In summary, serious NADEs, including cardiovascular diseases, cerebrovascular diseases, liver cirrhosis, chronic kidney diseases, and NADCs, also occurred in cART-naive AIDS patients in China in addition to AIDS-defining diseases, despite low prevalence. We found these serious NADEs distributed in different age and CD4 levels, which indicated earlier screening of serious NADEs, regardless of age and CD4 levels, was necessary. Other traditional risk factors, including cigarette smoking, hypertension, chronic HCV infection and hypercholesterolemia, were also associated with serious NADEs, and severe AIDS-defining events as a significant drivers were associated with serious NADEs-related death, which indicated earlier intervention of these risk factors helped reduce the occurrence of serious NADEs and its related death. Our results will remind physicians that earlier screening and intervention of serious NADEs are necessary, and multi-disciplinary cooperation and earlier initiation of cART is essential to reduce the burden of serious NADEs.S1 FigTo clarify the effects of severe pneumonia on survival, Kaplan-Meier survival curves were plotted for study subjects stratified by variable with/without severe pneumonia, which indicated that there was significant difference between the two groups (p<0.001).(TIF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S1 Data(XLS)Click here for additional data file.