Sotos syndrome is a congenital overgrowth syndrome associated with intellectual disability. This study investigated communicative abilities of children with Sotos syndrome (n = 31), using the Children’s Communication Checklist, second edition. A cross-syndrome approach was used to establish the specificity of these abilities. Children with Williams syndrome (n = 34) were used as a comparison group. In both groups, the majority of participants had communicative impairment. Children with Sotos syndrome had an uneven pragmatic language profile and greater impairment with social relations, compared with restricted interests. Overall, children with Sotos syndrome had difficulties with both language structure and pragmatic language and a specific profile of relative difficulty with using nonverbal communication, using context-appropriate language and understanding peer relationships. Sotos syndrome is a congenital overgrowth syndrome with an estimated incidence of approximately 1 in 14,000 (Tatton-Brown and Rahman Cross-syndrome comparisons are useful for assessing similarities and differences between phenotypes associated with distinct syndromes and can lead to identification of unique characteristic features of syndromes. These comparisons enable the specificity of strengths and difficulties associated with a particular syndrome to be established and can inform understanding of specific factors to target for intervention. Williams syndrome (WS) is a congenital syndrome with a similar incidence to that of Sotos syndrome . In addition, effective communication requires the ability to understand how to use language appropriately, or pragmatic language (e.g. using context-appropriate language and understanding the communicative partners’ experience of the interaction). Language structure ability is not necessarily related to pragmatic language ability. For example, developmental language disorder (DLD) is associated with relative difficulty with structural aspects of language, compared with functional pragmatic language, whereas ASD is associated with relative difficulty with pragmatic aspects of language, compared with language structure  Bishop  is desigTo date, language structure skills and pragmatic language ability have not been explored within the Sotos syndrome population and understanding of the communicative abilities of individuals within this population is limited. It is important to identify the prevalence and profile of language and communication difficulties within the Sotos syndrome population as impairments may have social and educational implications. For example, language skills are critical for social interaction so may impact peer relationships and identification of language and communication difficulties will enable appropriate services and provisions to be identified for individuals with Sotos syndrome. In addition, comparison of the strengths and difficulties of children with Sotos syndrome with those of children with WS will enable the specificity of the language and communicative profile associated with Sotos syndrome to be established. Once specific impairments have been established, these can be explored further in order to identify factors which may underlie these impairments. Ultimately, this approach will enable optimal strategies and interventions to be devised to address specific impairments.The primary aim of this study was to investigate the communication abilities of children with Sotos syndrome and to identify relative communicative strengths and difficulties associated with this syndrome, as assessed by the CCC-2. It was hypothesised that children with Sotos syndrome would have significant communicative difficulties. A secondary aim of this study was to compare the communicative abilities of children with Sotos syndrome with those of a matched group of children with WS in order to determine whether the communicative profiles are syndrome-specific. This is the first cross-syndrome comparison of Sotos syndrome and WS.The sample comprised 31 children with Sotos syndrome  and 34 children with WS , matched on chronological age and sex. Mean age of the Sotos syndrome participants was 9.12 years  and mean age of the WS participants was 9.4 years . The parent/caregiver of each child completed the CCC-2. Families of children with Sotos syndrome were recruited via the Child Growth Foundation  and advertisements on a Sotos syndrome support group on social media. Families of children with WS were recruited via the Williams Syndrome Foundation .The CCC-2 is a standardised 70-item questionnaire designed to assess communicative abilities in children (4–16 years 11 months) and can be used to identify children with significant communicative problems. Age-appropriate norms are provided. Items are coded on a Likert scale to determine the frequency of communicative difficulties and communicative strengths . The CCC-2 has 10 subscales which assess: (A) speech; (B) syntax; (C) semantics; (D) coherence; (E) inappropriate initiation; (F) stereotyped language; (G) use of context; (H) nonverbal communication; (I) social relations; (J) interests. Each of the subscales has 7 items; 5 relate to communicative difficulties and 2 relate to communicative strengths. A General Communication Composite (GCC) score provides an indication of the communicative ability of a child and is calculated as the sum of scaled scores for subscales A–H. Based on the standardisation sample, a GCC score of 54 is equivalent to the 10th percentile and GCC scores < 28 are equivalent to < 1st percentile. In addition, a language structure score  and a pragmatic language score  can be calculated in order to directly compare language structure skills and pragmatic language skills. For both language structure and pragmatic language, scores > 24 indicate typical functioning, scores of 17–24 indicate borderline functioning and scores < 17 indicate impaired functioning. The CCC-2 has been found to be a valid measure for differentiating between individuals with typical communicative ability and those with significant communicative impairments and within the CCC-2 standardisation sample, internal consistency of the subscales ranged from 0.65 to 0.80 Bishop .t-test was used to compare overall communicative ability of children with Sotos syndrome and children with WS. The analysis revealed no significant difference between GCC scores for the Sotos syndrome participants  and GCC scores for the WS participants ; t(63) = 0.23, p = .820, d = 0.06, indicating that both syndromes are associated with a similar level of overall communicative ability.Communication ability was assessed on the basis of GCC scores, with GCC scores < 55 (≤ 10th percentile) indicating that a child has significant communicative difficulties. For participants with Sotos syndrome, GCC scores ranged from 1 to 57 (< 1st percentile–13th percentile), demonstrating that the majority of children with Sotos syndrome had communicative difficulties of varying severity, with only one participant scoring in the normal range. GCC scores for participants with WS ranged from 4 to 60 (< 1st percentile–15th percentile), indicating that the majority of children with WS had communicative difficulties and once again, only one participant scored in the normal range. An independent samples F = 0.34, p = .564, ηρ² = .005, indicating no discrepancy between language structure skills and pragmatic language skills overall within this cohort. There was no effect of group; F = 0.05, p = .820, ηρ² = .001 and no skill x group interaction; F = 3.18, p = .079, ηρ² = .048. This suggests that both children with Sotos syndrome and children with WS had a similar degree of impairment with language structure skills and pragmatic language skills.In order to determine whether children with Sotos syndrome had an uneven profile of greater difficulty with either language structure or pragmatic language, scores for these abilities were compared. The Sotos syndrome profile was also compared to the WS profile to establish any syndrome-specific differences. Language structure scores were calculated as the sum of scaled scores for subscales A, B, C and D for participants with Sotos syndrome  and participants with WS . Pragmatic language scores were calculated as the sum of scaled scores for subscales E, F, G and H for participants with Sotos syndrome  and participants with WS . A 2 × 2 (Group: Sotos/WS x Language skill: structure/pragmatic) mixed measures ANOVA revealed no main effect of skill; X2 = 0.44, p = .801, and no significant association between group and pragmatic language ability category, X2 = 3.40, p = .183. This indicates that, for both Sotos syndrome and WS, a similar proportion of individuals had impaired, borderline and typical language structure and pragmatic language abilities (see Table A Chi square test of independence was used to assess the association between group (Sotos/WS) and category of language ability . There was no significant association between group and language structure ability category, R2 = 0.64, F = 16.27, p < .001, and inspection of the beta weights revealed that both language structure skills  and age  were significant predictors of pragmatic language ability. The same analysis was used to assess variance in pragmatic language ability for participants with WS. The regression equation was significant; R2 = 0.25, F = 3.33, p = .033, and inspection of the beta weights revealed that both language structure skills  and age  were significant predictors of pragmatic language ability. This suggests that language structure skills and age are significant predictors of pragmatic language ability for both children with Sotos syndrome and children with WS. Although the predictors were the same in both groups, language structure skills and age explained more variance in pragmatic language ability for children with Sotos syndrome (64%) than children with WS (25%). This indicates that other factors may account for variability in pragmatic language ability within the WS population.Although children with Sotos syndrome had similar overall difficulty with both language structure and pragmatic language abilities, there was significant variability in level of functioning of these abilities within each group. In order to investigate this variability, multiple regression was used to establish the extent to which variance in pragmatic language ability is explained by language structure skills, age and sex. The regression equation was significant; F = 2.16, p = .099, ηρ² = .067, indicating that children with Sotos syndrome had similar ability in all four language structure skills assessed by the CCC-2.In order to determine whether children with Sotos syndrome had particular difficulty with specific aspects of language structure, a repeated measures ANOVA was used to compare scaled scores for the four language structure subscales: (A) speech (e.g. pronunciation), (B) syntax (e.g. use of pronouns), (C) semantics (e.g. differentiation of words which sound similar) and (D) coherence (e.g. description of a sequence of events). A scaled subscale score ≤ 5 is indicative of significant communicative problems. The analysis identified no effect of subscale; F = 3.61, p = .014, ηρ² = .054 but no significant subscale x group interaction; F = 1.23, p = .302, ηρ² = .019 and no significant effect of group; F = 0.45, p = .504, ηρ² = .007. As there was no significant subscale x group interaction, this suggests that children with these syndromes had similar difficulty with the language structure skills assessed by the CCC-2. Figure The language structure skills of children with Sotos syndrome were compared with those of children with WS in order to investigate syndrome-specific differences in these abilities. A 2 × 4  mixed measures ANOVA was used to compare scaled scores for the four language structure subscales. The analysis identified a significant main effect of subscale; F3, 89 = 3.61F = 11.32, p < .001, ηρ² = .274, indicating that children with Sotos syndrome had an uneven profile of pragmatic language skills. Post-hoc paired samples t-tests  were used to compare scaled scores for the four pragmatic language subscales. The significant comparisons were stereotyped language > use of context, t(30) = 5.67, p < .001, d = 1.02; stereotyped language > nonverbal communication, t(30) = 4.68, p < .001, d = 0.84; inappropriate initiation > use of context, t(30) = 4.60, p < .001, d = 0.83. There was a trend for inappropriate initiation > nonverbal communication, t(30) = 2.76, p = .01, d = 0.49. This suggests that, in terms of the pragmatic language profile, children with Sotos syndrome have greater difficulty with use of context and nonverbal communication, whereas inappropriate initiation and stereotyped language are less problematic.In order to determine whether children with Sotos syndrome had particular difficulty with specific aspects of pragmatic language, a repeated measures ANOVA was used to compare scaled scores for the four pragmatic language subscales: (E) inappropriate initiation , (F) stereotyped language (e.g. repeating back things other people have said), (G) use of context (e.g. consistency of communication skills across different situations) and (H) nonverbal communication . The analysis identified a significant effect of subscale; F = 1.33, p = .253, ηρ² = .021. There was a significant main effect of subscale; F = 17.58, p < .001, ηρ² = .218, and a significant subscale x group interaction; F = 4.86, p = .003, ηρ² = .072, indicating that both groups had uneven pragmatic language profiles but the nature of these profiles differed.The pragmatic language abilities of children with Sotos syndrome were compared with those of children with WS in order to determine the specificity of the Sotos syndrome pragmatic language profile. A 2 × 4  mixed measures ANOVA was used to compare scores for the four pragmatic language subscales. The analysis identified no significant effect of group; p < .013 required for significance) were used to compare scores for the four pragmatic language subscales between the groups. The comparisons revealed a trend for the Sotos syndrome participants to have better stereotyped language scores, compared with the WS participants, t(63) = 2.19, p = .032, d = 0.55. There were no significant differences between groups for inappropriate initiation scores, t(63) = 1.27, p = .210, d = 0.32; use of context scores, t(63) = 1.46, p = .148, d = 0.37; or nonverbal communication scores, t(63) = -1.05, p = .298, d = 0.26. This suggests that the Sotos syndrome pragmatic language profile is characterised by less difficulty with stereotyped language. Figure As there was a significant subscale x group interaction, post-hoc comparisons  = − 5.99, p < .001, d = 1.08, indicating that children with Sotos syndrome had greater difficulty with social relations, compared with restricted interests. In order to establish whether this profile of behaviours was syndrome-specific, a 2 × 2  mixed measures ANOVA was used to compare scaled scores for the ASD subscales between participants with Sotos syndrome and participants with WS. The analysis revealed a significant main effect of subscale; F = 27.74, p < .001, ηρ² = .306 and a significant subscale x group interaction; F = 8.79, p = .004, ηρ² = .122, indicating that both groups had uneven ASD subscale profiles but the nature of these profiles differed. There was no effect of group; F = 0.04, p = .835, ηρ² = .001.The CCC-2 has two subscales which assess behaviours typically associated with ASD; social relations (e.g. interaction with other children) and interests (e.g. preference for the same favourite activity). In order to determine whether children with Sotos syndrome had relative differences in these behaviours, a paired samples p < .025 required for significance) were used to compare scores for the two ASD subscales within the Sotos syndrome and WS participants. As reported above, participants with Sotos syndrome had significantly greater difficulty with social relations, compared with restricted interests. However, the same analysis with participants with WS revealed no significant difference between the social relations subscale and the interests subscale, t(33) = − 1.60, p = .120, d = 0.27. Overall, this suggests that children with Sotos syndrome tend to have less difficulty with restricted interests compared with social relations, and this profile was specific to the Sotos syndrome participants. Figure As there was a significant subscale x group interaction, post-hoc comparisons (using a Bonferroni correction bscale, t3 = − 1.6The primary aim of this study was to investigate communicative abilities of children with Sotos syndrome, using the CCC-2. A cross-syndrome approach was used to compare communicative abilities of children with Sotos syndrome with a matched group of children with WS in order to investigate the specificity of the communicative profile associated with Sotos syndrome. The findings indicate that both syndromes are associated with communicative impairment and a similar level of overall communicative ability. There were no relative differences between overall language structure skills and pragmatic language skills, indicating that children with Sotos syndrome have similar difficulty with both of these linguistic abilities. This was also observed for children with WS. Furthermore, language structure skills and age were significant predictors of pragmatic language ability for both syndromes but accounted for greater variation in pragmatic language ability for the Sotos syndrome participants. Within the Sotos syndrome group, children had an uneven pragmatic language profile and ASD profile but similar difficulty with all language structure abilities assessed by the CCC-2. Specifically, the pragmatic language profile was characterised by greater difficulty with use of context and nonverbal communication but relatively less difficulty with inappropriate initiation and stereotyped language. The ASD profile was characterised by greater difficulty with social relations, compared with restricted interests. Both the pragmatic language profile and ASD profile were specific to the Sotos syndrome participants.The present study included a sample of 31 children with Sotos syndrome and this is the largest study to date to explore communicative abilities within this population. Overall, children with Sotos syndrome had communicative difficulties, compared with typically developing peers of the same age, as evidenced by low GCC scores. Only one participant with Sotos syndrome had a GCC score > 10th percentile. Furthermore, there was no significant difference between GCC scores for children with Sotos syndrome and children with WS, indicating that these populations are associated with a similar degree of overall communicative ability. However, it is important to note that there was considerable variability in communicative ability within each group. Previous research has established that both Sotos syndrome and WS are associated with relative strength in verbal ability, compared with nonverbal reasoning ability, as assessed by standardised cognitive assessments (Lane et al. Previous research indicates that different conditions are associated with uneven profiles of language structure and pragmatic language abilities (Geurts and Embrechts Although previous research has reported that children with Sotos syndrome have communication impairment and language delays, the communicative profile had not been explored in detail (Finegan et al. Although children with Sotos syndrome had difficulty with both ASD subscales, participants had significantly greater impairment with social relations, compared with restricted interests. Difficulty with these behaviours is consistent with previous research indicating that Sotos syndrome is associated with increased prevalence of behaviours typically associated with ASD (Lane et al. Due to the rarity of the syndrome, the present study used a parental questionnaire to assess communicative abilities, in order to obtain a relatively large sample of children with Sotos syndrome. The advantage of this methodology is that parents spend a lot of time with their children so are familiar with abnormal communicative abilities which may not be observed during a clinical test or observation. However, it will be important for future research to further understanding of the social and communicative abilities associated with Sotos syndrome by using paradigms during live social interactions, in order to directly assess these skills in children with the syndrome. For example, this approach has been used to investigate social attention in children with autism (Hanley et al. The present study focused on children with Sotos syndrome but it will be important for future research to investigate language and communication in adults with Sotos syndrome. Previous research indicates that difficulties with social interaction, restricted interests and repetitive behaviours may be less severe in adulthood, compared with childhood, within the Sotos syndrome population (Lane et al. In summary, the findings from the present study demonstrate that the majority of children with Sotos syndrome have communicative impairment, compared with typically developing peers and that children within this population struggle with both language structure and pragmatic language. Children with Sotos syndrome have an uneven pragmatic language profile characterised by relative difficulty with use of context and nonverbal communication, compared with inappropriate initiation and stereotyped language. This pragmatic language profile was specific to Sotos syndrome. Overall, the findings inform understanding of specific communicative difficulties that are common in children with Sotos syndrome and demonstrate the need for support with language and communication development within this population. In particular, children with Sotos syndrome may require additional support with understanding and using nonverbal communication and using context-appropriate language and may have difficulty with peer relationships.


Serum cystatin C (SCysC) and serum creatinine (SCr) are two biomarkers used in common practice to estimate the glomerular filtration rate (GFR). For SCysC and SCr to be used in a given population, normal values need to be determined to better assess patients. This study aimed to determine SCysC and SCr reference intervals (RIs) in a Cameroonian adult population and factors susceptible of influencing them.We carried-out a cross-sectional study from November 2016 to May 2017 in Yaoundé, Cameroon. Participants were Cameroonians aged 18 years and above, residing inside the country and found in good health at study inclusion. SCysC and SCr were determined by particle-enhanced turbidimetric immunoassay standardized against the ERM-DA471/IFCC reference material and by the IDMS reference modified Jaffe kinetic method, respectively. RIs were determined using the 2.5th and 97.5th percentiles and their respective 90% confidence intervals (CIs). The quantile regression served to identify potential factors likely influencing SCysC and SCr values.p <  0.001). Likewise, subjects aged 50 years and above had higher SCysC values in comparison to younger age groups (p <  0.001), which was not the case for SCr values (p = 0.491). Moreover, there was a positive and significant correlation between SCysC and SCr in women , in men  and globally . Furthermore, the sex influenced both biomarkers’ values across all quantile regression models while age and body surface area (BSA) influenced them inconsistently.We included 381 subjects comprising 49.1% females.. RIs for SCysC varied between 0.57 (90%CI: 0.50–0.60) and 1.03 mg/L (90%CI: 1.00–1.10) for females, and from 0.70 (90%CI: 0.60–0.70) to 1.10 mg/L (90%CI: 1.10–1.20) for males. Concerning SCr, its RIs ranged from 0.58 (90%CI: 0.54–0.61) to 1.08 mg/dL (90%CI: 1.02–1.21) for females, and from 0.74 (90%CI: 0.70–0.80) to 1.36 mg/dL (90%CI: 1.30–1.45) for males. Men had significantly higher SCysC and SCr values than women  contains supplementary material, which is available to authorized users. Glomerular filtration rate (GFR) is widely accepted as the most useful overall index of kidney function in health and disease . It is bAs a result of these limitations, alternative endogenous markers for GFR such as serum cystatin C have been proposed. Cystatin C is a biomarker formed at a constant rate by all nucleated cells of the body which do not correlate with lean tissue mass . EvidencFor an accurate interpretation of biomarkers levels, reference intervals specific to a population need to be established. Intriguingly and although serum creatinine is widely used in Cameroon, no previous study had yet focused at determining its reference intervals, interpretations relying on western countries’ data. Moreover, considering the growing importance of cystatin C as a prospective marker to assess the renal function, it is obvious that this marker would be introduced in routine clinical practice in Cameroon very soon. Therefore, we conducted the present study to determine the reference values of serum creatinine and cystatin C in a healthy adult Cameroonian population living inside the country. Besides, we aimed to identify potential factors likely influencing these reference intervals.Yaoundé 1, 2, 4 and 6 . The Kolmogorov Smirnov test was used to assess the normality of continuous variables’ distributions. Reference intervals (RIs) were determined by the nonparametric method as described in the IFCC guidelines . This mep = 0.290). By contrast, males had significantly higher BSA values than females: p = 0.002 aged between 18 and 71 years old with a median age of 28 years [IQR 23–40]. There were no differences in the distribution of age between male and female participants , in males  and in the total study population .Additionally, serum cystatin C levels were higher in persons aged 50 years and above compared to their counterparts aged less than 50 years old , except in the 50+ years age group. Concerning serum creatinine, the reference intervals ranged from 0.6 to 1.3 mg/dL; similarly, men had significantly higher levels than women (p < 0.001) across all age groups. Participants aged 50 years and above had higher serum cystatin C values than those aged less than 50 years (p < 0.001), which was not the case for serum creatinine values (p = 0.491). Moreover, the correlation between serum cystatin C and serum creatinine was positive and significant  and the quantile regression pointed mostly the sex, and to a certain extent the age and BSA as independent factors susceptible of influencing serum cystatin C and/or serum creatinine values.In agreement with IFCC recommendations , the refReference intervals for serum cystatin C obtained in this study (0.60–1.10 mg/L) are in compliance with those from previous studies which have also used turbidimetric assay. For instance, Köttgen et al. recorded in a US population a reference interval varying between 0.61–1.04 mg/L; Okonkwo et al. in a Nigerian population recorded a reference interval ranging between 0.64–1.12 mg/L and Li et al. in a Chinese population recorded a reference interval varying from 0.60 to 1.08 mg/L . By contThe sex-related differences in the non-parametric reference intervals for serum creatinine are in line with previous studies and reinforced by results of our quantile regression analysis indicating that the sex influenced serum creatinine values across all models, while adjusting for age and BSA. Indeed, muscular mass is higher in men compared to women , 6, 21. p < 0.001). These results corroborate those from Köttgen et al. in the US who reported a difference of 8% between males and females [p < 0.05) [In our study for instance, we found that the sex constituted one independent explanatory factor for serum cystatin C values, whatever the quantile regression model considered; additionally, serum cystatin C levels were 11% higher in men than in women  , 29. In  < 0.05) , 29, 30. < 0.05) .p = 0.125) while the difference persisted for serum creatinine levels . Actually, the influence of sex on serum cystatin C levels seems non-significant with increasing age, suggesting a physiological or pathological condition which should be more investigated in elderly. Further studies are warranted in this respect.Likewise, we found in our study that from 50 years old and beyond, differences of serum cystatin C levels between men and women became non-significant . Concurring with these results, several other studies have demonstrated an increase in cystatin C values above a threshold age varying from 40 to 70 years [On the other hand, subjects aged 50 years and over had 11% higher serum cystatin C levels compared to lower age groups . Likewise, Pottel et al. using a Caucasian population noticed that between 20 and 70 years old, the mean serum creatinine level was stable [Serum creatinine levels are also expected to increase around the same age (≥50 years); however, we observed that the distributions of serum creatinine values were similar across the various age groups , in females  and in the total population . These findings mirror those from Pottel et al. who reported a positive correlation between these two biomarkers in a Caucasian population of 8584 subjects  [We found a positive and significant correlation between serum cystatin C and serum creatinine, both in males  . Potter The inconsistent influence of age on both serum cystatin C and serum creatinine values was observed after applying the quantile regression analysis. Indeed, we found that age influenced significantly both serum cystatin C and serum creatinine values only at the 75th percentile quantile regression model, the estimator being insignificant at the 25th and 50th percentile models. We need further well-designed studies to better investigate the influence of age (and BSA) on serum cystatin C and serum creatinine values in our context.However, our findings need to be interpreted in the context of some limitations, mainly occurring from the non-random sampling method used and single measurement of serum cystatin C and serum creatinine. In fact, the representativeness of our study population and generalization of our results to the entire Cameroonian population would have been better obtained with randomization. Nevertheless, we selected the most populated health districts among the 6 that compose Yaoundé, the cosmopolitan capital city of Cameroon. On the other hand, participants were selected on the basis of their normal renal function which could be attested only by measurement of GFR by the gold standard (inuline). Nonetheless, the absence of risk factors for kidney disease and the normal clinical and biological tests performed among our participants could be some indirect indicators of normal kidney function. Furthermore, we used rigorous statistical procedures and applied the IFCC guidelines to depict our estimates. Notwithstanding and to the very best of our knowledge, this is the first study providing the reference values for serum cystatin C and serum creatinine in Cameroon, which could be translatable to similar sub-Saharan African populations.This study depicted serum cystatin C and serum creatinine reference intervals in a healthy adult Cameroonian population. Men had significantly higher levels of both biomarkers compared to women. Subjects aged 50 years old and above had significantly higher serum cystatin C values than those aged less than 50 years old. Therefore, the interpretation of both biomarkers should probably take into account the patient’s sex and to a certain extent, his/her age (and/or body surface area) for an appropriate diagnosis of a renal disease. Moreover, it is hoped that our data stimulate further research on a larger population that will be more representative of the whole country’s diversity.Additional file 1:Questionnaire. (DOCX 17 kb)


Cadherin-2 (CDH2) gene polymorphisms were reported to be associated with the induction and development of knee osteoarthritis (OA).This case–control study was designed to explore the association between CDH2 gene rs11564299 polymorphism and the risk of knee OA in Chinese subjects. The polymorphism was genotyped by polymerase chain reaction and Sanger sequencing.2 groups showed increased risk for knee OA. Additionally, this polymorphism was associated with CRP and Kellgren–Lawrence grade.G allele or GG genotype of CDH2 gene rs11564299 polymorphism was related to increased risk for knee OA in the Chinese Han population. Additionally, subgroup analyses indicated that the female, smoker, drinker, and BMI ≥ 25 kg/mIn summary, this current study reveals that CDH2 gene rs11564299 polymorphism is a risk factor for knee OA development in this Chinese population. The genotypes distribution differed significantly among OA patients and healthy controls and may be a useful tool in the evaluation of OA susceptibility in Chinese Han population. Osteoarthritis (OA) is one of the most common chronic joint diseases. It leads to diminished quality of life and even disability in the elderly worldwide. The main characteristic of OA is pain, limitation, and dysfunction of joint activity , and a sCDH2, also known as Cadherin 2 or N-cadherin, is a member of the cadherin gene superfamily. Cadherins are a group of cell surface molecules which recognize direct intercellular contact and mediate signal pathways into the cells. CDH2 is a kind of glycoproteins, which has been proved to play an important role in Ca2+ attachment and regulation of cell–cell functional protein adhesion , 12. CDHWe recruited 348 OA cases and 423 control consecutively from the Huai’an First People’s Hospital. Patients were diagnosed on the basis of the American College of Rheumatology criteria, which included primary OA with Kellgren–Lawrence grade (K-L grade) ≥ 2. The exclusion criteria were as follows: inflammatory arthritis, post-traumatic, any type of cancer, or developmental dysplasia. Participants were chosen without restriction to age, sex, or occupation.The healthy controls were selected from subjects receiving regular medical examination. No controls ever had any clinical or symptom sign of OA, other arthritis, or joint diseases  at any site based on medical record. No controls had relation to the patients or family history of OA.The demographic, lifestyle, and clinical characteristics of all participants, such as gender, age, body mass index (BMI), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and K-L grading, were collected from medical records. Individuals who had smoked at least 1 cigarette per day more than 1 year were considered to be smoker. We defined alcohol usage as consumption of at least one drink per week. Written informed consent was obtained from all participants prior to their participation. The research protocol was approved by the Ethics Committee of The Affiliated Huaian No.1 People’s Hospital of Nanjing Medical University. The ethical approval was consistent with the standards of the Declaration of Helsinki.Two milliliters of peripheral blood samples were collected using vacutainer tubes and transferred to tubes containing EDTA and stored at 4 °C until use. Genomic DNA was extracted using a QIAamp DNA blood mini kit  following the manufacturer’s instruction. The integrity and purity of the extracted DNA were tested by measuring the absorbance and running electrophoresis.2, 1 μL of 1 U/μL Taq DNA polymerase, 5 μL of 2.5 mM dNTPs, 33 μL of sterilized distilled water, and 1 μL of forward/reverse primers. The amplification conditions were as follows: 95 °C for 10 min; 30 cycles of 94 °C for 30 s, 55 °C for 30 s, 72 °C for 30 s; and final extension for 10 min at 72 °C. The PCR products were electrophoresed on 2% agarose gel and subjected to direct sequencing. In order to control the genotyping quality, 3% of samples were randomly selected for repeated assay by two different persons.Genotyping was carried out by polymerase chain reaction (PCR) and Sanger sequencing method. The primers used for the nucleotide extension reaction were 5′-AATAATAAATAATAGGCCTCTGATTACAAGA-3′ and 5′-ATAATAAATAATAGGCCTCTGATTACAAGG-3′. PCRs were performed each in a 50-μL volume containing 1 μL of DNA template, 5 μL of 10× PCR buffer containing 1.5 μM MgClt test and analysis of variance (ANOVA) were used for continuous data. A goodness-of-fit chi-square was used to test the Hardy–Weinberg equilibrium (HWE) of genotype distributions among controls. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated to evaluate the OA risk associated with genotypes and alleles of rs11564299 polymorphism by logistic regression analyses. All statistical analyses were performed using SAS 9.1.3 . P < 0.05 was the cutoff value of significance.The chi-square test was applied for categorical data, and unpaired Student’s P = 0.640) or the male/female ratio  . Logistic regression analyses revealed the risk of OA was significantly intensified by GG genotype (OR and 95%CI 2.66(1.30–5.47), P = 0.008 for GG vs. AA; 1.47(1.09–1.98), P = 0.013 for AG+GG vs. AA) or G allele carriers , P = 0.008 for A vs. G). Furthermore, we have investigated the role of CDH2 rs11564299 polymorphism in the risk of OA stratified by age, sex, smoking, BMI, and drinking (Table 2.The genotype and allele distributions for rs11564299 polymorphism are shown in Table CI 2.661.0–5.47, PSubsequently, we examined the association between rs11564299 polymorphism and clinical features of OA patients, including ESR, CRP, and K-L grade (Table 2. This SNP also showed significant correlation with CRP and K-L grade.We evaluated the effects of CDH2 gene rs11564299 polymorphism on knee OA risk in this current Chinese case–control study and found that CDH2 gene rs11564299 polymorphism may work as a risk factor in the progression of knee OA in this Chinese Han population, especially among female, smokers, drinkers, and subjects with BMI ≥ 25 kg/mUp to date, the etiologies of OA are still poorly understood, which should be attributed to interactions between systemic and local factors . SystemiN-cadherin, encoded by CDH2 gene in the human body, was known as a kind of transmembrane proteins expressed in various tissues and mediates cell–cell adhesion , 23. ChaRuedel et al. evaluated the relationship between CDH2 gene rs11564299 polymorphism and OA risk in a Germany population with 312 OA patients and 259 controls and found the minor allele of rs11564299 polymorphism was related to decreased risk for OA . In addiThere were some limitations in this present study. First, the correlation between the CDH2 gene rs11564299 polymorphism and knee OA susceptibility could not be entirely demonstrated by a single case–control study. Second, the facticity might be underpowered because of the relatively small sample size. Third, the patients or the healthy controls were all selected from hospitals, which may cause bias of population representativeness. Fourth, the ethnic distinction could not be ignored since we only designed this study among the Chinese population. And the results of this study cannot be extrapolated to different ethnic groups. Fifth, knee OA is a multifactorial etiopathogenetic disease, and the relationship between this disorder and other environmental factors should be investigated. In addition, the difference of two knee joints, strictly speaking, should be taken into consideration but we did not.To sum up, CDH2 gene rs11564299 polymorphism is associated with increased risk for knee OA in this Chinese Han population. This SNP may be a potential genetic marker to OA susceptibility in Chinese Han population, which was beneficial to early detection and treatment of OA. More studies with larger sample sizes in other races should be conformed to verify the relationship between this SNP and OA risk.


Multivariable analysis showed that a preoperative decrease in renal function according to all five equations was independently associated with an increased risk of postoperative AKI. The area under the receiver operating characteristics curve for predicting postoperative AKI was highest for the Mayo equation (0.713). Net improvements in reclassification and integrated discrimination were higher for the Mayo equation than for the other equations. The Mayo equation was the most accurate in predicting postoperative AKI in patients undergoing cardiovascular surgery.We aimed to compare the ability of preoperative estimated glomerular filtration rate (eGFR), calculated using five different equations, to predict adverse renal outcomes after cardiovascular surgery. Cohorts of 4,125 adult patients undergoing elective cardiovascular surgery were evaluated. Preoperative eGFR was calculated using the Cockcroft-Gault, Modification of Diet in Renal Disease (MDRD) II, re-expressed MDRD II, Chronic Kidney Disease Epidemiology Collaboration, and Mayo quadratic (Mayo) equations. The primary outcome was postoperative acute kidney injury (AKI), defined by Kidney Disease: Improving Global Outcomes Definition and Staging criteria based on changes in serum creatinine concentrations within 7 days. The MDRD II and Cockcroft-Gault equations yielded the highest (88.1 ± 26.7 ml/min/1.73 m However, despite its clinical importance, preoperative evaluation of renal function is often underused resources for clinicians.Preoperative renal dysfunction is prevalent in patients undergoing cardiovascular surgery, and is an independent risk factor for morbidity and mortality after surgery4. Thus, early detection and evaluation of patients with pre-existing renal dysfunction using eGFR may allow appropriate modification of perioperative care and ultimately improve postoperative outcomes. To date, several equations were developed to calculate eGFR. The commonly used equations to calculate eGFR include the Cockcroft-Gault (CG) and Modification of Diet in Renal Disease (MDRD) equation6. Other equations used to calculate eGFR include the re-expressed MDRD II equation, developed for use with standardized sCr assays7; the Mayo Quadratic (Mayo) equation, developed to better estimate GFR in healthy patients with preserved renal function8; and the recently developed Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation9. Of these five equations, CKD-EPI equation is known to have the highest accuracy in estimating GFR and is currently recommended for use to estimate GFR by the 2012 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guidelines10. However, in addition to accurately estimating GFR, the prognostic ability of these equations may also be clinically important. Indeed, the prognostic values of these equations have been compared in various medical settings, including in patients with heart failure and myocardial infarction16. To our knowledge, however, no study has compared the ability of these equations to predict outcomes after cardiovascular surgery.The level of glomerular filtration rate (GFR), which is generally accepted as the best overall indicator of renal function, is vital to the detection of renal dysfunction, understanding its severity, and making decisions about diagnosis, prognosis, and treatment. However, because of the impracticality of direct measurement of GFR in daily clinical practice, it has been recommended to use estimated GFR (eGFR) calculated from several equations incorporating variables such as serum creatinine (sCr), age, weight, and sexThe aim of this study therefore was to evaluate the agreement between eGFRs calculated using five different equations based on a single preoperative sCr value, as well as to confirm which equation can best predict postoperative renal dysfunction in patients undergoing cardiovascular surgery.Of the 4,810 patients who underwent cardiovascular surgery within the study period, 685 were excluded, and 4,125 were included in this analysis  and MDRD II yielded the highest value (88.1 ± 26.7 ml/min/1.73 m2).The distribution of patients into categories based on eGFRs calculated using the five equations is shown in Fig. 2 differed significantly when eGFR was calculated using the CG (21.3%), MDRD II (11.8%), re-expressed MDRD II (15.2%), CKD-EPI (13.0%), and Mayo (8.8%) equations (P < 0.001). Compared with the CKD-EPI equation, the CG equation reclassified a higher proportion of patients as having worse renal function and the Mayo equation reclassified a higher proportion of patients as having better renal function , intermediate when calculated by the re-expressed MDRD II equation (31.4%), and lowest when calculated by the CKD-EPI equation (30.4%)13. Another study of 4,039 patients with ST-elevation myocardial infarction found that the prevalence of eGFR <60 ml/min/1.73 m2 was highest when calculated by the CKD-EPI equation (26.5%), intermediate when calculated by the CG (25.7%) and MDRD II (24.3%) equations, and lowest when calculated by the Mayo equation (14.8%)15. These equation-dependent differences in the prevalence of eGFR <60 ml/min/1.73 m2 may be due to differences in the coefficients and variables included in these equations or differences in study populations. Indeed, the CG equation was developed in a population of male Caucasians with slightly impaired renal function for prediction of creatinine clearance5. Because this equation incorporated glomerular and tubular creatinine clearance and its numerator includes weight and 140-age, it may overestimate GFR in younger healthy patients and underestimate GFR in older patients and those with lower body weight22. Thus, our finding that mean eGFR was lowest and the prevalence of eGFR <60 ml/min/1.73 m2 was highest when calculated using the CG equation may be attributed to the relatively older age and lower body mass index of this patient population. However, because underlying GFR was not directly measured by any reference method in this study, the best equation for estimating actual GFR cannot be determined from our results.In contrast to previous studies assessing the effect of preoperative eGFR on postoperative outcomes using just one or two equations2 is linked to both short- and long-term prognosis after surgery3. However, as shown in our study, the eGFR of the same patient differed significantly depending on the equation employed, indicating a potential for incorrect diagnoses and therapy. For example, it is impossible to diagnose a patient with pre-operative renal dysfunction if eGFR calculated by the re-expressed MDRD II equation is <60 ml/min/1.73 m2 and eGFR calculated by the CKD-EPI equation is ≥60 ml/min/1.73 m2. Thus, if two different equations with the same sCr concentration yield different eGFR values , it may be necessary to check GFR directly using any reference method. On the other hand, if this criterion is incorporated into preoperative assessments, this group of patients would be identified as being at increased risk of poor postoperative outcomes. Indeed, our results indicated that patients with discordant eGFR, as calculated by these equations, showed poorer outcomes than patients with eGFR ≥60 ml/min/1.73 m2 calculated by all five equations. Thus, our finding suggests that estimating GFR using two or more equations may help in the risk stratification of surgical patients, with patients having equation-dependent preoperative eGFR ≥60 ml/min/1.73 m2 or <60 ml/min/1.73 m2 requiring closer monitoring and more intensive care during the perioperative period to improve outcomes. Although this will requires validation in a larger study population, it may be clinically meaningful, as this finding is in line with those of previous studies showing that patient whose eGFR estimated as ≥60 ml/min/1.73 m2 using one equation shifted to <60 ml/min/1.73 m2 using another equation had mortality rates that were intermediate between those with eGFR <60 ml/min/1.73 m2 and those with eGFR ≥60 ml/min/1.73 m2, according to all five equations in a broad spectrum of acute coronary syndrome patients15.It is well established that preoperative renal dysfunction defined as eGFR < 60 ml/min/1.73 m10. However, it is still unclear whether it is the best equation for predicting prognosis. Indeed, although several studies compared the ability of eGFR equations to predict prognosis in patients with various medical conditions, including heart failure and acute coronary syndrome, the results varied18. For example, a meta-analysis comparing the risk implications of the CKD-EPI and MDRD equations in 1,130,472 adults from 25 general populations found that the CKD-EPI equation more accurately classified risks of mortality and end-stage renal disease18. However, studies comparing eGFR equations in patients with heart failure and acute coronary syndrome found that the CG equation was better able to predict the risks of mortality and bleeding complications16. Additionally, a recent study comparing the CG, MDRD, CKD-EPI, Mayo, and inulin clearance-based eGFR equations in 8,726 patients with acute coronary syndrome found that the Mayo equation was better at predicting mortality than the other four equations15. In our study, the Mayo equation was more accurate in predicting postoperative AKI than other four equations. It is not clear why Mayo equation, the rarely used equation nowadays, was slightly more accurate in predicting postoperative AKI than other equations. A possible explanation for the better predictive value of Mayo equation over other equations is that it tends to show relatively better eGFR values during reclassification. Methodologically, both NRI and IDI showed better predictability when calculating higher eGFR value in patients without AKI and when calculating lower eGFR values in patients with AKI. In this study cohort, the overall incidence of AKI was approximately 30%, and the values calculated were higher for patients without than with AKI, suggesting that the Mayo equation showed good predictive power. Another potential explanation is that differences in the population that is evaluated may contribute to which equation is better as a predictor. The MDRD equation was developed in patients with chronic kidney disease which may systematically underestimate GFR at higher values9. By contrast, the CKD-EPI and Mayo equations were developed in patients with normal renal function and chronic kidney disease resulting in better estimations of GFR in populations with preserved renal function or nonsignificant renal dysfunction23. Given that the majority of our cohorts had a high pre-operative eGFR in all five equations, the poorer predictive ability of the MDRD equation and the better predictive ability of the CKD-EPI and Mayo equations could be partly explained.The KDIGO clinical practice guidelines recommend using the CKD-EPI equation, based on sCr concentration, for the detection, determination of severity, and treatment of kidney disease4. Our results suggest that preoperative eGFR may serve not only to assess renal function, but also to estimate the risk of postoperative AKI. Indeed, regardless of how it is calculated, preoperative eGFR <60 ml/min/1.73 m2 is an important predictor of postoperative AKI. Thus, our results suggest that preoperative assessment of renal function using eGFR in patients undergoing cardiovascular surgery may be needed to identify those at high risk of AKI. Additionally, in order to improve short- and long-term outcomes, renal protective strategies such as discontinuation of nephrotoxic agents or prevention of major hemodynamic events should be implemented early in patients with preoperative eGFR <60 ml/min/1.73 m2.eGFR is a cheap, practical, and fairly reliable method to evaluate renal function in clinical practice25. Second, we did not assess outcomes other than AKI after cardiovascular surgery. Thus, we cannot exclude the possibility that differences in outcomes may have contributed to the predictive ability of the eGFR equations. In fact, the Mayo equation was not superior to the CG and CKD-EPI equations for severe form of AKI (KDIGO stage ≥2) prediction in this cohort. Third, this study did not include data on directly measured GFR values using gold standard methods or on markers of kidney damage, including albuminuria, thus precluding a definitive conclusion about the association between actual preoperative renal function and postoperative AKI. In addition, this study assessed the ability of calculated eGFRs to predict postoperative AKI, not their accuracy in determining GFR. Therefore, although the Mayo equation was most accurate in predicting postoperative AKI, this does not mean that it should be used to replace other equations to estimate renal function. Indeed, the Mayo equation has several drawbacks, such as difficulty in establishing its extensive generalization and use, as it was derived from relatively few patients, and has shown conflicting results in patients with diabetes28. Moreover, this equation has not been evaluated in Asian populations. Indeed, in daily clinical practice, the CKD-EPI and CG equations, rather than the Mayo equation, are most commonly used to calculate eGFR or creatinine clearance. Thus, despite the fact that the Mayo equation was slightly more accurate in terms of predicting the risk of postoperative AKI in patients undergoing cardiovascular surgery, it should be emphasized that our results do not imply that the Mayo equation should be used for GFR estimation and that this equation is not recommended by updated guidelines. Finally, this was a single centre study conducted almost exclusively in East Asian patients. Because all five equations tested in this study can be influenced by race and ethnicity, care should be taken when generalizing these results to centres with different patient profiles.This study has several limitations. First, because of the retrospective and observational nature of this study, despite including many variables in our analyses, other hidden or unknown factors including fluid therapy or hemodynamics during perioperative period may have influenced our resultsIn conclusion, preoperatively decreased eGFR, as determined using all five equations, was an independent predictor of postoperative AKI in patients undergoing cardiovascular surgery. Although the differences in predictive ability between equations were very small, the Mayo equation was slightly more accurate than the other equations in predicting AKI after cardiovascular surgery.29. Patients lacking information on preoperative sCr concentration; those who underwent preoperative dialysis, endovascular aortic repair surgery, or preoperative implantation of an intra-aortic balloon pump or ventricular assist device support; and patients with a history of organ transplantation or nephrectomy were excluded. This study was performed in agreement with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines30, and was approved by the Institutional Review Board of Asan Medical Centre (AMC IRB 2017-0336), which waived the requirement for informed consent.This retrospective cohort included all patients aged ≥20 years who underwent elective cardiovascular surgery at Asan Medical Centre, a tertiary hospital in Seoul, South Korea, between January 2010 and July 2015. Clinical information, including demographic data, comorbidities, laboratory data, medication use, perioperative management, and morbidity and mortality, was acquired from the Cardiovascular Surgery and Anaesthesia Database of Asan Medical Centre and from a retrospective review of its computerized patient record system ® 8000 modular analyser series; Roche Diagnostics GmbH, Vienna, Austria). The five equations used to calculate eGFR were as follows:5: eGFR = [(140 − Age) × Weight/(72 × sCr)] × CG equation6: eGFR = 186 × sCr−1.154 × Age−0.203 ×  × (1.210 if African-American)MDRD II equation7: eGFR = 175 × sCr−1.154 × Age−0.203 ×  × (1.210 if African-American)re-expressed MDRD II equation9: eGFR = 141 × minα × max−1.209 × 0.993age × 1.018  × 1.159 (if Black), where κ is 0.7 for females and 0.9 for males, α is −0.329 for females and −0.411 for males, min indicates the minimum of sCr/κ or 1, and max indicates the maximum of sCr/κ or 1.CKD-EPI equation8: eGFR = exp [1.911 + 5.249/sCr − 2.114/sCr2 − 0.00686 × Age − ], if sCr < 0.8 mg/dl then sCr = 0.8.Mayo equationeGFR was calculated using five different equations, based on a single preoperative determination of sCr concentration, measured closest to the time of surgery (but within 30 days of surgery), using the kinetic Jaffe method (Cobas0.425 × Height0.725 31. Units are weight (kg), height (m), age (year), and sCr (mg/dl).The CG equation was adjusted for body surface area. Body surface area is calculated by the following DuBois equation: body surface area = 0.20247 × Weight2 10.Preoperative eGFRs calculated by each equation were classified into the five categories of the KDIGO classification: ≥90, 89–60, 59–45, 44–30, and <30 ml/min/1.73 m32. Patients who met the KDIGO criteria were classified as “AKI”, whereas those who did not were classified as “no AKI”. Patients with AKI were staged according to the maximum KDIGO criteria, with stage 1 defined as sCr increases of ≥0.3 mg/dl or ≥1.5 times baseline; stage 2 as sCr increases 2.0–2.9 times baseline; and stage 3 as sCr increases ≥3.0 times baseline or ≥4.0 mg/dl, or the initiation of renal replacement therapy. AKI was evaluated based on the highest sCr concentration measured within 7 days after surgery. AKI was not diagnosed based on urine output due to incomplete recording and the effects of administered diuretics. Secondary outcomes included the incidence of KDIGO stage ≥2 after surgery.The primary study outcome was the incidence of postoperative AKI, defined by KDIGO criteria as a ≥0.3 mg/dl increase in sCr concentration within 48 h of surgery or a ≥1.5-fold increase in sCr from baseline within 7 days of surgerya priori power analysis conducted. Categorical variables were expressed as numbers and percentages, and continuous variables were expressed as mean ± standard deviation or median and interquartile range.All data manipulations and statistical analyses were performed using R version 3.1.2  and IBM SPSS Statistics 21.0 . The sample size corresponded to all patients included in the study, with no Correlations between eGFR calculated using the CKD-EPI equation and the four other equations were assessed by Pearson correlation analyses. To assess the agreement between the values of each equation, Bland-Altman analyses and ICCs was used for continuous variables and weighted kappa statistic with squared weights was used for categorical variables.P value <0.05 in univariate analyses were included in the multivariable analyses. Adjusted odds ratio and 95% CI for the logistic regression were calculated. The Hosmer and Lemeshow goodness-of-fit test was used to measure calibration, or the ability of the model to make unbiased estimates of outcome. For sensitivity analysis, the effects of additional adjustment for potential confounding variables of known risk factors for AKI were also explored.Multivariable logistic regression analyses were performed to evaluate the independent associations between the preoperative eGFR and postoperative renal outcomes. All predictive preoperative clinical and surgical variables in Table 33. The continuous NRI was determined to assess the ability of the different equations to improve risk prediction of postoperative renal outcomes. The IDI for each eGFR was also calculated. The IDI evaluates the difference between the integrated sensitivity gain and the integrated specificity loss due to the addition of eGFR to the prognostic model.Receiver operating characteristic analyses were performed, and the results were presented as adjusted AUCs with 95% CIs, to evaluate the discriminatory ability and the ability of preoperative eGFR, calculated using the five equations, to predict postoperative renal outcomes. The AUCs of the models were compared as describedP values were two-sided, and P values < 0.05 were considered statistically significant.All reported Supplementary material


The Beta3‐LVH trial will test the hypothesis that the βBeta3‐LVH is a randomized, placebo‐controlled, double‐blind, two‐armed, multicentre, European, parallel group study. A total of 296 patients will be randomly assigned to receive either mirabegron 50 mg daily or placebo over 12 months. The main inclusion criterion is the presence of LV hypertrophy, that is, increased LV mass index (LVMi) or increased wall thickening by echocardiography. The co‐primary endpoints are a change in LVMi by cardiac magnetic resonance imaging and a change in LV diastolic function (assessed by the E/e′ ratio). Secondary endpoints include mirabegron's effects on cardiac fibrosis, left atrial volume index, maximal exercise capacity, and laboratory markers. Two substudies will evaluate mirabegron's effect on endothelial function by pulse amplitude tonometry and brown fat activity by positron emission tomography using 17F‐fluorodeoxyglucose. Morbidity and mortality as well as safety aspects will also be assessed.Beta3‐LVH is the first large‐scale clinical trial to evaluate the effects of mirabegron on LVMi and diastolic function in patients with LVH. Beta3‐LVH will provide important information about the clinical course of this condition and may have significant impact on treatment strategies and future trials in these patients. The ageing population along with increasing rates of hypertension, diabetes, and obesity creates a growing pool of individuals at particularly high risk for HF development. The American College of Cardiology/American Heart Association HF staging model emphasizes identification of these asymptomatic at risk patients without (Stage A) or with (Stage B) evidence of cardiac remodelling to facilitate preventative action prior to progression to symptomatic HF (Stage C).Despite the growing incidence of HFpEF over the last 15 years, there are currently no proven effective therapies. Indeed, despite encouraging results from some ALDOsterone receptor blockade in Diastolic Heart Failure (ALDO‐DHF)3 adrenergic receptor (β3AR) activation to attenuate/ prevent cardiac remodelling. β3AR is expressed in several human tissues, including bladder muscle, and also cardiac and vascular tissues.3AR couples to the nitric oxide (NO)/cGMP pathway, resulting in coronary vasodilatation, and raises cGMP in human myocardium, with a resulting effect on cardiac myocytes that is antipathetic to classical β1–2AR positive inotropic effects.3AR decreases myocardial hypertrophy and fibrosis in response to neurohormonal or haemodynamic stresses, without compromising LV function.1–2AR, leading to receptor desensitization/internalization, loss of contractile/frequency reserve, adverse remodelling, calcium overload, and myocyte loss, we reasoned that activation of the functionally antipathetic β3AR would protect against such deleterious effects of chronic adrenergic stimulation. The trial will test the effect of mirabegron, a β3AR‐selective agonist that was developed and marketed for clinical use in overactive bladder disease, on LV mass and diastolic function.Notably, both PARAMOUNT and SOCRATES‐PRESERVED tested drugs known to increase intracellular (including cardiac myocyte) cyclic guanosine monophosphate (cGMP). Despite mitigated results in these two trials, their partial efficacy raises the interest for therapeutic strategies acting on the same pathway, albeit through different pharmacodynamic mechanisms. Accordingly, the Beta3‐LVH trial will provide a proof of concept in humans for the clinical efficacy of β3AR‐specific agonist mirabegron is superior to placebo in decreasing LV mass and/or improving diastolic function in patients with LV structural remodelling with or without symptoms of HF (NYHA Class ≤II).The primary objective of this trial is to determine whether the βBesides the primary effect of mirabegron on LV hypertrophy, its effect on other indicators for HFpEF, that is, cardiac fibrosis, LA volume index, maximal exercise capacity, and laboratory markers, will be analysed.Beta3‐LVH is a two‐armed, prospective, randomized, placebo‐controlled, double‐blind, multicentric European Phase IIb clinical trial. Participating trial centres will screen all consecutive outpatients and inpatients for entry inclusion and exclusion criteria. Patients who fulfil study entry criteria will be randomized to receive either mirabegron or placebo (randomization ratio 1:1).FigureOver a 36 month period, we plan to recruit a total of 296 patients from 10 clinical trial sites in eight European countries. A study flow chart is shown in Table2 for female; ≥115 g/m2 for male) or end‐diastolic wall thickness ≥13 mm in at least one wall segment, in the absence of genetic hypertrophic cardiomyopathy and significant valvular disease.The study inclusion and exclusion criteria are listed in It is anticipated that most of these patients will have systemic hypertension; if so, they will be required to be on stable therapy according to current guideline algorithms (including stable medication for at least 4 weeks before inclusion) and a well‐controlled hypertension. This patient population is known to be most likely to develop progressive hypertensive cardiac remodelling and/or HFpEF.Each patient will be treated with placebo/mirabegron over a period of 12 months. Thus, trial participation encompasses 52 weeks per patient. There will be no long‐time follow‐up. A safety phone call will be performed 4 weeks after a patient has stopped taking study medication.3AR signalling) are not allowed and listed as exclusion criterion. Other medications not allowed in the trial are listed in TableMirabegron will be tested against placebo in patients receiving conventional background therapy (e.g. for hypertension), which will be prescribed at the discretion of the treating physician. Bupranolol, propranolol, or nebivolol  measured at baseline and 6 and 12 months after randomization. Cardiac magnetic resonance (CMR) is performed locally according to a standardized protocol, and LV mass index will be measured in the central CMR core lab. Regression of LV hypertrophy, which is reflected by reduction in the LV mass index, is known to be associated with favourable clinical outcomes.Change in LV mass index  measured at baseline and 6 and 12 months after randomization. This parameter will be assessed by echocardiography, performed locally according to a standardized protocol, and will be measured in the central echo core lab. E/e′ is an established indicator of diastolic function and has been shown to reliably detect changes in functional performance.We define two equally ranked, primary endpoints, in order to assess both structural and functional aspects of LV remodelling Table:Change TableFurthermore, Beta3‐LVH will investigate several secondary endpoints, as well as the safety of the study medication Table.All participants will undergo a CMR scan performed on the same 1.5T or 3T magnetic resonance system in each centre. Given the variation of magnetic resonance systems between centres, acquisitions are performed with sequences preferred by each centre, subject to the quality checks by the central core lab to assure that the images are fit for purpose.Typically, after standardized planning, CMR will be acquired with an electrocardiogram‐gated, breath‐hold, two‐dimensional, steady‐state free precession cine sequence as previously described.Pre‐contrast T1 mapping images will be acquired at the basal, mid‐cavity, and apical levels. A bolus of gadolinium‐based contrast agent (0.15 mmol/kg) and a 10 mL saline flush will be administered via a cannula in the patient's arm. Post‐contrast T1 measurements, at the exact same three short‐axis cuts as the pre‐contrast T1 maps, will follow approximately 5, 15, and 30 min after injection of contrast, using an appropriate post‐contrast T1 mapping sequence.Late gadolinium enhancement images are acquired using the clinical sequences of choice by each centre, subject to suitability checks by the central core lab. For quantification of extracellular volume,All the exams will be analysed (in a blinded fashion) by the CMR core lab. Reproducibility will be investigated and reported.Two‐dimensional and M‐mode images will be acquired in accordance with current American Society of Echocardiography guidelines.2) testing will be performed on bicycle according to a ramp test protocol (10 W/min) after an initial work rate at 20 W. All tests will be symptom limited, with strong encouragement to achieve a respiratory exchange ratio that is >1.10. Criteria for discontinuation of the exercise test are defined as recommended by the European Society of Cardiology.2), and other cardiopulmonary variables such as VE/VCO2 slope will be acquired by averaging breath‐by‐breath measurements over 10 s intervals. Peak heart rate and workload will be recorded immediately upon the end of exercise. Peak VO2 is defined as the maximum value of the last three 10 s averages during exercise, and anaerobic threshold will be detected using the V‐slope method.2 assessments will be performed at inclusion and Month 12.A reference laboratory will act as the blinded core lab for all aspects related to cardiopulmonary exercise testing. A final standard operating procedure for cardiopulmonary exercise testing is issued by the reference laboratory. Aerobic capacity  will include all randomized patients with valid informed consent and at least one valid measurement of the primary endpoints (baseline and 6 or 12 months). A per‐protocol set will also analyse all patients belonging to the intention to treat without major violations of the study protocol.For primary and secondary endpoints, mean changes from baseline mean will be analysed using a repeated measurement linear mixed model without intercept containing the fixed, categorical effects of visit (baseline and 6 and 12 months), treatment (active drug/placebo), treatment by visit interaction, atrial fibrillation (yes/no), diabetes mellitus (yes/no), and a patient‐specific, visit random effect .Sensitivity analyses  will include (i) the earlier model restricted to the per protocol population and (ii) analysis of covariance with baseline values as covariates and randomization group as factor in all randomized patients with baseline and 12 months measurements and with imputation of missing values by last information carried forward.3 receptors may occur under β1AR blockade.Additional baseline sources of variability will be explored during the blinded review of the data, for example, age, gender, and NYHA class, and included in explorative multivariate analyses as appropriate. Exploratory subgroup analyses will include use of a beta‐blocker in the standard treatment (yes/no); this is to test the hypothesis that differential regulation of the expression and coupling of the β2 will be analysed along the same lines as the primary endpoints. All measurements will be performed centrally in central core labs (cardiac magnetic resonance imaging and echocardiography), and reproducibility will be investigated and reported. Adverse and serious adverse events will be compared by χ2 tests. Odds ratios with 95% confidence intervals will be provided. All analyses will be pre‐specified in a detailed statistical analysis plan, which will be finalized before unblinding the data.All CMR and echo secondary endpoints as well as peak VO′, because reliable and consistent planning data for this parameter are available in the literature.′ decreases during follow‐up in treated patients, while it increases in control patients, leading to mean differences of the baseline‐to‐follow‐up changes of up to 2 between control and treatment group, with a typical baseline mean of about 12.We investigate two equally ranked, primary endpoints. We conservatively plan sample sizes for a significance level of 2.5%. We base our sample size calculation on the parameter assessing diastolic function, E/et‐test (NQuery Advisor® 7.0).In our trial, we aim to detect a difference of 1.2 between active drug and placebo group. This difference roughly corresponds to 5 points on the SF‐36 physical function scale,et al. 1% in 6 monthsBecause there are no data on LVMI in our specific target population, we cannot fully specify a planning scenario. However, with 272 patients, an effect size in the magnitude of 0.4 is detectable with a power of at least 85% at a significance level of 2.5%. In previous trials such as ALDO‐DHFThe Beta3‐LVH is a Phase IIb trial and investigates endpoints related to cardiac remodelling. The trial does not address hard clinical endpoints and is not designed nor powered to detect differences in long‐term clinical outcome. However, clinical events are collected .Two substudies will also assess the effect of mirabegron on endothelial function by pulse amplitude tonometry, coupled to measurements of nitrosylated haemoglobin and brown fat activity by positron emission tomography–computed tomography using 17F‐fluorodeoxyglucose. For each project, a separate protocol is provided . European (Voluntary Harmonization Procedure), national, and locally appointed ethics committees have approved the research protocol, and informed consent will have been obtained from all the study subjects.The investigation conforms with the principles outlined in the The principal investigator, the study coordinator, and the Clinical Trial Center Leipzig are responsible for all aspects of the study protocol and amendments. The Steering Committee guarantees scientific oversight and consulting in all study‐related aspects. A Data Safety and Monitoring Board operates independently of the other study committees and of the sponsor. The Data Safety and Monitoring Board will review the progress of the trial and, under blinded conditions, control the safety of the patients enrolled in Beta3‐LVH. Names and affiliations of all participants involved in Beta3‐LVH are listed in the Appendix.3AR activation to attenuate/prevent cardiac remodelling.A major contributor to HFpEF is myocardial remodelling, for example, hypertrophy and fibrosis, as well as cellular functional/structural modifications leading to impairment in functional properties (including relaxation) and LV distensibility. Unfortunately, despite the growing incidence of HFpEF over the last 15 years, there are currently no evidence‐based treatment strategies that will change its evolution. This puts more emphasis on new strategies and targets that may prevent the progression of remodelling towards the development of LV dysfunction and symptomatic HFpEF. This trial is designed to assess the clinical efficacy of a novel therapeutic concept: β3AR to the NO synthase/cGMP pathway, with an expected protection from myocardial remodellingFigure3AR; these mice (and their littermate controls) were submitted to a number of interventions all leading to myocardial stress . The results uniformly showed protection of the transgenic mice from the development of pathological remodelling contrary to the wild‐type controls.3AR may then be an attractive target to prevent adverse remodelling in the face of chronic adrenergic stimulation, all the more because it is distinctively resistant to homologous desensitization (rodent and human β3ARs lack consensus sequences for phosphorylation by βARK or PKA) and retains coupling to downstream signalling in the pathological heart, as demonstrated in human diseased myocardium ex vivo.1–2AR, its expression increases in the diseased myocardium. On the basis of observations in transgenic mice, one can assume that this β3AR upregulation is a protective mechanism in the face of myocardial stress. However, as the β3AR is typically activated by higher catecholamine concentrations (than β1/2AR), it is possible that this protective pathway is not maximally recruited even in circumstances of pathophysiological adrenergic activation. This would leave a therapeutic margin for additional activation by a potent and specific β3AR agonist, such as mirabegron.The underlying mechanistic concept is built on the preclinical demonstration of the coupling of β3AR agonists would be limited by cardiodepressive effects, following the demonstration that, ex vivo, cardiac β3AR stimulation was associated with negative inotropy in human ventricular samples. However, this was only observed at high concentrations of agonists that exceed clinically relevant plasma levels. That administration of BRL37344, a β3AR agonist, in large animal models of HF does not translate to decreased cardiac performance in vivo,Based on older evidence,3AR also mediate antioxidant effects3AR was also shown to attenuate the oxidative inactivation of the Na‐K‐ATPase pump in animal models, thereby reducing Na overload in the failing heart; this may also contribute to correct diastolic dysfunction.3AR activation on coronary microvascular endothelial cells, which would contribute paracrine effects on LV relaxation and increase coronary perfusion, thereby avoiding further ischaemic damage.Importantly, β3AR may provide a more regulated and targeted activation of cGMP downstream pathways than stimulators or activators of the soluble guanylyl cyclase, which need careful dose finding to avoid detrimental systemic hypotension. Mirabegron was also well tolerated in combination with β1–2AR‐blockers in the BEAT‐HF trial, an association also allowed in the present Beta3‐LVH trial; such combination would not only avoid off‐target agonism at β1–2AR but may even reinforce the effects on downstream NO synthase/cGMP signalling.1–2–3AR‐blockers, such as propranolol or bupranolol, are not allowed, as well as nebivolol which, aside from specific β1AR blockade, is also endowed with β3AR agonist activity. Note that commonly used β1–2AR‐blockers previously tested in RCT of HF  exhibit at least 100‐fold less affinity for β3AR and so would leave it unaffected.3AR in extracardiac targets, such as beige/brown fat, with ensuing improvements in peripheral metabolism and insulin sensitivity, justifying our substudies on endothelial function, metabolic parameters, and brown fat activation by fluorodeoxyglucose–positron emission tomography.Notably, activating βClinical data from the mirabegron clinical studies in overactive bladder disease did not raise major concerns in terms of safety and tolerability (see the 3AR agonist in chronic HF (BEAT‐HF) was recently conducted in 70 patients with NYHA Classes II and III HF and LVEF <40% at screening echocardiography.3AR stimulation by mirabegron increased LVEF in patients with severe HF. In that study, treatment with mirabegron appeared safe and did not cause prolongation of the QT interval in the entire cohort or in the subgroup with LVEF <40%. The exploratory data indicate that mirabegron increases contractility in the state of more dilated left ventricles, rather than induction of remodelling with reduced diastolic dimensions. However, LV mass was not reported.The‐first‐in‐man randomized trial of a β3 adrenergic receptor agonist on LV mass and diastolic function in patients with structural heart disease in order to prevent progression to more advanced stages. This trial will provide important information on therapeutic strategies in these patients.Heart failure with preserved ejection fraction is a common, disabling, and costly disease. However, no established therapeutic strategies exist. Beta3‐LVH is the first clinical trial to assess the effect of mirabegron, a βJ.‐L.B. reports consultancy fees from Sanofi, Amgen, and Merck. J.‐N.T. has received research grants from Novartis, Carmat, and Abbott and has consulted for Abbott, Amgen, Bayer, Carmat, QuantumGenomics, Novartis, Vifor Pharma, and Resmed. M.S. reports consultancy fees from Novartis, Bayer, Merk Sharpe & Dohme, and Abbot Vascular. S.A. received consultancy for Bayer, Boehringer Ingelheim, Novartis, Servier, and Vifor. D.B. reports consultancy fees from Novartis, Vifor Pharma, and Genzyme‐Sanofi. F.P. reports consultancy from Bayer, Boehringher Ingelheim, Novartis, Servier, and Vifor Pharma. The remaining authors report no conflicts of interest.This work was funded by the European Union Horizon 2020 grant (UE LSHM‐CT‐05‐018833) to J.‐L.B. B.C. is supported by the British Heart Foundation (RG/11/15/29375), the National Institute for Health Research Biomedical Research Centre, Oxford, the European Union's Horizon 2020 research and innovation programme (grant number 633196[CATCH ME]), and the British Heart Foundation Centre of Research Excellence, Oxford (grant number RE/08/004). S.P. and S.N. are supported by the NIHR Biomedical Research Centre, Oxford. They also acknowledge the support from the British Heart Foundation Centre of Research Excellence, Oxford, UK (RE/08/004 to R.W.). A.‐C.P. is sponsored by a Post‐doctorate Clinical Master Specialist of the Fondation Nationale de la Recherche Scientifique of the Belgian Government (FRSM: SPD 10844948).Ms Mary Norris and Ms Hanan Lamlum, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, John Radcliffe Hospital, OxfordProfessor V. M. Ferreira, Ms Jane M. Francis, Ms Henrike Puchta, and Ms Elena Lukaschuk, Oxford Centre for Clinical Magnetic Resonance Research (OCMR), Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of OxfordAna G. Almeida, MD, PhD, Inês Gonçalves, MD, Susana Gonçalves, MSc, Joana Rigueira, MD, and Luís B. Rosário, MD, PhD, Cardiology Department, Hospital de Santa Maria, CHLN, CCUL, Faculdade de Medicina da Universidade de Lisboa, PortugalInês Cabrita, PhD, and Susana Silva, MSc, Association for Research and Development of Lisbon Medical School (AIDFM), Cardiovascular Centre (CCUL), Universidade de Lisboa, PortugalData S1. Full description of biometric aspects.Click here for additional data file.


A total of 48426 eligible subjects were categorized based on the different definitions. After adjusting for all covariables, participants with O + F + P combination were more likely associated with the presence of DM. Participants with O + W combination were more associated with the presence of HTN than others. Participants with O + W + F + P had higher risk for the presence of MetS than others. The study addressed the associations between different obesity phenotypes and DM and HTN in the adult population. Better understanding the pathophysiological mechanisms underlined individual vulnerability and progression of cardiometabolic insults.The prevalence of obesity was increasing and became a growing problem worldwide. Obesity increased the risk of developing metabolic abnormalities and was associated adverse health outcomes. Our aim was to examine the associations among different combinations of obesity phenotypes (high body mass index > 27 kg/m Recently, the trend of obesity was reported to be accelerating in some developed countries2. It had become a growing public health issue not only in kinds of comorbidities but also in quality of life in Taiwan3. Obesity was proposed to be related to several adverse health outcomes such as metabolic syndrome (MetS), diabetes mellitus (DM), hypertension (HTN) and increased morbidity and mortality4. Numerous studies had proposed the associations between different obesity indices with metabolic disorders. As a traditional and commonly used indicator, body mass index (BMI) was reported to be associated with MetS and the risks of DM5. Abdominal obesity, caused by visceral fat accumulation, was significantly associated with insulin resistance6. Waist circumference (WC) was considered as a better index to predict MetS than others7.The epidemiology of obesity was prevalent and increasing dramatically worldwide in the past three decades9. In a previous study, high percentage body fat (PBF) was associated with a high cardiometabolic risks in Korean population10. Besides, PBF had association with all-cause and cardiovascular mortality, high fat mass had higher mortality risk than BMI12. Therefore, it may be crucial to determine the clinical usefulness of measuring PBF to evaluate the obesity-associated metabolic dysfunction. The aim of our study was to detemine whether the different obesity phenotypes were closely related to glucose intolerance and HTN.Body fat distribution was reported to have a significant association with the development of impaired glucose metabolism and MetS2 (O), high waist circumference  (W), fatty liver (F), percentage body fat in top 40% (P). There were 1507, 3082, 3997, and 247 participants in O, W, F, and P phenotype, respectively.All demographic information of study participants was shown in Table Tables After fully adjusting for pertinent covariables, F was significantly associated with the presence of DM with odds ratios (ORs) of 2.85 : 1.93–4.21). Other combinations of obesity phenotypes including O + W, W + F, W + P, P + F, O + W, O + W + P, O + F + P, W + F + P, and O + W + F + P also had significant association with the presence of DM (P < 0.05). O + F + P had risk for the presence of DM with ORs of 8.07 (95% CI: 3.23–20.16). W was associated with the presence of HTN with ORs of 1.44 (95% CI: 1.07–1.93). O + W, O + F, W + F, W + P, P + F, O + W + F, O + W + P, W + F + P, and O + W + F + P also had significant relationship with the presence of HTN. O + W had significantly higher risk of the presence of HTN with ORs of 5.43 (95% CI: 3.43–8.60) than others. W and F were associated with the presence of MetS with ORs of 8.57 (95% CI: 6.18–11.88) and 2.93 (95% CI: 2.22–3.86). O + W, O + F, W + F, W + P, P + F, O + W + F, O + W + P, O + F + P, W + F + P, and O + W + F + P were significantly associated with the presence of MetS (P < 0.05). O + W + F + P had higher risk for the presence of MetS than other combinations with odd ratios (ORs) of 38.26 (95% CI: 29.07–50.36).In our study, the primary finding was that different obesity phenotypes were significantly associated with the presence of DM and HTN. The presence of DM was more likely associated with F phenotype than others. Those with W phenotype had closer relationship with HTN. Furthermore, subjects with different combinations of obesity phenotypes had higher risks of cardiometabolic diseases than those with single obesity phenotype. The combination of obesity phenotypes seems to have increased risk of obese individuals on the process for developing adverse health outcomes.13. Cardiometabolic risk factors such as elevated blood pressure, dyslipidemia and hyperglycemia are substantially related to high PBF10. In two large scale population-based surveys, the high PBF group had higher risks of cardiovascular diseases than low PBF group among normal-weight males14. In an Italian study, subjects with high PBF had higher inflammatory biomarkers than control group, suggesting that high PBF might be an important indicator for MetS15. Obese subjects with higher PBF have higher insulin resistance and pro-inflammatory cytokines than those with normal BMI16. Insulin resistance plays an important role on the development of MetS caused by systemic inflammation with elevated circulating levels of CRP and TNF-α18.The clinical usefulness of PBF on MetS risks was addressed based on a nationally representative sample19. Rodriguez demonstrated that body fat distribution was a strong influence on the development of glucose intolerance and DM8. Previous studies had addressed the important roles for abdominal adiposity and specifically visceral fat accumulation on the development of prediabetes and DM21. However, our findings revealed that general obesity was considered as a better phenotype for predicting the risks of DM for both gender groups. In a cross-sectional study of 4828 participants concerning the prediabetes and DM development, PBF may be more imperative than BMI and WC22. Shea et al. indicated that participants in the highest tertile of PBF had high risks of developing cardiometabolic disease compared to those with low PBF23. Excess body fat was associated with numerous comorbidities included HTN, insulin resistance, dyslipidemia and systemic inflammation. In patients with and without DM, the leptin-to-adiponectin ratio was a useful indicator to assess insulin resistance and atherosclerotic risks25.Adiposity was a common risk factor for DM and cardiometabolic diseases26. Numerous evidences had supported a strong relationship between NAFLD and diabetes risk that subjects would have approximately 5-fold risks of developing DM if they had NAFLD28. The presence of NAFLD and prediabetes or DM was associated with significant hepatic insulin resistance compared with subjects matched for adiposity without a fatty liver29. The plausible mechanism for NAFLD associated with prediabetes and DM in obesity was dysfunctional adipose tissue that promoted insulin resistance and pancreatic β-cell dysfunction31. Lopez and his colleagues demonstrated that the presence of insulin resistance of adipose tissue deteriorated the progression of glucose metabolism by multiple pathways that include subclinical inflammation and lipotoxicity29.Non-alcoholic fatty liver disease (NAFLD) was highly prevalent in patients with DM32. Central type body fat distribution was more closely associated with renal-related hypertension than peripheral type obesity33. Previous studies had suggested that obesity-associated hypertension was characterized by an endothelial dysfunction34. The relationship between obesity and endothelial dysfunction might be through several pathways such as insulin resistance, inflammation and free fatty acid metabolisms35. Production of nitric oxide from oxidative stress might contribute to endothelial dysfunction in the pathophysiology of obesity. Hypoxia related adipose tissue inflammation secretes many reactive oxygen species and cytokines, leading to deterioration of nitric oxide signaling pathways in the endothelial cells36. Elevated endothelin-1 activity also played an important role in obesity- associated endothelial dysfunction37.Increased WC, as defined as central obesity phenotypes in our study, was associated with elevated blood pressureThere were several potential limitations among our study. First, it was a cross-sectional design that casual inference was no assessible between obesity phenotypes and adverse outcomes. A longitudinal survey was suggested to be examined in further studies. Second, the study sample was obtained from health examinations in a single medical center. Limited ethnicity diversity in the participants might not reflect the association of obesity phenotypes and cardiometabolic diseases in racial difference. Third, the measurement for PBF in the health check-up was used by BIA, but not DEXA, a standard measurement for body composition with higher accuracy. Last, the diagnosis of fatty liver was determined by abdominal sonography, bias of image interpretation caused by physicians might occur. Despite the limitations mentioned above, our study had some advantages. A relatively large population-based sample included 20665 subjects was analyzed compared to others examined in small population. Besides, multivariable adjustment consisted with potential confounders and lifestyles such as smoking and alcoholic assumption was conducted in the statistical analysis.In summary, our study emphasized the important characteristics of these four obesity phenotypes and various combinations for different clinical implications. Identifying the distinct obesity phenotypes associated with DM and HTN in general population has implications for the stratification of cardiometabolic risk. Better understanding the pathophysiological mechanisms underlined individual vulnerability and progression of cardiometabolic insults. Therefore, association between body fat distribution with metabolic alternation and prolonged follow-up research for predicting risks of incident cardiometabolic diseases were necessary.2 according to the criteria of the Department of Health in Taiwan4; W was defined as subjects with high WC ; F was defined as subjects with fatty liver diagnosed by abdominal sonography. P was categorized into subjects along with PBF in top 40% of the entire obesity population.The retrospective cross-sectional was performed from health examinations in Tri-Service General Hospital from 2010 to 2016. There were 69226 participants received comprehensive examinations enrolling in the health check-up during the period. According to the step-by-step orders of flow chart shown in Fig. The protocol was approved by the Tri-Service General Hospital Institutional Review Board based on the Declaration of Helsinki. Written informed consent was obtained from participants prior to the study. During the entire study process, characteristics of participants correlated with individual identification were eliminated and remained anonymously.38.PBF was the indicator used in the study and was measured by BIA , an effective and validated method that was widely used for assessing body composition40.MetS was diagnosed when having ≥3 of the following features: (1) large waist circumference (WC): a waistline that measures at least 80 centimeters for women and 90 centimeters for men; (2) high triglyceride levels (TG): higher than 150 mg/dL; (3) reduced high-density lipoprotein cholesterol (HDL-C) levels: less than 50 mg/dL in women and 40 mg/dL in men; (4) increased blood pressure (BP): 130/85 mmHg or higher; and (5) elevated fasting plasma glucose (FPG): 100 mg/dL or higher based on the Harmonized criteria for MetS in 2009 with the Asian cut-off for WC41.As reported by the American Diabetes Association criteria, subjects with one of the following components were diagnosed of T2DM: (1) fasting plasma glucose ≥126 mg/dL (2) hemoglobin A1c test ≥6.5% (3) random plasma glucose ≥200 mg/dL (4) past history of diabetes status, or use of antidiabetic agents42.Participants who had HTN was diagnosed by the guidelines of the Taiwan Society of Cardiology and the Taiwan Hypertension Society for the management of hypertension (1) blood pressure was higher than 140/90 mmHg (2) subjects were taking antihypertensive agents2). WC was measured at the mid-level between the iliac crest and the lower border of the 12th rib. Biochemistry data was collected by drawing blood samples from subjects after fasting for at least 8 hours. Serum profiles included total cholesterol (TC), uric acid (UA), creatinine (Cr), aspartate aminotransferase (AST), albumin, and C-reactive protein (CRP) were analyzed by using standard methods.BMI was calculated by a formula that the weight of the subject in kilograms divided by the square of the height in meters  for Windows. The differences among these obesity phenotypes in terms of demographic information and biochemistry data were examined by analysis of variance and chi-square test. A two-sided