There is a need for continued drug development for nonalcoholic steatohepatitis (NASH). Bergamot is a plant whose fruit juice is enriched with flavonoids and phenolic compounds which improves dyslipidemia and markers of systemic inflammation in patients with Metabolic Syndrome. The aim of this study was to perform a preclinical "proof of concept" study of Bergamot polyphenolic formulation (BPF99) for the treatment of NASH. A disease reversal study was performed in the diet-induced animal model of NAFLD (DIAMOND). Groups of 8 weeks old mice were randomly assigned to receive chow diet, high fat diet with sugar in drinking water (Western diet-WD). Mice on WD were further randomized to continue on WD gavaged with vehicle or continue on WD with additional gavage of BPF99 (50 mg/kg) after 16 weeks of diet. Mice were euthanized after 11 additional weeks. The primary endpoint was resolution of NASH. Secondary endpoints included changes in individual histological features, body weight, liver enzymes, dyslipidemia, markers of oxidative stress and molecular markers of disease activity and fibrosis. The results showed that BPF99 reduced ALT (mean 71.6 vs 44.6 IU/l, p < 0.01), triglycerides (38.8 vs 28.1 mg/dl, p < 0.05), LDL-C (39.2 vs 23.7 mg/dl, p < 0.001). It significantly improved NASH resolution (p < 0.001) and the SAF scores (p < 0.05) while the NAS improvement approached significance. BPF99 reduced markers of oxidative stress, along with reduced JNK and p38 MAP kinase activity. BPF99 did not reduce the number of mice with fibrosis but improved collagen proportional area (p < 0.04) and procollagen I and III expression. Collectively our results showed that BPF99 resolves NASH and ameliorates key histological and pathophysiological features of NASH along with improvement in ALT and dyslipidemia in the DIAMOND mice.

Photoageing represents the addition of extrinsic chronic ultraviolet radiation induced damage on intrinsic aging and accounts for most age-associated changes in skin appearance. The skin contains numerous endogenous antioxidants to help provide protection from reactive oxidative species generated during normal cellular metabolism. However, overexposure to UV radiation can lead to a significant reduction in the antioxidant supply accompanied by an increase of proinflammatory cytokines leading to accelerated oxidative damage. Photochemoprevention with botanical antioxidants is a strategy shown to be capable of blunting the damaging effects of ultraviolet radiation.Together with antioxidant properties, dietary flavonoids and their metabolites may modulate basic cellular signal transduction pathways leading to anti-proliferative, anti-aging and immune modulating responses. Here, we describe the effects of bergamot polyphenolic fraction (38% BPF), a highly concentrated extract of flavonoids derived from the citrus bergamot fruit, able to inhibit UVB mediated decrease in cell viability, overexpression of inflammatory cytokine biomarker interleukin-1beta (IL-1β), telomere shortening and decreases in telomerase activity.

Nonalcoholic fatty liver disease (NAFLD) is the most common liver disease in industrialized countries. Defective autophagy of lipid droplets (LDs) in hepatocytes, also known as lipophagy, has recently been identified as a possible pathophysiological mechanism of NAFLD. Experimental and epidemiological evidence suggests that dietary polyphenols may prevent NAFLD. To address this hypothesis and analyze the underlying mechanisms, we supplemented bergamot polyphenol fraction (BPF) to cafeteria (CAF) diet-fed rats, a good model for pediatric metabolic syndrome and NAFLD. BPF treatment (50 mg/kg/day supplemented with drinking water, 3 months) potently counteracted the pathogenic increase of serum triglycerides and had moderate effects on blood glucose and obesity in this animal model. Importantly, BPF strongly reduced hepatic steatosis as documented by a significant decrease in total lipid content (-41.3% ± 12% S.E.M.), ultrasound examination and histological analysis of liver sections. The morphometric analysis of oil-red stained sections confirmed a dramatic reduction in LDs parameters such as total LD area (48.5% ± 15% S.E.M.) in hepatocytes from CAF+BPF rats. BPF-treated livers showed increased levels of LC3 and Beclin 1 and reduction of SQSTM1/p62, suggesting autophagy stimulation. Consistent with BPF stimulation of lipophagy, higher levels of LC3II were found in the LD subcellular fractions of BPF-expose livers. This study demonstrates that the liver and its lipid metabolism are the main targets of bergamot flavonoids, supporting the concept that supplementation of BPF is an effective strategy to prevent NAFLD.

Introduction: To determine whether bergamot polyphenolic fraction (BPF), a proprietary extract from a unique antioxidant-rich citrus fruit (bergamot) known to be beneficial in subjects with metabolic syndrome and dyslipidemias, could significantly improve hepatic structure and function in patients with both metabolic syndrome and non-alcoholic fatty liver disease (NAFLD). Methods: One hundred seven patients who met the NCEP-ATP III criteria for metabolic syndrome and had ultrasonic evidence of severe NAFLD (hepato-renal index 2.5-3.5) after exclusion of alcohol, viral, and immune disorders were admitted to the study. Before and after 120 days of BPF 650 mg twice a day, all patients had full lipid analysis including lipoprotein fractionation (NMR), fasting glucose, ALT, AST, steato test, γ-GT, TNF-α (ELISA), CRP, and ultrasonographic hepatorenal tests. Results: Hepatic tests include: steato test (baseline: 0.74 ± 0.12; after 120 days BPF: 0.44 ± 0.09), ALT (U/L) (baseline: 54 ± 5.4; after 120 days BPF: 36 ± 5.3), AST (U/L) (baseline: 52. ± 6.4; after 120 days BPF: 41 ± 5.2), γ-GT (IU/L) (baseline: 38 ± 5.2; after 120 days BPF: 29.33 ± 1.1), hepatorenal index (baseline: 2.8 ± 0.4; after 120 days BPF: 1.5 ± 0.5). Inflammatory tests include: Hs-CRP (mcg/dL) (baseline: 1.2 + 0.8; after 120 days BPF: 0.94 + 0.6) and TNF-α (pg/mL) (baseline: 14.4 ± 1.9; after 120 days BPF: 10.7 ± 1.7). Metabolic tests include: fasting glucose (mg/mL) (baseline: 118 ± 1.4; after 120 days BPF: 98 ± 0.8). All values p<0.05. Standard lipid levels (TC, LDL, HDL, TG, IDL, VLDL) were significantly improved as were the size, density and number of all atherogenic lipoprotein particles (e.g., small dense LDL, NMR, LDL particle number). Conclusion: Bergamot polyphenolic extract (BPF) derived from the Calabrian bergamot citrus fruit is a potent anti-oxidant, AMP kinase activator, and HMG-CoA reductase inhibitor that has been proven to address all components of the metabolic syndrome. In a group of 107 patients with confirmed NAFLD and metabolic syndrome, BPF given twice per day before meals significantly improved all measured biochemical and ultrasonographic characteristics of both NAFLD and metabolic syndrome in 120 days without reported side effects. There was a striking improvement in hepatic function (biochemical) and structure (echogenic visual loss of hepatic fat) accompanied by lower levels of inflammation. As there is a dearth of proven therapeutic options for NAFLD and metabolic syndrome, this study suggests that BPF may be a safe and important therapeutic option for these conditions. Disclosure - James E. Ehrlich--consultant for Nat Health Solutions, distributor of BergaMet. Ross Walker--consultant for Nat Health Solutions. Vincenzo Mollace--consultant for Nat Health Solutions.Figure 1

PURPOSETo investigate the effect of a radioprotective oral agent containing a formulation of antioxidants and glutathione-elevating compounds on the extent of x-ray-induced γ-H2AX foci formation.MATERIALS AND METHODSThe study was approved by local ethics committee and informed consent was obtained from each subject. In vitro experiments with blood lymphocytes of 25 healthy volunteers were performed without antioxidants and with antioxidants added either before or immediately after irradiation (10 mGy). For in vivo/in vitro tests, blood samples were obtained before, 15, 30, and 60 minutes (n=17) after, and 2, 3, and 5 hours (n=11) after oral ingestion of antioxidant pills and were irradiated (10 mGy). DNA double-strand breaks (DSBs) were quantified in isolated lymphocytes 5 minutes (in vitro and in vivo/in vitro) and 15 minutes (in vitro) after irradiation by enumerating γ-H2AX foci. To validate the data, additional in vitro experiments with use of 53BP1 as another independent marker for DSBs were performed. Nonirradiated samples served as controls. Statistical analyses were performed by using Wilcoxon rank-sum tests (in vitro), repeated-measures test, and Dunnett test (in vivo/in vitro).RESULTSIn the in vitro experiments, 15-minute preincubation with antioxidants significantly reduced mean γ-H2AX foci levels by 23% (P<.0001), whereas addition of antioxidants immediately after irradiation did not lead to a reduction of x-ray-induced foci (P=.6905). Mean 53BP1 foci were also reduced by preincubation with the radioprotectant. In the in vivo/in vitro tests, oral pretreatment with antioxidants also led to a significant reduction of γ-H2AX foci formation; administration 60 minutes before irradiation resulted in a mean foci reduction of 58% (P<.0001).CONCLUSIONThe tested formulation of antioxidants significantly reduced formation of γ-H2AX and 53BP1 foci after irradiation at a radiologic radiation dose typical for computed tomographic imaging; administration 60 minutes prior to irradiation seems to be appropriate and leads to a significant reduction in foci.

BACKGROUND:Lipoprotein-associated phospholipase A₂ (Lp-PLA₂) is a lipoprotein-associated enzyme that cleaves oxidized phosphatidylcholines, generating pro-atherosclerotic lysophosphatidylcholine and oxidized free fatty acids. Lp-PLA₂ is independently associated with cardiovascular disease (CVD) in a variety of populations. Coronary calcium is a measure of subclinical CVD, and progression of coronary calcification predicts future CVD events. In type 1 diabetes there is an increase in coronary calcium and CVD despite a favorable lipid profile. Levels of Lp-PLA₂ in type 1 diabetes are not known, nor is the relationship between Lp-PLA₂ and progression of coronary calcification.METHODS:The Coronary Artery Calcification in Type 1 Diabetes study measured coronary calcium by electron-beam computed tomography twice over a 2.6 ± 0.3-year interval. Lp-PLA₂ mass and activity were measured at baseline (n = 1,097 subjects, 506 with and 591 without type 1 diabetes).RESULTS:In type 1 diabetes Lp-PLA₂ mass was marginally higher (285 ± 79 vs. 278 ± 78 ng/mL, P = 0.1), and Lp-PLA₂ activity was significantly lower (137 ± 30 vs. 146 ± 36 nmol/min/mL, P < 0.0001) than in those without diabetes. There was a greater proportion of those with progression of coronary calcification in type 1 diabetes compared with those without diabetes (24% vs. 10%, P < 0.0001). Lp-PLA₂ activity was independently associated with progression of coronary calcification in multivariate analysis (4th quartile verses bottom three quartiles, odds ratio = 1.77 [1.08-2.91], P = 0.02). LpPLA₂ mass was not significantly associated with progression of coronary calcification in this cohort (P = 0.09).CONCLUSIONS:Lp-PLA₂ activity predicts progression of subclinical atherosclerosis in individuals with and without type 1 diabetes.

AIM:Reduced heart rate variability (HRV) is a manifestation of cardiac autonomic neuropathy, a known complication of type 1 diabetes (T1D). We evaluated whether HRV predicted coronary artery calcium (CAC) progression.METHODS:Subjects between 19 and 56 years of age with T1D or those without diabetes from the Coronary Artery Calcification in Type 1 Diabetes study underwent supine deep breathing 12-lead electrocardiograms. The SD of consecutive RR intervals was used as a measure of HRV. CAC was measured at two visits 6.0 ± 0.5 years apart. Progression of CAC was defined as an increase in square root transformed CAC volume of ≥ 2.5 mm(3), excluding patients who had cardiovascular events during follow-up.RESULTS:Reduced HRV was associated with older age, higher hemoglobin A1c, elevated albuminuria, CAC volume at baseline, and increased fibrinogen. Higher HRV at baseline was associated with lower likelihood CAC progression (odds ratio = 0.71, 95% confidence interval 0.56-0.90, P = 0.005), and the adjustment for known cardiovascular risk factors did not change this strong association, including adjustment for inflammatory markers.CONCLUSIONS:Reduced HRV predicted progression of CAC in adults with and without T1D. This association further supports the participation of autonomic neuropathy in the atherosclerosis process.

Hemodialysis InternationalVolume 13, Issue 3 p. 360-362 A randomized double-blind pilot study of serum phosphorus normalization in chronic kidney disease: A new paradigm for clinical outcomes studies in nephrology Geoffrey A. BLOCK, Geoffrey A. BLOCK Denver Nephrologists, PC, Denver, Colorado, USASearch for more papers by this authorMartha S. PERSKY, Martha S. PERSKY Denver Nephrologists, PC, Denver, Colorado, USASearch for more papers by this authorMarkus KETTELER, Markus KETTELER Nephrologische Klinik, Klinikum Coburg, Coburg, GermanySearch for more papers by this authorBryan KESTENBAUM, Bryan KESTENBAUM University of Washington, Seattle, Washington, USASearch for more papers by this authorRavi THADHANI, Ravi THADHANI Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USASearch for more papers by this authorLaura KOOIENGA, Laura KOOIENGA Denver Nephrologists, PC, Denver, Colorado, USASearch for more papers by this authorDavid SPIEGEL, David SPIEGEL University of Colorado Denver HSC, Denver, Colorado, USASearch for more papers by this authorJohn ASPLIN, John ASPLIN Litholink Corporation, Labcorp Inc.Search for more papers by this authorJames EHRLICH, James EHRLICH University of Colorado Denver HSC, Denver, Colorado, USASearch for more papers by this authorVincent DENNIS, Vincent DENNIS Ambulatory Services of America, Brentwood, Tennessee, USASearch for more papers by this authorAllen NISSENSON, Allen NISSENSON David Geffen School of Medicine at UCLA, Davita Inc.Search for more papers by this authorGlenn M. CHERTOW, Glenn M. CHERTOW Stanford University, Palo Alto, California, USASearch for more papers by this authorDavid C. WHEELER, David C. WHEELER Centre for Nephrology, Royal Free Campus, University College London Medical School, London, UK.Search for more papers by this author Geoffrey A. BLOCK, Geoffrey A. BLOCK Denver Nephrologists, PC, Denver, Colorado, USASearch for more papers by this authorMartha S. PERSKY, Martha S. PERSKY Denver Nephrologists, PC, Denver, Colorado, USASearch for more papers by this authorMarkus KETTELER, Markus KETTELER Nephrologische Klinik, Klinikum Coburg, Coburg, GermanySearch for more papers by this authorBryan KESTENBAUM, Bryan KESTENBAUM University of Washington, Seattle, Washington, USASearch for more papers by this authorRavi THADHANI, Ravi THADHANI Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USASearch for more papers by this authorLaura KOOIENGA, Laura KOOIENGA Denver Nephrologists, PC, Denver, Colorado, USASearch for more papers by this authorDavid SPIEGEL, David SPIEGEL University of Colorado Denver HSC, Denver, Colorado, USASearch for more papers by this authorJohn ASPLIN, John ASPLIN Litholink Corporation, Labcorp Inc.Search for more papers by this authorJames EHRLICH, James EHRLICH University of Colorado Denver HSC, Denver, Colorado, USASearch for more papers by this authorVincent DENNIS, Vincent DENNIS Ambulatory Services of America, Brentwood, Tennessee, USASearch for more papers by this authorAllen NISSENSON, Allen NISSENSON David Geffen School of Medicine at UCLA, Davita Inc.Search for more papers by this authorGlenn M. CHERTOW, Glenn M. CHERTOW Stanford University, Palo Alto, California, USASearch for more papers by this authorDavid C. WHEELER, David C. WHEELER Centre for Nephrology, Royal Free Campus, University College London Medical School, London, UK.Search for more papers by this author First published: 17 August 2009 https://doi.org/10.1111/j.1542-4758.2009.00387.xCitations: 18 G. A. Block, Denver Nephrologists, PC, Denver, CO 80202, USA.E-mail: [email protected] Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume13, Issue3July 2009Pages 360-362 RelatedInformation

Context: Coronary artery disease is increased in women with type 1 diabetes (T1D), compared with nondiabetic (Non-DM) women. Women with T1D have more menstrual dysfunction and are less likely to use hormonal birth control (BC) than Non-DM women.Objective: The purpose of this study was to determine whether coronary artery calcium (CAC) is associated with menstrual dysfunction and BC use in women with T1D.Materials and Methods: This was a prospective cohort study, and participants were followed up for an average of 2.4 yr.Patients: Patients included 612 women (293 T1D, 319 Non-DM) between the ages of 19 and 55 yr who had CAC measured twice by electron beam tomography.Results: Irregular menses and amenorrhea were more common in T1D than Non-DM women (22.1 vs. 14.9%, P < 0.05 and 16.6 vs. 7.0%, P < 0.001). T1D women reported less BC use than Non-DM women (79.8 vs. 89.9%, P < 0.001) and reached menarche at an older age (13.1 +/- 1.8 vs. 12.8 +/- 1.5 yr, P < 0.05). Use of BC was associated with less CAC progression in all women, but this association was stronger in T1D women (P value for interaction = 0.02). Irregular menses were associated with greater CAC progression only among T1D women.Conclusions: A prior history of BC use is associated with reduced CAC progression among all women, with a stronger association in T1D than in Non-DM women. Women with T1D who report irregular menses have increased CAC progression, compared with those with regular menses.

Background Coronary artery calcium (CAC) scanning is being increasingly used. for cardiac risk assessment in asymptornatic patients, particularly in those with a Framingham 10-year risk of 10% to 20%. Physician awareness of this technology and its appropriate uses and limitations is crucial to appropriate use.Methods With the goal of establishing clinical paradigms, this document integrates the results of key published articles, Framingham Risk Score, National Cholesterol Education Program Adult Treatment Plan III guidelines, American College of Cardiology/American Heart Association exercise testing and angiographic guidelines, and the authors' extensive clinical experience.Results Coronary artery calcium scanning is best used in the asymptomatic population with a 10% to 20% risk of cardiac events over 10 years, with selected application in higher and lower risk categories. In the 10%-20% risk patient, coronary artery calcium scores > 100 or > 75th percentile for age and sex transform the moderately high-risk patient to higher risk status with the attendant recommendation for more aggressive therapy; scores from 11 to 100 and < 75th percentile are consistent with the 10%-20% 10-year risk status and scores from 0 to 10 and < 75th percentile convert the patient to lesser risk categories. If stress testing is planned in the asymptornatic patient, it should be preceded by coronary artery calcium scanning and performed only for scores > 400; it should always precede coronary angiography in these patients.Conclusions Coronary artery calcium scanning is an important risk assessment tool with direct clinical applications; it is of particular utility in the Framingham 10%-20% 10-year risk population.

BACKGROUND Hemodialysis patients are at increased risk for progressive coronary artery calcification; however, the development and progression of this disease process in patients new to hemodialysis is unknown. METHOD One hundred and twenty-nine patients new to hemodialysis were randomized to receive calcium containing phosphate binders or the noncalcium phosphate binder sevelamer hydrochloride. Subjects underwent electron beam computed tomography scanning (EBCT) at entry into the study and again at 6, 12, and 18 months. RESULTS One hundred and nine patients underwent baseline and at least one additional assessment of coronary calcification. At baseline, 37% of sevelamer treated and 31% of calcium treated patients had no evidence of coronary calcification. No subject with a zero coronary artery calcium score (CACS) at baseline progressed to a CACS >30 over 18 months. Subjects with a CACS > 30 at baseline showed progressive increases in CACS in both treatment arms (P < 0.05 for each time point in both groups). Subjects treated with calcium containing phosphate binders showed more rapid and more severe increases in CACS when compared with those receiving sevelamer hydrochloride (P= 0.056 at 12 months, P= 0.01 at 18 months). CONCLUSION New hemodialysis patients with no evidence of coronary calcification showed little evidence of disease development over 18 months independent of phosphate binder therapy. However, subjects with evidence of at least mild coronary calcification had significant progression at 6, 12, and 18 months. Use of calcium containing phosphate binders resulted in more rapid progression of coronary calcification than did use of sevelamer hydrochloride.

OBJECTIVES The efficacy of combination therapy with pegylated interferon (PEG IFN) α plus ribavirin (RBV) in the retreatment of chronic hepatitis C (CHC) in patients who previously failed combination standard IFN plus RBV or IFN monotherapy has not been well established. METHODS Three hundred and twenty-one CHC patients including virologic nonresponders to combination IFN plus RBV (n = 219) or IFN monotherapy (n = 47), and relapsers to combination therapy (n = 55) were randomized to receive PEG IFN α-2b 1.5 μg/kg per wk plus RBV 800 mg per day (Regimen A, n = 160) or PEG IFN α-2b 1.0 μg/kg per wk plus RBV 1,000–1,200 mg per day (Regimen B, n = 161) for 48 wks. RESULTS Sustained virologic response (SVR) occurred in 16% of the overall study population (Regimen A vs B, 18% vs 13%, p = 0.21), in 8% of the combination therapy nonresponders (10% vs 6%, p = 0.35), in 21% of the IFN monotherapy nonresponders (16% vs 27%, p = 0.35), and in 42% of the combination therapy relapsers (50% vs 32%, p = 0.18). In nonresponders to prior combination therapy, HCV ribonucleic acid levels <100,000 copies/mL at the end of the prior treatment course were associated with an increased SVR compared with levels ≥100,000 copies/mL (21% vs 5%, p = 0.002). In the overall study population, genotype 1 patients had lower SVR rates than others (14% vs 33%, p = 0.01), and African Americans had lower SVR than Caucasians (4% vs 18%, p = 0.01). CONCLUSION Combination therapy with PEG IFN α-2b plus RBV is more effective in patients who relapsed after combination standard IFN plus RBV than in nonresponders to either combination therapy or IFN monotherapy. There was no significant effect of dosing regimen.

American Heart Hospital JournalVolume 2, Issue 1 p. 34-38 Early Noninvasive Identification of Atherosclerosis: A New Paradigm in Preventive Cardiology George P. Rodgers MD, George P. Rodgers MD From Heart Hospital of Austin, TX;1 and Colorado Heart Imaging, Denver, CO2Search for more papers by this author 1 Kent Beasley MD, Kent Beasley MD From Heart Hospital of Austin, TX;1 and Colorado Heart Imaging, Denver, CO2Search for more papers by this author 1 James Enrlich MD, James Enrlich MD From Heart Hospital of Austin, TX;1 and Colorado Heart Imaging, Denver, CO2Search for more papers by this author 2 George P. Rodgers MD, George P. Rodgers MD From Heart Hospital of Austin, TX;1 and Colorado Heart Imaging, Denver, CO2Search for more papers by this author 1 Kent Beasley MD, Kent Beasley MD From Heart Hospital of Austin, TX;1 and Colorado Heart Imaging, Denver, CO2Search for more papers by this author 1 James Enrlich MD, James Enrlich MD From Heart Hospital of Austin, TX;1 and Colorado Heart Imaging, Denver, CO2Search for more papers by this author 2 First published: 09 October 2008 https://doi.org/10.1111/j.1541-9215.2004.03219.xCitations: 1 George P. Rodgers, MD, Heart Hospital of Austin, 3801 North Lamar, Suite 300, Austin, TX 78756-4081; e-mail: grodgers@austinheart.com Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume2, Issue1Winter 2004Pages 34-38 RelatedInformation

There is growing recognition that the progression of cardiovascular disease can be inhibited in both the general and end-stage renal disease (ESRD) populations. Nephrologists can play a vital role in reducing cardiovascular morbidity and mortality in their patients by early identification of those at greatest risk and by management of known risk factors, particularly calcium load, lipid profile, and blood pressure. The measurement and monitoring of cardiac calcium-a marker of cardiovascular disease and risk-can be achieved by using advanced imaging modalities. This article reviews the occurrence, prevention, monitoring, and management of cardiovascular calcification in ESRD, while describing additional cardiovascular tests relevant to contemporary nephrology practice.