Vol 4, No 1 (2025)

Aim: Chronological age is a strong predictor of physical decline and mortality but fails to capture inter-individual variability in health and aging. Biological age metrics, such as PhenoAge and PhenoAgeAccel, integrate clinical biomarkers (e.g., inflammatory markers) to better reflect physiological aging. While these measures may predict well inflammation-driven outcomes, their utility for broader functional outcomes in general older populations remains unclear. This study compares their predictive power for physical function decline and all-cause mortality to chronological age in community-dwelling older adults.
Methods: Data from the InCHIANTI study were analyzed3. Participants aged ≥ 65 years with complete biomarker data for PhenoAge calculation (creatinine, albumin, glucose, C-reactive protein, red cell distribution width, mean corpuscular volume, lymphocyte percentage, white blood cell count, and alkaline phosphatase) and baseline Short Physical Performance Battery (SPPB) assessments were included (N=979; median age 73 years; 56% women). PhenoAgeAccel was calculated as the difference berween PhenoAge and chronological age. Physical function was assessed using the Short Physical Performance Battery (SPPB). Linear mixed models and Cox regression assessed associations with longitudinal changes in a continuous rescaled score of SPPB (rSPPB) and 10-year all-cause mortality. Logistic regression examined, in a subset of participants with normal physical function at baseline (N=504) the associations of these metrics with the onset of compromised physical function, defined as a drop in SPPB score from normal (≥10) at baseline to impaired (<10) at 6-year follow-up.
Results: Chronological age showed the strongest association with rSPPB decline (-0.50 points/10 years, p<0.001) and all-cause mortality (HR 1.15, p<0.001). PhenoAge and PhenoAgeAccel were associated with physical function decline (-0.32 and -0.15 points/10 years, respectively; p<0.001) and mortality (HR 1.10 and 1.09, respectively; p<0.001) but did not outperform chronological age. For the onset of compromised physical performance, chronological age demonstrated the strongest association and the highest predictive accuracy (OR 1.17, AUC=0.71) compared to PhenoAge (OR 1.10, AUC=0.69) and PhenoAgeAccel (OR 1.05, AUC=0.55).
Conclusions: While significantly associated with physical function decline and mortality, PhenoAge and PhenoAgeAccel do not surpass chronological age as predictive tools for these outcomes in general older populations. These outcomes are likely influenced by a complex interplay of factors – including musculoskeletal, psychosocial, and environmental determinants – that extend beyond those captured by these measures biomarker panels. These findings highlight the need for more comprehensive biological aging metrics to improve risk stratification and intervention planning in geriatric populations.

Aim: Circulating mitochondrial DNA (mtDNA) profiles could refine risk stratification, but current methods do not account for different fractions of circulating mtDNA. We aimed to explore whether patients with cardiometabolic disease have a specific signature of the total circulating mtDNA profile.
Methods: We performed a complete clinical assessment, including blood tests, 12-lead ECG and ultrasound at rest and during cardiopulmonary exercise. Ultrasound congestion was defined at rest as inferior vena cava of ≥21 mm, lung B-lines ≥4, or discontinuous renal venous flow. In fasting whole blood and plasma samples collected at rest, we simultaneously measured the copy number of the cellular and cell-free components of mtDNA by real-time quantitative polymerase chain reaction. We calculated the ratio of cell mtDNA to cell-free mtDNA as an index of mitochondrial efficiency.
Results: We enrolled 120 consecutive patients: 42% with HF and preserved ejection fraction (HFpEF), 33% with HF and reduced ejection fraction (HFrEF) and 25% at risk of developing HF; 35% had diabetes. Cell-free mtDNA was increased in patients with HF (and higher in HFrEF than HFpEF) and with diabetes. Cell-free mtDNA was higher in patients with systemic inflammation (high-sensitivity C-reactive protein [hs-CRP] ≥0.2 mg/dL with neutrophil-lymphocyte ratio [NLR] >3) and more ultrasound signs of congestion. The mtDNA ratio showed opposite trends (all p<0.05). Cell-free mtDNA and mtDNA ratio independently predicted the presence of ≥2 ultrasound signs of congestion and effort intolerance (peak oxygen consumption <16 mL/kg/min) at ROC analysis and using multivariable regressions after adjustment for age, sex, hs-CRP, NLR, high-sensitivity Troponin T and NT-proBNP.
Conclusions: Cardiometabolic patients have an altered circulating mtDNA signature characterised by higher cell-free mtDNA and lower mtDNA ratio. Both are associated with impaired response to exercise, higher systemic inflammation and increased congestion. Circulating mitochondrial profile could be a new biomarker of mitochondrial status in cardiometabolic diseases.

Aim: Familial hypercholesterolemia (FH) is a genetic condition characterized by high low-density lipoprotein cholesterol (LDL-C). The presence of risk modifiers could promote the atherosclerotic injury beyond LDLC. Our aim was to evaluate metabolic and innate immunity profiles in FH subjects with or without subclinical atherosclerosis.
Methods: In this cross-sectional observational study, we evaluated 211 genetically confirmed FH subjects on LDLC target and without cardiovascular diseases. Biochemical analyses, LDL-C burden (LCB) calculation and vascular profile evaluation were obtained from all subjects. Study population was divided into two groups according to subclinical atherosclerosis: the subclinical atherosclerosis (SA) group and non-subclinical atherosclerosis (NSA) group.
Results: SA group had higher LDL-C at diagnosis (288.35±24.52 vs 267.92±23.86, p<0.05) and LCB (13,465.84±3617.46 vs 10,872.63±3594.7, p<0.001) than NSA group. SA group had higher white blood cell count (WBCC, 6.9±1.66 vs 6.1±1.16), neutrophil count (NC, 4.2±1.3 vs 3.6±1.11), monocyte count (MC, 0.8±0.2 vs 0.4±0.1), triglyceride to high-density lipoprotein ratio (TG/HDL, 1.73±0.72 vs 1.45±0.69), triglyceride-glucose index (TyG, 8.29±0.35 vs 8.01±0.33) than NSA group (p value for all <0.01). Multivariate logistic regression analysis showed that LCB (p<0.01), WBCC (p<0.01), NC (p<0.05), MC (p<0.05) were associated with subclinical atherosclerosis. Simple linear regression analyses showed that LCB was associated with WBCC, NC, MC (p value for all <0.01).
Conclusion: An increased LCB and an impaired innate immunity profile were found in FH subjects with subclinical atherosclerosis and they were independently associated with atherosclerotic injury. LCB could modulate the innate immunity profile.

Background and aims: Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) is a chronic liver condition affecting approximately 30% of the global population. The burden of MASLD is significantly impacted by the rising prevalence of obesity and type 2 diabetes (T2DM). There is no specific medical therapy approved and last guidelines (2024) primarily focus on lifestyle modifications and nutritional interventions. Aims of our study are to assess the effectiveness of a multidisciplinary hepatological and nutritional approach in adult patients with MASLD, focusing on changes in key anthropometric parameters such as weight, BMI, waist circumference and fibroscan value.
Patients and Methods: We enrolled 52 consecutive patients, affiliated to MASLD multidisciplinary Clinic, Liver Unit Verona. Patients were enrolled between January 2022 and September 2024. All patients underwent a hepatological and internistic visit followed by a nutritional evaluation at baseline. Patients were evaluated based on recent laboratory tests and an initial non-invasive assessment of liver fibrosis using TE with FibroScan (Echosens). The follow-up process included one or more reassessments, both hepatological and nutritional. In particular, the hepatological follow up consists in a 6-month follow up visit for a reassessment of blood tests and TE, the dietician follow-up usually consists on a 3-month evaluation in order to obtain a better compliance to the dietetic plan.
Results: All 52 patients, median age of 53 years (IQR 13.3), male 69%, underwent after hepatological visit to nutritional approach. At the baseline visit, pharmacological treatment for arterial hypertension was optimized in 26% of patients with hypertension. Lipid lowering therapy was introduced or optimized in 60% of dyslipidemic patients. Antidiabetic therapy was adjusted in 43% of patients with T2DM. TE showed a median liver stiffness of 6.10 KPa (IQR 2,75 KPa) and a median controlled attenuation parameter (CAP) value of 282 dB/m (IQR 71 dB/m). After 6 months of follow up, we observed a median reduction of 2 Kg of body wight with a significant improvement (p<0.05) in the lipid profile with reduction in total cholesterol levels (median values: 194 to 172 mg/dL), in LDL levels (122 to 102 mg/dL), in triglyceride levels (143 to 120 mg/dL), and an increase in HDL levels (46 to 47 mg/dL at follow-up). We observed a slight decrease in HbA1c (41 to 40 mmol/mol at follow-up, p=0.07). No significant changes were found in the hepatic profile, TE at follow u 5.10 KPa (IQR 2,55 KPa) and CAP 280 dB/m (IQR 64 dB/m). Only in subgroup with higher TE value at baseline (upper third quartile) we observed a significant reduction (p<0.05).
Conclusion: The results of our study highlight that multidisciplinary approach with nutritional intervention, among patients with MASLD, reached a better biochemical profile and for those with a significant levels of liver stiffness at also an improvement in FibroScan value.

Background: Statin therapy represents the gold standard in lipid lowering therapy, although it is associated with an increasing rate of therapeutic abandonment especially due to the onset of muscle symptoms (statin associated muscle symptoms SAMS). In literature, a higher incidence of SAMS in the female population has already been documented, probably attributable to differences in pharmacokinetics and pharmacodynamics between genders. A relevant element in this condition would seem to reside in the SLCO1B1 gene, responsible for the tissue transport of statins, whose mutation would determine an increased plasma concentration of the same with consequent development of SAMS.
Aim: The aim of our study was to evaluate the real-life prevalence of statin intolerance in patients referred at our Center and how this determines whether or not the 2019 ESC guideline’s LDL target was reached. The influence of genetic factors (specifically the SLCO1B1 mutation) and of patients’ general and clinical characteristics (gender, age, BMI) on the achievement of the target was also analyzed.
Methods: We selected a population of 185 patients attending our Center and enrolled in the LIPIGEN project (96 F; 89 M), of whom 131 FH+ (67 F; 64 M). In 97% of the total population it was possible to evaluate the SLCO1B1 gene, which was found to be mutated in 67 out of 179 patients (37 F; 30 M). The mean age of our patients was 35 years (18 to 74 years; 41 f, 30 m), the mean BMI was 24.2 (23.9 f; 24.5 m).
Discussion: In accordance with the literature, our data showed a greater statin intolerance in female (58% f vs 42% m). In particular, Atorvastatin was the worst tolerated, with predominantly SAMS development even in the absence of CPK elevation (only 2 patients). If intolerance was referred by the patient, we preferred to shift to Rosuvastatin, generally characterized by better tolerability. Intolerance showed a continuous growth trend in relation to age in both sexes, more significant in female (5-fold increase from 35 to 75 years). The evaluation of the BMI was affected by the different numerical representation between classes, given the prevalence of normal weight and overweight population. From our preliminary data, the BMI would seem to be directly correlated with the development of statin intolerance; less significant the correlation with the achievement of the target since the poor representation of some groups could determine confounding results. Of the 179 patients analyzed for mutations of the SLCO1B1 gene, 37% presented its mutation. By stratifying the data based on sex, the influence of this mutation on the development of statin intolerance in female was confirmed, independently of the diagnosis of familial hypercholesterolemia, particularly in female FH+.
Conclusions: Statin intolerance still represents an obstacle to therapeutic compliance and the achievement of the LDL target. Particular importance seems to be related to age and the presence of SLCO1B1 mutations; the role of BMI/waist circumference is still uncertain.

Aim: The implementation of new techniques has significantly reduced mortality and morbidity in older cardiovascular patients undergoing cardiac surgery. However, few studies have assessed post-surgery functional and cognitive outcomes in this demographic. This study aims to characterize baseline cognitive and functional status of patients undergoing elective cardiothoracic surgery (CS) and to evaluate their modifications over a 3-month follow-up.
Methods: Data were extracted from a prospective study starting May 2023. Patients aged 65+ undergoing elective CS received pre-operative geriatric assessments. Postoperative complications and delirium were monitored, with a 3-month follow-up assessing functional and cognitive status. Kruskal-Wallis and Fisher's tests analyzed clinical and demographic features, and linear regression examined the relationship between follow-up functional autonomy and preoperative cognitive status.
Results: Seventy-seven patients (median age: 72 [IQR, 68.00-75.25], 53% males) were included in the study, showing a median Instrumental Activities of Daily Living (IADL) of 8 [5.00-8.00]. The median pre-operative Montreal Cognitive Assessment (MoCA) was 22.88 [19.96-24.80]. 21.4% of patients with impaired cognitive performance at baseline experienced delirium, compared to 2.3% of those without impairment (p=0.052). At follow-up, 58 patients were re-assessed, showing a median IADL of 7.5 [5.00, 8.00] and an almost 64.3% prevalence of impaired cognitive performance on Telephone MoCA testing. At the linear regression analysis, pre-operative MoCA was correlated with three-month IADL decline [β = 0.144; 95% CI 0.044-0.243; p=0.005].
Conclusions: Routine cognitive assessments reveal significant cognitive deficits in older CS patients. Preliminary findings suggest a link between preoperative cognitive impairment and functional decline.

Aim: This study aims to determine the in vivo safety of newly synthesized PCSK9 inhibitors (MR-compounds). PCSK9 controls peripheral and central cholesterol levels and it plays a crucial role in hypercholesterolemia, being a well-established pharmacological target to treat this pathology, while a possible involvement in the aetiopathogenesis of AD has been postulated. Currently, the available PCSK9i to counteract hypercholesterolemia are very expensive biotechnological drugs and only subcutaneously administrated. Based on these premises, orally bioavailable small-molecules may be a valuable addition to existing treatments.
Methods: After preliminary in vitro screening in human hepatocyte and neuroblastoma cells of 30 compounds, 4 compounds were selected to test tolerability and bioavailability in vivo in wild-type mice (C57BL/6J) at 12.5mg/kg, 25mg/kg, 50mg/kg, and 100mg/kg for 5 days. MR-532 and MR-533 were administered subcutaneously, while MR-3 and MR-644 both subcutaneously and orally. Body weight and phenotype analysis were assessed daily to evaluate tolerability and macroscopic toxicity. After the sacrifice, hepatic toxicity (histological analysis and ALT activity) and biodistribution (LC-MS/MS) were evaluated.
Results: All doses of compounds were well tolerated (no changes in body weight, food intake, coat; no lethargy was observed). The MR-532 and MR-533 at 100mg/kg did not show elevated levels of ALT activity compared to vehicle (66mU±55, 76mU±127, and 130mU±203, respectively) or inflammatory cell infiltration or necrosis in liver sections (histological analysis). Interestingly, MR-532 and MR-533 were detected at all doses in plasma (261-318nM; 159-192nM), liver (522-1063pmol/g; 2824-3135mol/g) and brain (513-779pmol/g; 457-380mol/g), respectively, without a dose-dependent trend. MR-3 and MR-644 analyses are in progress.
Conclusion: All tested compounds proved to be safe. MR-532 and MR-533 showed plasma and hepatic bioavailability. They can reach the CNS, although at low concentrations. Further investigations are needed to understand how the route of administration affects biodistribution and to evaluate the efficacy of these compounds in cardiovascular and neurodegenerative diseases.

Aim: To assess whether an early post-discharge Cardio-Geriatric (CG) outpatient service reduces 1-year mortality compared to usual care (UC), and to evaluate 1-year rehospitalization rates and days alive and out of hospital (DAOH).
Methods: In this single-center, controlled before-and-after study, patients aged ≥75 years hospitalized for acute HF were included. In the UC group, patients discharged between January 2018 and December 2019 received standard follow-up with referrals to a cardiologist and general practitioner. In the CG group, patients discharged between January 2020 and December 2022 attended a Cardio-Geriatric ambulatory care within three weeks of discharge. Primary outcomes were one-year all-cause mortality, heart failure readmissions, and days out of hospital (DOAH). The effectiveness of CG follow-up was assessed using a 1:1 propensity score matched (PSM) analysis.
Results: A total of 652 patients (mean age 86 years, 56% female) were included in the study, with 477 receiving UC and 175 referred to CG follow-up. After propensity score matching of 350 patients (50% CG), we observed a significant reduction in 1-year rehospitalizations (36.5% vs. 50.8%, p<0.001) and mortality (20.0% vs. 40.0%, p<0.001) in the CG group. CG patients also had nearly double the days alive and out of hospital (DAOH) compared to UC patients (300±100 vs. 162±145 days, p<0.001). Cox regression analysis confirmed that the CG integrated approach was a protective factor for mortality [HR 0.34, 95% CI: 0.24-0.47]. Respiratory diseases, neurological conditions, and infections were common causes of readmission.
Conclusion: Early referral to a CG outpatients service post-discharge for acute HF significantly improves outcomes, highlighting the value of integrated care for older adults with complex needs.

Aim: Dyslipidemia encompasses various forms of lipid abnormalities and represents a central component of metabolic syndrome. The relationship between dyslipidemia subtypes and broader metabolic profiles is poorly characterized in modern populations. This study provides a comprehensive metabolic characterization of patients presenting with distinct dyslipidemic patterns – low high-density lipoprotein cholesterol (HDL-c) and elevated low-density lipoprotein cholesterol (LDL-c) – at a dedicated tertiary-center outpatient clinic.
Methods: Patients evaluated at the Metabolic Health Clinic of San Raffaele Hospital, Milan, between January 2023 and October 2024, were included. Medical history, anthropometrics (i.e. body mass index, BMI, and waist circumference), serum lipids and liver enzymes were recorded. Patients with low HDL-c or high LDL-c, as defined according to current guidelines, were compared to patients with normal values. Network analysis identified patient distinct metabolic clusters.
Results: A total of 496 individuals were included. Patients with low HDL-c levels (n=193, 38.9%) exhibited higher BMI (28.6 vs 25.6 kg/m², p<0.001), waist circumference (100.0 vs 94.0 cm, p<0.001), ALT levels (28.0 vs. 23.0 U/L, p<0.001), and triglycerides (146.0 vs. 99.0 mg/dL, p<0.001), and a greater prevalence of fatty liver disease (33% vs. 21%, p 0.006) and arterial hypertension (51% vs. 39%, p 0.012) than those with normal HDL-c levels. HDL-c showed significant inverse correlations with both BMI (R coefficient -0.272, p<0.0001) and waist circumference (R coefficient -0.325, p<0.0001). Network analysis highlighted strong associations among HDL-c, triglycerides, ALT levels, BMI, and waist circumference. Conversely, high LDL-c levels, found in 382 (77%) patients, showed no association with metabolic parameters.
Conclusions: Low HDL-c was associated with obesity, central adiposity, hypertriglyceridemia, and fatty liver disease. In striking contrast, LDL-c appears to be independent of these metabolic alterations. These findings underscore the interconnectedness of HDL-c with the metabolic landscape, while emphasizing the importance of assessing LDL-c levels regardless of patient anthropometrics and metabolic phenotype.

The genetic basis of complex diseases like ischemic stroke probably consists of several predisposing risk factors, such as genes involved in inflammation and thrombotic pathways. Some genetic polymorphisms have been associated with the risk of stroke.
Aim: On this basis the aim of this study was to evaluate:
- the frequency of some single nucleotide polymorphisms (SNPs) of genes of pro-inflammatory cytokines and coagulation factors in stroke patients;
- the relationship between each identified SNP and TOAST stroke subtype;
- the relationship between the serum levels of the cytokines analyzed and the diagnostic subtype of ischemic stroke;
- the relationship between the serum levels of the analyzed cytokines and stroke prognosis regarding event recurrence, AMI recurrence, and mortality.
Materials and methods: All patients aged > 18 years admitted for acute ischemic stroke in the period between 2011 and 2021 were prospectively enrolled. Each patient was subjected to genetic analysis to evaluate various genetic polymorphisms and to the analysis of the levels of cytokines circulating in the different collection times (T0, T1, and T2). Three different biallelic polymorphisms, of the IL-10 gene were identified.
Results: 624 subjects were enrolled, including 429 patients with ischemic stroke and 195 controls. Stroke subtype: 47% LAAS, 27% LAC, and 26% CEI. Regarding the immunoinflammatory variables, patients with CEI showed significantly higher levels of serum glucose and all the cytokines analyzed, compared to patients with both LAC and LAAS.
Logistic regression analysis revealed that elevated IL-10, TNF-alpha, IL-6, and IL-1beta values are predictive of LAAS and CEI subtypes, respectively. IL-10 levels were lower in patients who developed stroke during follow-up, whereas TNF-alpha, IL-1, and IL-6 levels were significantly higher in patients with recurrent stroke at follow-up, who developed a new vascular event or who experienced death during follow-up. From the analysis of the distribution of the genotypic frequencies of the polymorphisms analyzed, a statistically significant difference emerged between the cases and the controls for all the polymorphisms in the genes of pro-inflammatory cytokines, TPA and PAI-1.
These results demonstrated an association between some pro-inflammatory and prothrombotic polymorphisms and the risk of ischemic stroke.

Aim: Optimizing drug treatments in older individuals is essential for improving health outcomes and reducing drug-related issues. However, targeting older adults for interventions is challenging and tools to identify and prioritize individuals with potentially inappropriate medications (PIMs) are lacking. This study aims to develop a prioritization algorithm for medication review, with a proof-of-concept established using Italian administrative data, and to assess the association between PIMs and all-cause hospitalization.
Methods: Eight indicators were selected:
1) medications that should be avoid in elderly,
2) drugs linked to fall risk or orthostatic hypotension,
3) drug-drug interactions,
4) Anticholinergic Cognitive Burden,
5) Sedative Load,
6) therapeutic duplicates,
7) polytherapy,
8) drugs with higher risk of adverse drug reactions.
This study focused on the first indicator. Administrative healthcare data from Local Health Units (LHUs) in Lombardy were used to identify over 65 individuals who redeemed a PIM between 2015 and 2018, with index date defined as the first PIM redemption. Risk-set matching was used to select controls, adjusted for high-dimensional propensity scores (HDPS) logistic regression models were used to assess the odds of all-cause hospitalization within 90 days.
Results: A total of 499,511 over 65 adults across the LHUs were evaluated. Between 27.4% and 37.7% individuals were exposed to at least one PIM with higher prevalence in adults aged 65-74 years and women. After matching, 128,063 pairs were analyzed. Hospitalization rates were higher among exposed individuals (8.3-10.2%) compared to controls (5.1-6.0%). Multivariate regression showed a 55% increased risk of hospitalization for those exposed to PIMs (OR 1.55, 95% CI 1.48-1.62).
Conclusions: This proof-of-concept study made it possible to develop an analytical model, which will be implemented for the other indicators. The strength of the association between each indicator and the risk of hospitalisation will be used as a weight in the construction of the prioritisation algorithm.

Background: Patients with chronic inflammatory diseases, including inflammatory bowel diseases (IBD), have a 20% increased risk for atherosclerotic cardiovascular disease (ASCVD) and death as compared to non-inflamed subjects. A more in-depth screening of patients has become important with the EMA warning for JAK-inhibitors. The current validated cardiovascular risk (CVR) stratification algorithms are based on traditional risk factors, not taking into account the contribution of chronic inflammation.
Aim of the study: Our study aimed to stratify the CV risk of IBD patients using validated scores (SCORE2/SCORE2-OP/SCORE- 2Diabetes) and performing carotid ultrasonography to identify subclinical atherosclerosis.
Materials and methods: Data from 120 consecutive IBD patients [Ulcerative Colitis(UC): 67; Crohn’s disease(CD):53] aged ≥40 years under care in the IBD Unit of the University Hospital of Messina (April-to-July 2024) were collected. We recorded data on age, gender, region of origin, body mass index, smoking history, family, personal and pharmacological history, blood pressure values, biochemistry (creatinine, fasting glucose, glycated hemoglobin, total cholesterol, HDL-cholesterol, triglycerides). LDL-C/non-HDL-C were thus calculated. Additional IBD-related parameters potentially associated with an increased CVR were investigated (i.e., disease activity, current therapies, duration of disease, and extraintestinal manifestations).
Results: Based on their medical history, 48% of patients were classified as at intermediate CVR, 34% as high CVR, and 18% as very high CVR. Carotid ultrasound detected subclinical atherosclerosis in 48.3% of patients. CV risk reclassification occurred in 21%, increasing the proportion of patients with high/very-high risk from 50% to 71%. Active disease (p=0.047) and concomitant spondyloarthropathies (p=0.03) were identified as additional risk factors.
Conclusions: Our findings demonstrate that carotid ultrasonography significantly reclassifies CV risk, revealing that traditional risk scores underestimate CV risk in IBD patients. Tailored CV risk stratification, incorporating chronic inflammation, is crucial before initiating therapies like JAK-inhibitors to minimize side effects, including CV complications. Active intestinal disease and spondyloarthritis further exacerbate CV risk, underscoring the need for integrated screening and management strategies in this population.

Background: Acute kidney injury (AKI) is a very common life-threatening disease. Early diagnosis is the cornerstone for limiting the progression and chronicity of renal damage and reducing mortality. Estimating the glomerular flow velocity is the most used method to evaluate renal function. However, detecting new circulating molecules has taken hold for the early identification of kidney damage. To investigate the correlation between the urinary and serum biomarker concentrations and renal dysfunction, we studied a cohort of patients with AKI, accounting for aetiology. Aims: Our study aimed to find an association between some new circulating markers of renal injury and the pathogenic mechanism of acute kidney failure. In particular, we have evaluated the possible association between the urinary and serum concentrations of LFABP, CYR61, TIMP2, IGFBP7, PENK, and KIM-1 and AKI's prerenal or intrinsic pathogenesis. The secondary aims of the study were (i) evaluating the possible association between the urinary or serum concentrations of the markers with the severity of the acute kidney injury by the estimation of the variation between the serum creatinine at the admission compared with the basal values reported on the previous documentation exhibited; (ii) identifying the prognostic role of these markers and evaluating their association with the range of variation of the creatinine at discharge versus the values at admission. Methods: In this cross-sectional, observational trial, 57 patients with acute kidney disease were consecutively enrolled and underwent a complete medical history to evaluate comorbidities, physical examination, and routine blood tests after eight hours of fasting; urinary and serum concentrations L-FABP, CYR61, TIMP-2, IGFBP-7, and PENK E KIM-1 were obtained in all patients. Results: Urinary TIMP2, NGAL, and IGFBP7 and serum PENK values were higher in patients with AKI compared with the control group, with statistical significance. Moreover, higher concentrations of FABP1, Cyr61, TIMP-2, NGAL, IGFB7, and TIMP-2 X IGFBP-7 were found in patients with renal AKI compared with prerenal aetiology. A significant association between the urinary values of FABP1 and TIMP-2 and the serum concentrations of KIM-1 (p= 0,0001) with the variation of the creatinine values from the baseline to the values at the enrollment was found. Furthermore, a statistically significant association was found between KIM-1 and the creatinine variation at the discharge compared with the admission values Discussion: In this trial, we evaluated the serum and urinary concentrations of some novel biomarkers of acute kidney injury in a cohort of 57 patients diagnosed with acute renal failure, divided on the aetiology. With the primary aim of finding an association between these markers and the aetiology of the kidney injury, we demonstrated a statistically significant association between the concentrations of FABP1, Cyr61, TIMP-2, NGAL, IGFB7, and TIMP-2 X IGFBP-7 and the intrinsic aetiology of the AKI. Evaluating these "early diagnostic" biomarkers could help identify the underlying physiopathologic mechanism of the renal injury: considering the role of IGFBP-7 and TIMP2 in the cellular cycle and, in particular, in the mechanisms of cellular death, it is clear how the expression of these biomarkers is increased after a direct injury to the renal cells rather than prerenal injury: the levels of IGFBP7 persisted statistically associated with the AKI's aetiology after the multinomial regression, as not affected by other variables. Furthermore, our study has found an association between some of these biomarkers and creatinine variations. In particular, urinary FABP1, TIMP2, and serum KIM-1 levels were associated with a higher variation between the creatinine values at admission compared with the basal values, supporting a possible role of these proteins in defining the severity of renal injury. Moreover, KIM-1 concentrations were proportionally associated with the change of the creatinine values during the hospitalization, with a higher KIM-1 value as much as a higher reduction of the creatinine at recovery compared with admission: we confirm the protective role of KIM-1 in the worsening of renal dysfunction, but the constitutive expression of this protein on the tubule results in gradual fibrosis and progression towards chronic nephropathy. Considering the protective role of KIM-1, the increased values of KIM-1 may be related to a higher probability of recovery from renal dysfunction. Finally, in our study, we confirm the diagnostic role of some of these molecules. In particular, we have found that urinary values of TIMP2, NGAL, and IGFB7 and serum concentrations of PENK were statistically higher in patients with AKI compared to controls. Our study provides further evidence concerning the possible use of these novel biomarkers of AKI in clinical practice. Given their diagnostic and predictive role, these molecules could be used to identify the population at risk for the development of AKI and to identify renal injury early, even before the increase in serum creatinine or cystatin C values.