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Halim A, Burney HN, Li X, Li Y, Tomkins C, Siedlecki AM, Lu TS, Kalim S, Thadhani R, Moe S, Ting SM, Zehnder D, Hiemstra TF, Lim K. FGF23 and Cardiovascular Structure and Function in Advanced Chronic Kidney Disease. Kidney360 2022; 3:1529-1541. [PMID: 36245643 PMCID: PMC9528374 DOI: 10.34067/kid.0002192022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/29/2022] [Indexed: 11/27/2022]
Abstract
Background Fibroblast growth factor 23 (FGF23) is a bone-derived phosphatonin that is elevated in chronic kidney disease (CKD) and has been implicated in the development of cardiovascular disease. It is unknown whether elevated FGF23 in CKD is associated with impaired cardiovascular functional capacity, as assessed by maximum exercise oxygen consumption (VO2Max). We sought to determine whether FGF23 is associated with cardiovascular functional capacity in patients with advanced CKD and after improvement of VO2Max by kidney transplantation. Methods We performed secondary analysis of 235 patients from the Cardiopulmonary Exercise Testing in Renal Failure and After Kidney Transplantation (CAPER) cohort, which recruited patients with stage 5 CKD who underwent kidney transplantation or were waitlisted and hypertensive controls. All patients underwent cardiopulmonary exercise testing (CPET) and echocardiography and were followed longitudinally for 1 year after study enrollment. Results Patients across FGF23 quartiles differed in BMI (P=0.004) and mean arterial pressure (P<0.001) but did not significantly differ in sex (P=0.5) or age (P=0.08) compared with patients with lower levels of FGF23. Patients with higher FGF23 levels had impaired VO2Max (Q1: 24.2±4.8 ml/min per kilogram; Q4: 18.6±5.2 ml/min per kilogram; P<0.001), greater left ventricular mass index (LVMI; P<0.001), reduced HR at peak exercise (P<0.001), and maximal workload (P<0.001). Kidney transplantation conferred a significant decline in FGF23 at 2 months (P<0.001) before improvement in VO2Max at 1 year (P=0.008). Multivariable regression modeling revealed that changes in FGF23 was significantly associated with VO2Max in advanced CKD (P<0.001) and after improvement after kidney transplantation (P=0.006). FGF23 was associated with LVMI before kidney transplantation (P=0.003), however this association was lost after adjustment for dialysis status (P=0.4). FGF23 was not associated with LVMI after kidney transplantation in all models. Conclusions FGF23 levels are associated with alterations in cardiovascular functional capacity in advanced CKD and after kidney transplantation. FGF23 is only associated with structural cardiac adaptations in advanced CKD but this was modified by dialysis status, and was not associated after kidney transplantation.
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Affiliation(s)
- Arvin Halim
- Division of Nephrology and Hypertension, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Heather N. Burney
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
| | - Xiaochun Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
| | - Yang Li
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
| | - Claudia Tomkins
- Biochemistry Department, Kettering General Hospital NHS Foundation Trust, Kettering, United Kingdom
| | - Andrew M. Siedlecki
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tzong-shi Lu
- Division of Renal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sahir Kalim
- Nephrology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Ravi Thadhani
- Mass General Brigham, Harvard Medical School, Massachusetts
| | - Sharon Moe
- Division of Nephrology and Hypertension, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Stephen M.S. Ting
- Department of Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Daniel Zehnder
- Department of Nephrology and Department of Acute Medicine, North Cumbria University Hospital NHS Trust, Carlisle, United Kingdom
| | - Thomas F. Hiemstra
- School of Clinical Medicine, University of Cambridge; Clinical Trials Unit (CTU), Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Kenneth Lim
- Division of Nephrology and Hypertension, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Lim K, Ting SMS, Hamborg T, McGregor G, Oxborough D, Tomkins C, Xu D, Thadhani R, Lewis G, Bland R, Banerjee P, Fletcher S, Krishnan NS, Higgins R, Zehnder D, Hiemstra TF. Cardiovascular Functional Reserve Before and After Kidney Transplant. JAMA Cardiol 2021; 5:420-429. [PMID: 32022839 DOI: 10.1001/jamacardio.2019.5738] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Importance Restitution of kidney function by transplant confers a survival benefit in patients with end-stage renal disease. Investigations of mechanisms involved in improved cardiovascular survival have relied heavily on static measures from echocardiography or cardiac magnetic resonance imaging and have provided conflicting results to date. Objectives To evaluate cardiovascular functional reserve in patients with end-stage renal disease before and after kidney transplant and to assess functional and morphologic alterations of structural-functional dynamics in this population. Design, Setting, and Participants This prospective, nonrandomized, single-center, 3-arm, controlled cohort study, the Cardiopulmonary Exercise Testing in Renal Failure and After Kidney Transplantation (CAPER) study, included patients with stage 5 chronic kidney disease (CKD) who underwent kidney transplant (KTR group), patients with stage 5 CKD who were wait-listed and had not undergone transplant (NTWC group), and patients with hypertension only (HTC group) seen at a single center from April 1, 2010, to January 1, 2013. Patients were followed up longitudinally for up to 1 year after kidney transplant. Clinical data collection was completed February 2014. Data analysis was performed from June 1, 2014, to March 5, 2015. Further analysis on baseline and prospective data was performed from June 1, 2017, to July 31, 2019. Main Outcomes and Measures Cardiovascular functional reserve was objectively quantified using state-of-the-art cardiopulmonary exercise testing in parallel with transthoracic echocardiography. Results Of the 253 study participants (mean [SD] age, 48.5 [12.7] years; 141 [55.7%] male), 81 were in the KTR group, 85 in the NTWC group, and 87 in the HTC group. At baseline, mean (SD) maximum oxygen consumption (V̇O2max) was significantly lower in the CKD groups (KTR, 20.7 [5.8] mL · min-1 · kg-1; NTWC, 18.9 [4.7] mL · min-1 · kg-1) compared with the HTC group (24.9 [7.1] mL · min-1 · kg-1) (P < .001). Mean (SD) cardiac left ventricular mass index was higher in patients with CKD (KTR group, 104.9 [36.1] g/m2; NTWC group, 113.8 [37.7] g/m2) compared with the HTC group (87.8 [16.9] g/m2), (P < .001). Mean (SD) left ventricular ejection fraction was significantly lower in the patients with CKD (KTR group, 60.1% [8.6%]; NTWC group, 61.4% [8.9%]) compared with the HTC group (66.1% [5.9%]) (P < .001). Kidney transplant was associated with a significant improvement in V̇O2max in the KTR group at 12 months (22.5 [6.3] mL · min-1 · kg-1; P < .001), but the value did not reach the V̇O2max in the HTC group (26.0 [7.1] mL · min-1 · kg-1) at 12 months. V̇O2max decreased in the NTWC group at 12 months compared with baseline (17.7 [4.1] mL · min-1 · kg-1, P < .001). Compared with the KTR group (63.2% [6.8%], P = .02) or the NTWC group (59.3% [7.6%], P = .003) at baseline, transplant was significantly associated with improved left ventricular ejection fraction at 12 months but not with left ventricular mass index. Conclusions and Relevance The findings suggest that kidney transplant is associated with improved cardiovascular functional reserve after 1 year. In addition, cardiopulmonary exercise testing was sensitive enough to detect a decline in cardiovascular functional reserve in wait-listed patients with CKD. Improved V̇O2max may in part be independent from structural alterations of the heart and depend more on ultrastructural changes after reversal of uremia.
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Affiliation(s)
- Kenneth Lim
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Stephen M S Ting
- Department of Medicine, University Hospitals Birmingham National Health Service Foundation Trust, Birmingham, United Kingdom
| | - Thomas Hamborg
- Pragmatic Clinical Trials Unit, Centre for Primary Care and Public Health, Queen Mary, University of London, London, United Kingdom
| | - Gordon McGregor
- Department of Nephrology, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom.,Department of Cardiology, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - David Oxborough
- Research Institutes of Sports and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Claudia Tomkins
- Department of Pathology Service, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - Dihua Xu
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Ravi Thadhani
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Gregory Lewis
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Rosemary Bland
- Division of Biomedical Sciences, University of Warwick, Coventry, United Kingdom
| | - Prithwish Banerjee
- Department of Cardiology, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom.,Centre for Innovative Research Across the Life Course, Coventry University, Coventry, United Kingdom
| | - Simon Fletcher
- Department of Nephrology, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - Nithya S Krishnan
- Department of Nephrology, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - Robert Higgins
- Department of Nephrology, University Hospital Coventry and Warwickshire National Health Service Trust, Coventry, United Kingdom
| | - Daniel Zehnder
- Department of Nephrology, North Cumbria University Hospital National Health Service Trust, Carlisle, United Kingdom.,Department of Acute Medicine, North Cumbria University Hospital National Health Service Trust, Carlisle, United Kingdom
| | - Thomas F Hiemstra
- Cambridge Clinical Trials Unit and School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
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Widlak MM, Neal M, Daulton E, Thomas CL, Tomkins C, Singh B, Harmston C, Wicaksono A, Evans C, Smith S, Savage RS, Covington JA, Arasaradnam RP. Risk stratification of symptomatic patients suspected of colorectal cancer using faecal and urinary markers. Colorectal Dis 2018; 20:O335-O342. [PMID: 30248228 DOI: 10.1111/codi.14431] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/15/2022]
Abstract
AIM Faecal markers, such as the faecal immunochemical test for haemoglobin (FIT) and faecal calprotectin (FCP), have been increasingly used to exclude colorectal cancer (CRC) and colonic inflammation. However, in those with lower gastrointestinal symptoms there are considerable numbers who have cancer but have a negative FIT test (i.e. false negative), which has impeded its use in clinical practice. We undertook a study of diagnostic accuracy CRC using FIT, FCP and urinary volatile organic compounds (VOCs) in patients with lower gastrointestinal symptoms. METHOD One thousand and sixteen symptomatic patients with suspected CRC referred by family physicians were recruited prospectively in accordance with national referring protocol. A total of 562 patients who completed colonic investigations, in addition to providing stool for FIT and FCP as well as urine samples for urinary VOC measurements, were included in the final outcome measures. RESULTS The sensitivity and specificity for CRC using FIT was 0.80 [95% confidence interval (CI) 0.66-0.93] and 0.93 (CI 0.91-0.95), respectively. For urinary VOCs, the sensitivity and specificity for CRC was 0.63 (CI 0.46-0.79) and 0.63 (CI 0.59-0.67), respectively. However, for those who were FIT-negative CRC (i.e. false negatives), the addition of urinary VOCs resulted in a sensitivity of 0.97 (CI 0.90-1.0) and specificity of 0.72 (CI 0.68-0.76). CONCLUSIONS When applied to the FIT-negative group, urinary VOCs improve CRC detection (sensitivity rises from 0.80 to 0.97), thus showing promise as a second-stage test to complement FIT in the detection of CRC.
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Affiliation(s)
- M M Widlak
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.,Medical School, University of Warwick, Coventry, UK
| | - M Neal
- Department of Statistics, University of Warwick, Coventry, UK
| | - E Daulton
- School of Engineering, University of Warwick, Coventry, UK
| | - C L Thomas
- Department of Biochemistry, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - C Tomkins
- Department of Biochemistry, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - B Singh
- Department of Colorectal Surgery, Leicester General Hospital, Leicester, UK
| | - C Harmston
- Department of Colorectal Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - A Wicaksono
- School of Engineering, University of Warwick, Coventry, UK
| | - C Evans
- Department of Colorectal Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - S Smith
- Department of Biochemistry, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.,Midlands and North West Bowel Cancer Screening Hub, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - R S Savage
- Department of Statistics, University of Warwick, Coventry, UK
| | - J A Covington
- School of Engineering, University of Warwick, Coventry, UK
| | - R P Arasaradnam
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.,Medical School, University of Warwick, Coventry, UK.,Applied Biological and Experimental Sciences, University of Coventry, Coventry, UK
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Widlak MM, Thomas CL, Thomas MG, Tomkins C, Smith S, O'Connell N, Wurie S, Burns L, Harmston C, Evans C, Nwokolo CU, Singh B, Arasaradnam RP. Diagnostic accuracy of faecal biomarkers in detecting colorectal cancer and adenoma in symptomatic patients. Aliment Pharmacol Ther 2017; 45:354-363. [PMID: 27910113 DOI: 10.1111/apt.13865] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 08/15/2016] [Accepted: 10/26/2016] [Indexed: 01/02/2023]
Abstract
BACKGROUND The diagnosis of colorectal cancer (CRC) can be difficult as symptoms are variable with poor specificity. Thus, there is a quest for simple, non-invasive testing that can help streamline those with significant colonic pathology. AIM To assess using faecal immunochemical test for haemoglobin (FIT) or faecal calprotectin (FCP) to detect CRC and adenoma in symptomatic patients referred from primary care. METHODS A total of 799 referred for urgent lower gastrointestinal investigations were prospectively recruited. Of these, 430 completed colonic investigations and returned stool samples, and were included in the final statistical analysis. Faecal immunochemical test for haemoglobin was performed on HM-JACKarc analyser (Kyowa Medex, Tokyo, Japan), and FCP by the EliA Calprotectin immunoassay (Thermo Fisher Scientific, Waltham, United States). RESULTS The negative predictive value (NPV) using FIT alone or both markers (FIT and FCP) in combination was similar at 99% for CRC, with a sensitivity and specificity of 84% and 93%, respectively. FIT measurements were significantly higher in left-sided colonic lesions compared with the right side; 713 vs. 94; P = 0.0203). For adenoma, the NPV using FIT alone, or both markers (FIT and FCP) in combination, was similar at 94% with a sensitivity and specificity of 69% and 56%, respectively. CONCLUSIONS Undetectable faecal immunochemical test for haemoglobin is sufficiently sensitive to exclude colorectal cancer, with higher values in left-sided lesions. FCP in combination does not appear to provide additional diagnostic information. Further studies to determine the health economic benefits of implementing faecal immunochemical test for haemoglobin in primary care are required.
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Affiliation(s)
- M M Widlak
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire, Coventry, UK.,Medical School, University of Warwick, Coventry, UK
| | - C L Thomas
- Department of Biochemistry, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - M G Thomas
- Medical School, University of Oxford, Oxford, UK
| | - C Tomkins
- Department of Biochemistry, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - S Smith
- Midlands and North West Bowel Cancer Screening Hub, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - N O'Connell
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - S Wurie
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - L Burns
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - C Harmston
- Department of Colorectal Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - C Evans
- Department of Colorectal Surgery, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - C U Nwokolo
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - B Singh
- Department of Colorectal Surgery, University Hospitals of Leicester, Leicester, UK
| | - R P Arasaradnam
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire, Coventry, UK.,Medical School, University of Warwick, Coventry, UK.,Applied Biological and Experimental Sciences, University of Coventry, Coventry, UK
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Dhaliwal A, Zeino Z, Tomkins C, Cheung M, Nwokolo C, Smith S, Harmston C, Arasaradnam RP. Utility of faecal calprotectin in inflammatory bowel disease (IBD): what cut-offs should we apply? Frontline Gastroenterol 2015; 6:14-19. [PMID: 25580205 PMCID: PMC4283700 DOI: 10.1136/flgastro-2013-100420] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 02/08/2014] [Accepted: 02/26/2014] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Faecal calprotectin (FC), a cytosolic protein released by neutrophils (S100 family) in response to inflammation, is a simple, non-invasive test that can be used to differentiate irritable bowel syndrome (IBS) with inflammatory bowel disease (IBD), where there can be considerable symptom overlap. AIMS AND METHODS The aims of the study were (1) to be able to predict the ability of FC to exclude IBD and determine cut-offs when in remission, (2) to investigate the effects of time and temperature on stability of FC and (3) compare three ELISA kits to measure FC: Buhlmann, PhiCal v1 and PhiCal v2. A total of 311 patients with altered bowel habit were tested for FC; 144 with IBS, 148 with IBD and 19 with other organic causes. RESULTS Sensitivity and specificity of FC (with PhiCal v2 kit) to distinguish between functional disorder (IBS) and IBD using cut-off 50 μg/g were 88% and 78%, respectively, with a negative predictive value of 87%. Area under the receiver operating curve was 0.84 (CI 0.78 to 0.90). For those with IBD, FC values below 250 μg/g corresponded with remission of disease with a sensitivity and specificity of 90% and 76%, respectively. Area under the receiver operating curve was 0.93 (CI 0.89 to 0.97). FC was stable once extracted and frozen for up to 2.5 months. Pearson correlation was good between Buhlmann assay and PhiCal v2 (r2 = 0.95). CONCLUSIONS FC has up to 87% negative predictive value to exclude IBD, and cut-offs less than 250 μg/g had 90% sensitivity to determine remission in IBD. Once frozen, FC is stable and the ELISA monoclonal plates were broadly comparable.
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Affiliation(s)
- A Dhaliwal
- Department of Gastroenterology,University Hospitals Coventry and Warwickshire,Coventry, UK
| | - Z Zeino
- Department of Gastroenterology,University Hospitals Coventry and Warwickshire,Coventry, UK
| | - C Tomkins
- Department of Biochemistry, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - M Cheung
- Department of Gastroenterology,University Hospitals Coventry and Warwickshire,Coventry, UK
| | - C Nwokolo
- Department of Gastroenterology,University Hospitals Coventry and Warwickshire,Coventry, UK
| | - S Smith
- Department of Biochemistry, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - C Harmston
- Department of Colorectal Surgery, University Hospitals Coventry and Warwickshire,Coventry, UK
| | - R P Arasaradnam
- Department of Gastroenterology,University Hospitals Coventry and Warwickshire,Coventry, UK,Clinical Sciences Research Institute, Coventry, UK
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Affiliation(s)
- C Tomkins
- Medical Defence Union, 230 Blackfriars Road London SE1 8PJ, UK.
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Vorobieff P, Mohamed NG, Tomkins C, Goodenough C, Marr-Lyon M, Benjamin RF. Scaling evolution in shock-induced transition to turbulence. Phys Rev E Stat Nonlin Soft Matter Phys 2003; 68:065301. [PMID: 14754257 DOI: 10.1103/physreve.68.065301] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2003] [Indexed: 05/24/2023]
Abstract
In this experimental study, a column of heavy gas (SF6) surrounded by light gas (air) is accelerated by a planar Mach 1.2 shock. Richtmyer-Meshkov instability on the initially diffuse air-SF6 interface determines the repeatable large-scale vortex dynamics of the system after the shock passage. Subsequently secondary instabilities form, with the system eventually transitioning to turbulence. We present highly resolved measurements of two components of the instantaneous velocity fields. With these measurements, we investigate the evolution of velocity statistics over a substantial range of scales in terms of structure functions. The latter evolve to exhibit late-time behavior consistent with the Kolmogorov scaling law for fully developed turbulence, despite the transitional character, anisotropy, and inhomogeneity of our flow. Ensemble averaging and comparison with instantaneous results reveal a trend towards the same scaling manifested much earlier by the structure functions of the fluctuating velocity components.
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Affiliation(s)
- P Vorobieff
- The University of New Mexico, Albuquerque, New Mexico 87131, USA
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Cox B, Percival D, Shail G, Tomkins C. An inexpensive method for transmitting and receiving core temperature changes in unrestrained animals [proceedings]. Br J Pharmacol 1977; 61:496P. [PMID: 588842 PMCID: PMC1667888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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