Prognostic utility of B-type natriuretic peptides in patients with heart failure and renal dysfunction

Predictive value of perioperative NT-proBNP levels for acute kidney injury in patients with compromised renal function undergoing cardiac surgery: a case control study

BACKGROUND

Acute kidney injury (AKI) significantly increases morbidity and mortality following cardiac surgery, especially in patients with pre-existing renal impairments. N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a marker of cardiac stress and dysfunction, conditions often exacerbated during cardiac surgery and prevalent in chronic kidney disease (CKD) patients. Elevated NT-proBNP levels can indicate underlying cardiac strain, hemodynamic instability and volume overload. This study evaluated the association between perioperative changes in NT-proBNP levels and the incidence of AKI in this particular patient group.

METHODS

This retrospective study involved patients with impaired renal function (eGFR 15-60 ml/min/1.73 m²) who underwent cardiac surgery from July to December 2022. It analyzed the association between the ratio of preoperative and ICU admittance post-surgery NT-proBNP levels and the development of AKI and AKI stage 2-3, based on KDIGO criteria, using multivariate logistic regression models. Restricted cubic spline analysis assessed non-linear associations between NT-proBNP and endpoints. Subgroup analysis was performed to assess the heterogeneity of the association between NT-proBNP and endpoints in subgroups.

RESULTS

Among the 199 participants, 116 developed postoperative AKI and 16 required renal replacement therapy. Patients with AKI showed significantly higher postoperative NT-proBNP levels compared to those without AKI. Decreased baseline eGFR and increased post/preoperative NT-proBNP ratios were associated with higher AKI risk. Specifically, the highest quantile post/preoperative NT-proBNP ratio indicated an approximately seven-fold increase in AKI risk and a ninefold increase in AKI stage 2-3 risk compared to the lowest quantile. The area under the receiver operating characteristic curve for predicting AKI and AKI stage 2-3 using NT-proBNP were 0.63 and 0.71, respectively, demonstrating moderate accuracy. Subgroup analysis demonstrated that the positive association between endpoints and logarithmic transformed post/preoperative NT-proBNP levels was consistently robust in subgroup analyses stratified by age, sex, surgery, CPB application, hypertension, diabetes status and fluid balance.

CONCLUSION

Perioperative NT-proBNP level changes are predictive of postoperative AKI in patients with pre-existing renal deficiencies undergoing cardiac surgery, aiding in risk assessment and patient management.

An update on utilising brain natriuretic peptide for risk stratification, monitoring and guiding therapy in heart failure

INTRODUCTION

Heart failure (HF) is a dominant health problem with an overall poor prognosis. Natriuretic peptides (NPs) are upregulated in HF as a compensatory mechanism. They have extensively been used for diagnosis and risk stratification.

AREAS COVERED

This review addresses the history and physiology of NPs in order to understand their current role in clinical practice. It further provides a detailed and updated narrative review on the utility of those biomarkers for risk stratification, monitoring, and guiding therapy in HF.

EXPERT OPINION

NPs show excellent predictive ability in heart failure patients, both in acute and chronic settings. Understanding their pathophysiology and their modifications in specific situations is key for an adequate interpretation in specific clinical scenarios in which their prognostic value may be weaker or less well evaluated. To better promote risk stratification in HF, NPs should be integrated with other predictive tools to develop multiparametric risk models. Both inequalities of access to NPs and evidence caveats and limitations will need to be addressed by future research in the coming years.

NT-Pro-BNP and echocardiography for the early assessment of cardiovascular dysfunction in neonates with sepsis

To investigate the predictive manner of N-terminal fragment of brain natriuretic peptide (NT-Pro-BNP) and echocardiography in the early assessment of cardiovascular dysfunction (CVD) in neonates with sepsis, we recruited 108 neonates with sepsis in intensive care units and divided them into a sepsis with CVD (sepsis + CVD) group (n = 48) and a sepsis only group (n = 60). Neonates with other infections (n = 65) constituted the control group. Clinical, laboratory, and bedside echocardiography findings were evaluated. Compared to both the sepsis only and control groups, the sepsis + CVD group showed an earlier onset of symptoms [52.94 (0-185.6) h], higher NT-Pro-BNP levels (P = .02), a higher Tei index (0.52 + 0.03; P = .03), and lower ejection fraction (62.61% ± 12.31%, P < .05). Compared to the control group, the sepsis + CVD group exhibited hematogenous etiology (P < .05), lower albumin (ALB) levels (P = .04), lower white blood cell counts (P = .03), a higher high-sensitivity C-reactive protein/ALB ratio, and a larger right-ventricle-inner diameter (10.74 + 2.42 mm; P = .01). CVD in the septic neonates could be predicted by either NT-Pro-BNP levels (cut-off: 12,291.5 pg/L; sensitivity, 80%; specificity, 79%; area under the curve-receiver operating characteristic, 0.81) or Tei index (cut-off: 0.45; sensitivity, 74%; specificity, 77%; area under the curve-receiver operating characteristic, 0.78). NT-Pro-BNP levels and echocardiography can be used to determine early onset of CVD in neonatal sepsis, which facilitates timely pharmacological interventions and treatment.

In-hospital mortality is associated with high NT-proBNP level

Objective

To compare in-hospital mortality in unselected adult patients according to N-terminal pro-brain natriuretic peptide (NT-proBNP) levels.

Method

Retrospective study including 3833 adult patients (median age 72 years, 45% women) hospitalized between January 2013 and April 2015 in a Swiss university hospital, with at least one NT-proBNP level measurement during hospitalization. Patients were categorized in quintiles regarding their highest NT-proBNP level. In-hospital mortality and length of stay (LOS) were compared between the highest and the other quintiles.

Results

In-hospital mortality rate and LOS (average±standard deviation) were higher in the fifth quintile than in the others (6.5% vs 20.3%, and 20.8±24.0 vs. 14.9±26.5 days respectively, both p<0.001). After multivariate adjustment on age, gender, principal diagnoses, stage 5 renal failure and type of management, patients in the fifth quintile had a hazard ratio [95% confidence interval] of 1.97 [1.57–2.46] for in-hospital mortality and an adjusted LOS (average±standard error) of 20.4±1.0 vs. 14.9±0.5 days for the other quintiles (p<0.001). Further stratification on the main diagnosis at discharge led to similar findings.

Conclusion

Patients with high levels of NT-proBNP are at higher risk of in-hospital mortality and longer LOS, regardless of their clinical characteristics. NT-proBNP level can be a helpful tool for predicting in-hospital patient outcome in unselected adult patients.

Amino-Terminal Pro-B-Type Natriuretic Peptide for Diagnosis and Prognosis in Patients With Renal Dysfunction: A Systematic Review and Meta-Analysis

OBJECTIVES

This study sought to determine if amino-terminal pro-B-type natriuretic peptide (NT-proBNP) has different diagnostic and prognostic utility in patients with renal dysfunction.

BACKGROUND

Patients with renal dysfunction have higher NT-proBNP, which may complicate interpretation for diagnosis of acute decompensated heart failure (ADHF) or prognosis.

METHODS

We searched MEDLINE and EMBASE through August 2014 for studies with a subgroup analysis by renal function of the diagnostic or prognostic ability of NT-proBNP.

RESULTS

For diagnosis, 9 studies were included with 4,287 patients and 1,325 ADHF events. Patients were mostly divided into subgroups with and without renal dysfunction by an estimated glomerular filtration rate of 60 ml/min/1.73 m(2). In patients with renal dysfunction, the area under the curve (AUC) for NT-proBNP ranged from 0.66 to 0.89 with a median cutpoint of 1,980 pg/ml, while the AUC ranged from 0.72 to 0.95 with a cutpoint of 450 pg/ml in patients with preserved renal function. For prognosis, 30 studies with 32,203 patients were included, and mortality in patients with renal dysfunction (25.4%) was twice that of patients with preserved renal function (12.2%). The unadjusted pooled risk ratio for NT-proBNP and mortality was 3.01 (95% confidence interval [CI]: 2.53 to 3.58) in patients with preserved renal function and was similar in patients with renal dysfunction (3.25; 95% CI: 2.45 to 4.30). Upon meta-regression, heterogeneity was partially explained if patients with heart failure or coronary artery disease were enrolled.

CONCLUSIONS

NT-proBNP retains utility for diagnosis of ADHF in patients with renal dysfunction with higher cutpoints. Elevated NT-proBNP confers a worse prognosis regardless of renal function.