Advertisement

Internal and Emergency Medicine

, Volume 12, Issue 5, pp 593–603 | Cite as

Different trajectories and significance of B-type natriuretic peptide, congestion and acute kidney injury in patients with heart failure

  • Matteo Beltrami
  • Gaetano Ruocco
  • Aladino Ibrahim
  • Barbara Lucani
  • Beatrice Franci
  • Ranuccio Nuti
  • Alberto PalazzuoliEmail author
IM - ORIGINAL

Abstract

The exact relationship existing among congestion status, brain natriuretic peptide (BNP) changes and acute kidney injury (AKI) has not been elucidated in patients with acute heart failure (AHF). The aims of this study are: to investigate the relation and prognostic role of BNP, AKI and clinical congestion after discharge; to define the exact BNP cut off value or a BNP in-hospital reduction to identify patients with higher risk during vulnerable post-discharge phase. We consecutively enrolled 157 patients with a diagnosis of AHF. BNP and creatinine were measured in all patients, and degree of failure was assessed. AKI was defined as a creatinine increase ≥0.3 mg/dL or eGFR reduction ≥20% during hospitalization. All patients were followed for 1 and 3 months. Of 146 included patients, 110 patients (75%) displayed effective decongestion, 116 (79%) showed a BNP decrease ≥30%, and 28 (19%) developed in-hospital AKI. BNP in-hospital decrease ≥30% was found more often in patients who showed good decongestion in comparison to patients in persistent failure (63 vs 22%; p < 0.001). The ROC curve analyses at 3 months show that both BNP reduction of 30% between admission and discharge and decongestion at discharge identifies patients with a reduced incidence of cardiovascular events (AUC = 0.79, confidence interval 0.68–0.90, sensibility 90%, sensitivity 50% p < 0.001). Kaplan–Meier survival plots show a better outcome in patients with a BNP decrease ≥30% and good decongestion at discharge (p = 0.03). BNP reduction in AHF is associated with decongestion. BNP reduction associated with decongestion at discharge is a favorable prognostic indicator at 90-day survival irrespective of the AKI occurrence.

Keywords

B-type natriuretic peptide Clinical congestion Heart failure Acute kidney injury Outcome 

Notes

Acknowledgements

MB made a substantial contribution to the concept or design of the work; or acquisition, analysis or interpretation of the data; GR made a substantial contribution to the concept or design of the work; or acquisition, analysis or interpretation of the data; AI revised the english language; BL analyzed blood samples; BF analyzed blood samples; AP made a substantial contribution to the concept or design of the work; or acquisition, analysis or interpretation of the data, drafted the article or revised it critically for important intellectual content and approved the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Statement of human and animal rights

This study was approved by the Local Investigational Human Review Board.

Informed consent

All patients gave their signed informed consent.

References

  1. 1.
    Gheorghiade M, Zannad F, Sopko G, Klein L, Piña IL, Konstam MA, Massie BM, Roland E, Targum S, Collins SP, Filippatos G, Tavazzi L, International Working Group on Acute Heart Failure Syndromes (2005) Acute heart failure syndromes: current state and framework for future research. Circulation 112:3958–3968CrossRefPubMedGoogle Scholar
  2. 2.
    Lala A, McNulty SE, Mentz RJ, Dunlay SM, Vader JM, AbouEzzeddine OF, DeVore AD, Khazanie P, Redfield MM, Goldsmith SR, Bart BA, Anstrom KJ, Felker GM, Hernandez AF, Stevenson LW (2015) Relief and recurrence of congestion during and after hospitalization for acute heart failure: insights from diuretic optimization strategy evaluation in acute decompensated heart failure (DOSE-AHF) and cardiorenal rescue study in acute decompensated heart failure (CARESS-HF). Circ Heart Fail 8:741–748CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Gheorghiade M, Gattis WA, O’Connor CM, Adams KF Jr, Elkayam U, Barbagelata A, Ghali JK, Benza RL, McGrew FA, Klapholz M, Ouyang J, Orlandi C, Acute and Chronic Therapeutic Impact of a Vasopressin Antagonist in Congestive Heart Failure (ACTIV in CHF) Investigators (2004) Effects of tolvaptan, a vasopressin antagonist, in patients hospitalized with worsening heart failure: a randomized controlled trial. JAMA 291:1963–1971CrossRefPubMedGoogle Scholar
  4. 4.
    Kelder JC, Cramer MJ, van Wijngaarden J, van Tooren R, Mosterd A, Moons KG, Lammers JW, Cowie MR, Grobbee DE, Hoes AW (2011) The diagnostic value of physical examination and additional testing in primary care patients with suspected heart failure. Circulation 124:2865–2873CrossRefPubMedGoogle Scholar
  5. 5.
    Palazzuoli A, Beltrami M, Ruocco G, Pellegrini M, Nuti R (2013) The role of natriuretic peptides for the diagnosis of left ventricular dysfunction. Sci World J 2013:784670CrossRefGoogle Scholar
  6. 6.
    Maisel AS, Krishnaswamy P, Nowak RM, McCord J, Hollander JE, Duc P, Omland T, Storrow AB, Abraham WT, Wu AH, Clopton P, Steg PG, Westheim A, Knudsen CW, Perez A, Kazanegra R, Herrmann HC, McCullough PA; (2002) Breathing Not Properly Multinational Study Investigators. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med 347:161–167Google Scholar
  7. 7.
    Aspromonte N, Valle R, Peacock WF, Vanderheyden M, Maisel A (2008) Inpatient monitoring and prognostic importance of B-type natriuretic peptide. Congest Heart Fail 14:30–34CrossRefPubMedGoogle Scholar
  8. 8.
    Bellomo R, Kellum JA, Ronco C (2012) Acute kidney injury. Lancet 380:756–766CrossRefPubMedGoogle Scholar
  9. 9.
    Smith GL, Lichtman JH, Bracken MB, Shlipak MG, Phillips CO, DiCapua P, Krumholz HM (2006) Renal impairment and outcomes in heart failure systematic review and meta-analysis. J Am Coll Cardiol 47:1987–1996CrossRefPubMedGoogle Scholar
  10. 10.
    Kociol RD, McNulty SE, Hernandez AF, Lee KL, Redfield MM, Tracy RP, Braunwald E, O’Connor CM, Felker GM, NHLBI Heart Failure Network Steering Committee and Investigators (2013) Markers of decongestion, dyspnea relief, and clinical outcomes among patients hospitalized with acute heart failure. Circ Heart Fail 6:240–245CrossRefPubMedGoogle Scholar
  11. 11.
    Gheorghiade M, Follath F, Ponikowski P, Barsuk JH, Blair JE, Cleland JG, Dickstein K, Drazner MH, Fonarow GC, Jaarsma T, Jondeau G, Sendon JL, Mebazaa A, Metra M, Nieminen M, Pang PS, Seferovic P, Stevenson LW, van Veldhuisen DJ, Zannad F, Anker SD, Rhodes A, McMurray JJ, Filippatos G, European Society of Cardiology, European Society of Intensive Care Medicine (2010) Assessing and grading congestion in acute heart failure: a scientific statement from the acute heart failure committee of the heart failure association of the European Society of Cardiology and endorsed by the European Society of Intensive Care Medicine. Eur J Heart Fail 12:423–433CrossRefPubMedGoogle Scholar
  12. 12.
    Kidney Disease Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. Kidney Disease: Improving Global Outcomes (KDIGO) (2012) KDIGO clinical practice guideline for acute kidney injury. Kidney Int 2(Suppl. 1):1–138Google Scholar
  13. 13.
    Levey AS, Coresh J, Greene T, Stevens LA, Zhang YL, Hendriksen S, Kusek JW, Van Lente F, Chronic Kidney Disease Epidemiology Collaboration (2006) Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med 145:247–254CrossRefPubMedGoogle Scholar
  14. 14.
    Di Somma S, Marino R, Zampini G, Magrini L, Ferri E, Shah K, Clopton P, Maisel AS (2015) Predictive value for death and rehospitalization of 30-day postdischarge B-type natriuretic peptide (BNP) in elderly patients with heart failure. Sub-analysis of Italian RED Study. Clin Chem Lab Med 53:507–513CrossRefPubMedGoogle Scholar
  15. 15.
    Greene SJ, Maggioni AP, Fonarow GC, Solomon SD, Böhm M, Kandra A, Prescott MF, Reimund B, Hua TA, Lesogor A, Zannad F, Gheorghiade M, ASTRONAUT Investigators and Coordinators (2015) Clinical profile and prognostic significance of natriuretic peptide trajectory following hospitalization for worsening chronic heart failure: findings from the ASTRONAUT trial. Eur J Heart Fail 17:98–108CrossRefPubMedGoogle Scholar
  16. 16.
    Metra M, Dei Cas L, Bristow MR (2008) The pathophysiology of acute heart failure—it is a lot about fluid accumulation. Am Heart J 144:1–5CrossRefGoogle Scholar
  17. 17.
    O’Connor CM, Hasselblad V, Mehta RH, Tasissa G, Califf RM, Fiuzat M, Rogers JG, Leier CV, Stevenson LW (2010) Triage after hospitalization with advanced heart failure: the ESCAPE (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness) risk model and discharge score. J Am Coll Cardiol 55:872–878CrossRefPubMedGoogle Scholar
  18. 18.
    Ambrosy AP, Pang PS, Khan S, Konstam MA, Fonarow GC, Traver B, Maggioni AP, Cook T, Swedberg K, Burnett JC Jr, Grinfeld L, Udelson JE, Zannad F, Gheorghiade M, EVEREST Trial Investigators (2013) Clinical course and predictive value of congestion during hospitalization in patients admitted for worsening signs and symptoms of heart failure with reduced ejection fraction: findings from the EVEREST trial. Eur Heart J 34:835–843CrossRefPubMedGoogle Scholar
  19. 19.
    Metra M, Davison B, Bettari L, Sun H, Edwards C, Lazzarini V, Piovanelli B, Carubelli V, Bugatti S, Lombardi C, Cotter G, Dei Cas L (2012) Is worsening renal function an ominous prognostic sign in patients with acute heart failure? The role of congestion and its interaction with renal function. Circ Heart Fail 5:54–62CrossRefPubMedGoogle Scholar
  20. 20.
    Maisel A, Hollander JE, Guss D, McCullough P, Nowak R, Green G, Saltzberg M, Ellison SR, Bhalla MA, Bhalla V, Clopton P, Jesse R; (2004) Rapid Emergency Department Heart Failure Outpatient Trial investigators. Primary results of the rapid emergency department heart failure outpatient trial (REDHOT): a multicenter study of B-type natriuretic peptide levels, emergency department decision making, and outcomes in patients presenting with shortness of breath. J Am Coll Cardiol 44:1328–1333Google Scholar
  21. 21.
    Palazzuoli A, Pellegrini M, Ruocco G, Martini G, Franci B, Campagna MS, Gilleman M, Nuti R, McCullough PA, Ronco C (2014) Continuous versus bolus intermittent loop diuretic infusion in acutely decompensated heart failure: a prospective randomized trial. Crit Care 18:R134CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Parrinello G, Paterna S, Di Pasquale P, Torres D, Mezzero M, Cardillo M, Fasullo S, La Rocca G, Licata G (2011) Changes in estimating echocardiography pulmonary capillary wedge pressure after hypersaline plus furosemide versus furosemide alone in decompensated heart failure. J Card Fail 17:331–339CrossRefPubMedGoogle Scholar
  23. 23.
    Richards AM, Doughty R, Nicholls MG, MacMahon S, Sharpe N, Murphy J, Espiner EA, Frampton C, Yandle TG, Australia–New Zealand Heart Failure Group (2001) Plasma N-terminal pro-brain natriuretic peptide and adrenomedullin: prognostic utility and prediction of benefit from carvedilol in chronic ischemic left ventricular dysfunction. J Am Coll Cardiol 37:1781–1787CrossRefPubMedGoogle Scholar
  24. 24.
    Fonarow GC, Peacock WF, Phillips CO, Givertz MM, Lopatin M (2009) Admission B-type natriuretic peptide levels and in-hospital mortality in acute decompensated heart failure. J Am Coll Cardiol 49:1943–1950CrossRefGoogle Scholar
  25. 25.
    Jourdain P, Jondeau G, Funck F, Gueffet P, Le Helloco A, Donal E, Aupetit JF, Aumont MC, Galinier M, Eicher JC, Cohen-Solal A, Juillière Y (2007) Plasma brain natriuretic peptide-guided therapy to improve outcome in heart failure: the STARS-BNP Multicenter Study. J Am Coll Cardiol 49:1733–1739CrossRefPubMedGoogle Scholar
  26. 26.
    Karlström P, Alehagen U, Boman K, Dahlström U, UPSTEP-study group (2011) Brain natriuretic peptide-guided treatment does not improve morbidity and mortality in extensively treated patients with chronic heart failure: responders to treatment have a significantly better outcome. Eur J Heart Fail 13:1096–1103CrossRefPubMedGoogle Scholar
  27. 27.
    Shah MR, Califf RM, Nohria A, Bhapkar M, Bowers M, Mancini DM, Fiuzat M, Stevenson LW, O’Connor CM (2011) The STARBRITE trial: a randomized, pilot study of B-type natriuretic peptide-guided therapy in patients with advanced heart failure. J Card Fail 17:613–621CrossRefPubMedGoogle Scholar
  28. 28.
    Noveanu M, Breidthardt T, Potocki M, Reichlin T, Twerenbold R, Uthoff H, Socrates T, Arenja N, Reiter M, Meissner J, Heinisch C, Stalder S, Mueller C (2011) Direct comparison of serial B-type natriuretic peptide and NT-proBNP levels for prediction of short- and long-term outcome in acute decompensated heart failure. Crit Care 15:R1CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Mentz RJ, Kjeldsen K, Rossi GP, Voors AA, Cleland JG, Anker SD, Gheorghiade M, Fiuzat M, Rossignol P, Zannad F, Pitt B, O’Connor C, Felker GM (2014) Decongestion in acute heart failure. Eur J Heart Fail 16:471–482CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Richards AM, Troughton RW (2012) Use of natriuretic peptides to guide and monitor heart failure therapy. Clin Chem 58(1):62–71CrossRefPubMedGoogle Scholar
  31. 31.
    De Berardinis B, Gaggin HK, Magrini L, Belcher A, Zancla B, Femia A, Simon M, Motiwala S, Bhardwaj A, Parry BA, Nagurney JT, Coudriou C, Legrand M, Sadoune M, Di Somma S, Januzzi JL Jr, Global Research on Acute Conditions Team (GREAT) (2015) Comparison between admission natriuretic peptides, NGAL and sST2 testing for the prediction of worsening renal function in patients with acutely decompensated heart failure. Clin Chem Lab Med 53:613–621CrossRefPubMedGoogle Scholar
  32. 32.
    Forman DE, Butler J, Wang Y, Abraham WT, O’Connor CM, Gottlieb SS, Loh E, Massie BM, Rich MW, Stevenson LW, Young JB, Krumholz HM (2004) Incidence, predictors at admission, and impact of worsening renal function among patients hospitalized with heart failure. J Am Coll Cardiol 43:61–67CrossRefPubMedGoogle Scholar
  33. 33.
    van Deursen VM, Hernandez AF, Stebbins A, Hasselblad V, Ezekowitz JA, Califf RM, Gottlieb SS, O’Connor CM, Starling RC, Tang WH, McMurray JJ, Dickstein K, Voors AA (2014) Nesiritide, renal function, and associated outcomes during hospitalization for acute decompensated heart failure: results from the Acute Study of Clinical Effectiveness of Nesiritide and Decompensated Heart Failure (ASCEND-HF). Circulation 130:958–965CrossRefPubMedGoogle Scholar
  34. 34.
    Berra G, Garin N, Stirnemann J, Jannot AS, Martin PY, Perrier A, Carballo S (2015) Outcome in acute heart failure: prognostic value of acute kidney injury and worsening renal function. J Card Fail 21:382–390CrossRefPubMedGoogle Scholar
  35. 35.
    Cowie MR, Komajda M, Murray-Thomas T, Underwood J, Ticho B, Investigators POSH (2006) Prevalence and impact of worsening renal function in patients hospitalized with decompensated heart failure: results of the prospective outcomes study in heart failure (POSH). Eur Heart J 27:1216–1222CrossRefPubMedGoogle Scholar
  36. 36.
    Nohria A, Hasselblad V, Stebbins A, Pauly DF, Fonarow GC, Shah M, Yancy CW, Califf RM, Stevenson LW, Hill JA (2008) Cardiorenal interactions:insights from the ESCAPE trial. J Am Coll Cardiol 51:1268–1274CrossRefPubMedGoogle Scholar
  37. 37.
    Núñez J, Garcia S, Núñez E, Bonanad C, Bodí V, Miñana G, Santas E, Escribano D, Bayes-Genis A, Pascual-Figal D, Chorro FJ, Sanchis J (2014) Early serum creatinine changes and outcomes in patients admitted for acute heart failure: the cardio-renal syndrome revisited. Eur Heart J Acute Cardiovasc Care. doi: 10.1177/2048872614540094
  38. 38.
    Ather S, Bavishi C, McCauley MD, Dhaliwal A, Deswal A, Johnson S, Chan W, Aguilar D, Pritchett AM, Ramasubbu K, Wehrens XH, Bozkurt B (2013) Worsening renal function is not associated with response to treatment in acute heart failure. Int J Cardiol 167:1912–1917CrossRefPubMedGoogle Scholar
  39. 39.
    Sheerin NJ, Newton PJ, Macdonald PS, Leung DY, Sibbritt D, Spicer ST, Johnson K, Krum H, Davidson PM (2014) Worsening renal function in heart failure: the need for a consensus definition. Int J Cardiol 174:484–491CrossRefPubMedGoogle Scholar

Copyright information

© SIMI 2017

Authors and Affiliations

  • Matteo Beltrami
    • 1
  • Gaetano Ruocco
    • 1
  • Aladino Ibrahim
    • 1
  • Barbara Lucani
    • 1
  • Beatrice Franci
    • 1
  • Ranuccio Nuti
    • 1
  • Alberto Palazzuoli
    • 1
    • 2
    Email author
  1. 1.Cardiovascular Diseases Unit, Department of Internal Medicine, S. Maria alle Scotte HospitalUniversity of SienaSienaItaly
  2. 2.Department of Internal Medicine and Metabolic Diseases, CardiologyLe Scotte HospitalSienaItaly

Personalised recommendations