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      Association between Brain Natriuretic Peptide and Extracellular Water in Hemodialysis Patients

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          Background: Brain natriuretic peptide (BNP) is a hormone released by the left ventricle (LV) as a consequence of pressure or volume load. BNP increases in left ventricle hypertrophy (LVH), LV dysfunction, and it can also predict cardiovascular mortality in the general population as well as those undergoing hemodialysis (HD). We investigated the association between BNP and volume load in HD patients. Methods: We studied 32 HD patients (60 ± 17.1 years) treated thrice-weekly for at least 6 months. Exclusion criteria were: LV dysfunction, atrial fibrillation, malnutrition. Blood chemistries and BNP were determined on mid-week HD day. Blood pressure (BP) and cardiac diameters were determined on mid-week inter-HD day by using 24-hour ambulatory blood pressure monitoring and echocardiography. Bioimpedance was performed after HD and extracellular water (ECW%), calculated as a percentage of total body water, was considered as the index of volume load. Results: Patients were divided into quartiles of 8 patients depending on the BNP value: 1st qtl BNP ≤45.5 pg/ml (28.4 ± 10.9 pg/ml), 2nd qtl BNP > 45.5 pg/ml and ≤99.1 pg/ml (60.9 ± 15.8 pg/ml), 3rd qtl BNP > 99.1 pg/ml and ≤231.8 pg/ml (160.5 ± 51.8 pg/ml), 4th qtl BNP > 231.8 pg/ml (664.8 ± 576.6 pg/ml). No inter-quartile differences were reported in age, HD age, body mass index spKt/V, or blood chemistries. As expected patients in the 4th BNP quartile showed the highest values of 24-hour pulse pressure (PP) and LV mass index (LVMi). The study of body composition revealed significant differences in ECW%, which was higher in the 4th quartile when compared to the others (4th q: 50 ± 9.6%, vs 1st q. 40.1 ± 2.4%, 2nd q. 41.9 ± 5%, 3rd q. 42.8 ± 6.9%). Using multiple stepwise linear regression where BNP was the dependent variable, and PP and ECW% the independent variables, only ECW% maintained statistical significance as a predictor of BNP levels (PP: Beta = 0.86, p = 0.58; ECW%: Beta = 0.64, p < 0.001 p < 0.001). Conclusions: Few studies have investigated the relationship between plasma BNP and volume load, and direct evidence is lacking. We used bioimpedance and the determination of ECW% to assess volume state in HD patients finding an association between BNP and ECW. The increased synthesis and release of BNP from the LV in HD patients appear to be mainly related to volume stress rather than to pressure load.

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            Biochemical detection of left-ventricular systolic dysfunction

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              The Prognostic Role of Brain Natriuretic Peptides in Hemodialysis Patients

              Background: Although plasma concentrations of brain natriuretic peptides (BNP) increase in hemodialysis (HD) patients as well as patients with cardiovascular diseases (CD), the clinical significance of BNP in HD patients has yet to be elucidated. In this study, we investigated the pathophysiological significance of BNP in HD patients. Methods: Plasma BNP concentrations were measured in 164 HD patients after HD and 14 healthy volunteers. In 12 patients without CD, BNP was also measured before HD. Multiple regression analysis was performed to determine the important factors causing increased plasma BNP concentrations. Cardiac mortality was monitored for 36 months after baseline analysis, and the prognostic role of BNP was examined by Cox proportional hazards regression analysis. Results: Plasma BNP concentrations of HD patients without CD decreased significantly during HD session (124.5 ± 90.7 vs. 91.4 ± 67.6 pg/ml, mean ± SD, p = 0.004), but were still significantly higher than those of the healthy subjects (9.7 ± 9.2 pg/ml, p = 0.0002). Plasma BNP concentrations of patients with CD were significantly higher than of those without CD (579.6 ± 564.3 vs. 204.0 ± 241.5 pg/ml, p 2 = 0.303, p 700 pg/ml) differed between the four groups (p 700 pg/ml) had the lowest survival. When compared with patients with BNP 700 pg/ml were 2.3 [95% confidence interval (CI) 0.14–36.7], 18.7 (1.9–183.4) and 51.9 (6.5–416.3), respectively. The univariate Cox proportional hazards model showed that BNP, left ventricular ejection fraction, LVMI, age, DM, serum albumin and C-reactive protein (CRP) were significantly associated with the risk of cardiac mortality. By stepwise multivariate Cox proportional hazards analysis, only BNP, LVMI and CRP remained powerful independent predictors of cardiac death. The relative risk ratios were 1.002 (95% CI 1.001–1.002) for BNP, 2.192 (1.532–3.135) for CRP and 1.027 (1.013–1.042) for LVMI. Conclusion: High plasma BNP concentrations in HD patients were associated with volume overload, left ventricular hypertrophy, CD and DM. Plasma BNP concentration may be a useful parameter for assessing the risk of cardiac death in HD patients by providing prognostic information independently of other variables previously reported.

                Author and article information

                Nephron Clin Pract
                Nephron Clinical Practice
                S. Karger AG
                October 2003
                17 November 2004
                : 95
                : 2
                : c60-c66
                aNephrology-Dialysis Department, Ospedale Silvestrini, Azienda Ospedaliera di Perugia, bInstitute of Nuclear Medicine, University of Perugia, and cCardiology Department, Ospedale Silvestrini, Azienda Ospedaliera di Perugia, Perugia, Italy
                73669 Nephron Clin Pract 2003;95:c60–c66
                © 2003 S. Karger AG, Basel

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                Figures: 4, Tables: 4, References: 44, Pages: 1
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