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      Is Brain Natriuretic Peptide a Reliable Biomarker of Hydration Status in All Peritoneal Dialysis Patients?

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          Abstract

          Background: Achievement of euvolemia is a fundamental challenge in the peritoneal dialysis (PD) population. Bioimpedance spectroscopy (BIS) is one of the best techniques for routine assessment of hydration status (HS) in PD, but in recent years, the role of brain natriuretic peptides (BNP) in the assessment of volume status has gained interest. The aim of this study was to investigate the relation between BNP and volume status as measured by BIS in PD patients and to assess how these variables correlate according to the time that a patient has been on PD. Methods: We prospectively studied 68 PD patients from whom measurements of BNP and assessments of HS by BIS were performed every 3 months. Three groups were defined based on HS: group A, measurements of HS <-1.1 liters (underhydrated); group B, measurements of HS between -1.1 and +1.1 liters (normohydrated), and group C, measurements of HS >+1.1 liters (overhydrated). Measurements were also separated according to the time on PD (<6 vs. ≥6 months). Correlation between HS and BNP was performed using Spearman's correlation. Results: We performed a total of 478 measurements of HS and BNP. There was a statistically significant difference in BNP (p < 0.001) among three HS groups, with higher levels of BNP detected in overhydrated patients. We found a positive correlation between HS and BNP (r<sub>s</sub> = 0.28; p <0.001) that seemed stronger in the first 6 months on PD (r<sub>s</sub> = 0.42; p = 0.006). Conclusions: BNP correlated positively with fluid overload measured by HS, and this correlation was stronger in the first 6 months on PD.

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          Most cited references 15

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          Towards improved cardiovascular management: the necessity of combining blood pressure and fluid overload.

          Hypertension and fluid overload (FO) are well-recognized problems in the chronic kidney disease (CKD) population. While the prevalence of hypertension is well documented, little is known about the severity of FO in this population. A new bioimpedance spectroscopy device (BCM-Body Composition Monitor) was selected that allows quantitative determination of the deviation in hydration status from normal ranges (DeltaHS). Pre-dialysis systolic blood pressure (BPsys) and DeltaHS was analysed in 500 haemodialysis patients from eight dialysis centres. A graphical tool (HRP-hydration reference plot) was devised allowing DeltaHS to be combined with measurements of BPsys enabling comparison with a matched healthy population (n = 1244). Nineteen percent of patients (n = 95) were found to have normal BPsys and DeltaHS in the normal range. Approximately one-third of patients (n = 133) exhibited reasonable control of BPsys and fluids (BPsys 150 mmHg) with a concomitant DeltaHS >2.5 L (possible volume-dependent hypertension). In contrast, 13% of patients (n = 69) were hypertensive with DeltaHS <1.1 L (possible essential hypertension). In 10% of patients (n = 52), BPsys <140 mmHg was recorded despite DeltaHS exceeding 2.5 L. Our study illustrated the wide variability in BPsys regardless of the degree of DeltaHS. The HRP provides an invaluable tool for classifying patients in terms of BPsys and DeltaHS and the proximity of these parameters to reference ranges. This represents an important step towards more objective choice of strategies for the optimal treatment of hypertension and FO. Further studies are required to assess the prognostic and therapeutic role of the HRP.
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            Predischarge B-type natriuretic peptide assay for identifying patients at high risk of re-admission after decompensated heart failure.

            The aim of this study was to determine the value of serial B-type natriuretic peptide (BNP) assay for predicting post-discharge outcome of patients admitted for decompensated congestive heart failure (CHF). Patients hospitalized for decompensated CHF are frequently re-admitted. Thus, identification of high-risk patients before their discharge is a major issue that remains challenging. B-type natriuretic peptide measurement could be useful. Serial BNP measurements were performed from admission to discharge in two samples of consecutive patients. Survivors were monitored for six months; the main end point combined death or first re-admission for CHF. Among the 105 survivors of the derivation study, all serial BNP values, percentage change in BNP levels, and predischarge Doppler mitral pattern correlated with the outcome. In contrast, clinical variables and left ventricular ejection fraction were poorly predictive. The predischarge BNP assay had the best discriminative power (area under the receiver operating characteristic [ROC] curve = 0.80) and remained the lone significant variable in multivariate analysis (hazard ratio [HR] = 1.14 [95% confidence interval [CI], 1.02 to 1.28], p = 0.027). Among the 97 survivors of the validation study, the predischarge BNP assay was also the most predictive parameter (area under the ROC curve = 0.83). The risk of death or re-admission increased in stepwise fashion across increasing predischarge BNP ranges (p 700 ng/l, compared with BNP <350 ng/l. High predischarge BNP assay is a strong, independent marker of death or re-admission after decompensated CHF, more relevant than common clinical or echocardiographic parameters and more relevant than changes in BNP levels during acute cares.
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              Biology of the natriuretic peptides.

              The biology of the natriuretic peptide (NP) system is complex, yet highly phylogenetically preserved. It regulates salt and water handling, promotes vasodilatation, and exerts favorable effects on the heart in the context of processes such as heart failure. Prior assumptions about the production of B-type NP (BNP) and its amino-terminal precursor fragment (NT-proBNP) have recently been refuted. It is now recognized that rather than a 1:1 secretion of these 2 NPs, a mixture of cleaved and uncleaved NPs is released by the cardiomyocyte. It is also recognized that BNP is rapidly modified into a mixture of various fragments. Commercial assays for the detection of BNP and NT-proBNP measure a mixture of cleaved and uncleaved NPs as well as varying amounts of degraded BNP. BNP and NT-proBNP are cleared differentially: BNP is actively removed from the bloodstream and also has passive clearance mechanisms, including renal clearance; NT-proBNP is cleared more passively by organs with high rates of blood flow, including the kidney.
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                Author and article information

                Journal
                BPU
                Blood Purif
                10.1159/issn.0253-5068
                Blood Purification
                S. Karger AG
                0253-5068
                1421-9735
                2014
                July 2014
                12 June 2014
                : 37
                : 3
                : 238-242
                Affiliations
                aDepartment of Nephrology, Ospedale S. Bortolo, and bInternational Renal Research Institute of Vicenza, Vicenza, Italy; cDepartment of Nephrology and Internal Medicine, University of Virginia, Charlottesville, Va., USA
                Author notes
                *Claudio Ronco, Department of Nephrology, Dialysis and Transplantation, IRRIV, San Bortolo Hospital, Viale Rodolfi, 37, IT-36100 Vicenza (Italy), E-Mail cronco@goldnet.it
                Article
                362155 Blood Purif 2014;37:238-242
                10.1159/000362155
                24943906
                © 2014 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 1, Tables: 3, Pages: 5
                Categories
                Original Paper

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