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      N-Terminal Pro-B-type Natriuretic Peptide and Its Correlation to Haemodialysis-Induced Myocardial Stunning


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          Background: Haemodialysis (HD) is able to induce recurrent myocardial ischemia and segmental left-ventricular dysfunction (myocardial stunning). The association of N-terminal Pro-B-type natriuretic peptide (NTpro-BNP) with HD-induced myocardial stunning is unclear. Methods: In 70 prevalent HD patients, HD-induced myocardial stunning was assessed echocardiographically at baseline and after 12 months. The extent to which pre-dialysis NTpro-BNP was associated with the occurrence of HD-induced myocardial stunning was assessed as the primary endpoint. Results: The median Ntpro-BNP concentration in this cohort was 2,154 pg/ml (IQR 1,224-3,014). Patients experiencing HD-induced myocardial stunning at either time point displayed elevated NTpro-BNP values (2,418 pg/ml, IQR, 1,583-3,474 vs. 1,751 pg/ml, IQR (536-2,029), p = 0.02). NTpro-BNP levels did not differ between patients showing HD-induced stunning at baseline and those developing stunning during the observational period (p = 0.8). NTpro-BNP levels drawn at the beginning of the dialysis session achieved a poor diagnostic accuracy for the detection of myocardial stunning (area under the ROC curve 0.61, 95% CI 0.45-0.77), but provided an accurate rule out for myocardial stunning during the subsequent year (AUC 0.85, 95% CI 0.70-0.99). The calculated cut-off of 1,570 pg/ml achieved a sensitivity of 66% and a specificity of 78% for the exclusion of myocardial stunning at any time point. In logistic regression analysis, only low NTpro-BNP levels (OR 0.92 for every additional 100 pg/ml, 95% CI 0.85-0.99, p = 0.03) were significantly associated with absence of myocardial stunning at any time point. Conclusion: Predialytic NTpro-BNP levels fail to adequately diagnose current dialysis-induced myocardial stunning, but help to identify patients with a propensity to develop dialysis-induced myocardial stunning at any time during the next 12 months.

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          Most cited references12

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          Hemodialysis-induced cardiac injury: determinants and associated outcomes.

          Hemodialysis (HD)-induced myocardial stunning driven by ischemia is a recognized complication of HD, which can be ameliorated by HD techniques that improve hemodynamics. In nondialysis patients, repeated ischemia leads to chronic reduction in left ventricular (LV) function. HD may initiate and drive the same process. In this study, we examined the prevalence and associations of HD-induced repetitive myocardial injury and long-term effects on LV function and patient outcomes. Seventy prevalent HD patients were assessed for evidence of subclinical myocardial injury at baseline using serial echocardiography and followed up after 12 mo. Intradialytic blood pressure, hematologic and biochemical samples, and patient demographics were also collected at both time points. Sixty-four percent of patients had significant myocardial stunning during HD. Age, ultrafiltration volumes, intradialytic hypotension, and cardiac troponin-T (cTnT) levels were independent determinants associated with its presence. Myocardial stunning was associated with increased relative mortality at 12 mo (P = 0.019). Cox regression analysis showed increased hazard of death in patients with myocardial stunning and elevated cTnT than in patients with elevated cTnT alone (P < 0.02). Patients with myocardial stunning who survived 12 mo had significantly lower LV ejection fractions at rest and on HD (P < 0.001). HD-induced myocardial stunning is common, and may contribute to the development of heart failure and increased mortality in HD patients. Enhanced understanding of dialysis-induced cardiac injury may provide novel therapeutic targets to reduce currently excessive rates of cardiovascular morbidity and mortality.
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            The stunned myocardium: prolonged, postischemic ventricular dysfunction.

            Myocardial ischemia has, for many decades, been viewed as an all-or-none process that causes myocardial necrosis when prolonged and severe, but whose effects are transient when it is brief or mild. In view of the evidence that the ischemic process may "hit, run and stun," perhaps our thinking about the consequences of myocardial ischemia should be expanded. According to this formulation, an ischemic insult not of sufficient severity of duration to produce myocardial necrosis may acutely affect myocardial repolarization and cause angina (hit); but these changes wane rapidly (run), when the balance between myocardial oxygen supply and demand has been reestablished. However, the ischemia may interfere with normal myocardial function, biochemical processes and ultrastructure for prolonged periods (stun). The severity and duration of these postischemic changes depend on the length and intensity of the ischemia, as well as on the condition of the myocardium at the onset of the ischemic episode. Furthermore, it is likely that when the myocardium is repeatedly stunned, it may exhibit chronic postischemic left ventricular dysfunction, an ill-defined condition. If prolonged, chronic postischemic left ventricular dysfunction can progress to myocardial scarring and ischemic cardiomyopathy, it may be important to determine how often it can be ameliorated by permanent improvement of myocardial perfusion by surgical treatment.
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              Dialysis-induced regional left ventricular dysfunction is ameliorated by cooling the dialysate.

              Dialysis patients who develop cardiac failure have a poor prognosis. Recurrent subclinical myocardial ischemia is important in the genesis of heart failure in nondialysis patients. It has previously been demonstrated that subclinical ischemia occurs during hemodialysis; therefore, this study examined whether the improved stability of cool-temperature dialysis lessens this phenomenon. Ten patients who were prone to intradialytic hypotension entered a randomized, crossover study to compare the development of dialysis-induced left ventricular (LV) regional wall motion abnormalities (RWMA) at dialysate temperatures of 37 and 35 degrees C. Serial echocardiography with quantitative analysis was used to assess ejection fraction and regional systolic LV function. BP and hemodynamic variables were measured using continuous pulse wave analysis. The severity of thermal symptoms was scored using a simple questionnaire. Forty-nine new RWMA developed in nine patients during hemodialysis with dialysate at 37 degrees C (HD(37)), compared with thirteen RWMA that developed in four patients during HD(35) (odds ratio 3.8; 95% confidence interval 2.1 to 6.9). The majority of RWMA displayed improved function by 30 min after dialysis. Overall, regional systolic LV function was significantly more impaired during HD(37) (P < 0.001). BP was higher during HD(35), with fewer episodes of hypotension as a result of a higher peripheral resistance and no difference in stroke volume. The development of thermal symptoms was heterogeneous, with most patients tolerating HD(35) well. This study confirms previous findings of reversible LV RWMA that develop during hemodialysis. It also shows that this phenomenon can be ameliorated by reducing dialysate temperature, a simple intervention with no cost implications.

                Author and article information

                Nephron Clin Pract
                Nephron Clinical Practice
                S. Karger AG
                August 2013
                18 July 2013
                : 123
                : 1-2
                : 118-122
                School of Graduate Entry Medicine and Health, University of Nottingham Medical School at Derby and Department of Renal Medicine, Royal Derby Hospital, Derby, UK
                Author notes
                *Tobias Breidthardt, MD, Department of Renal Medicine, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE (UK), E-Mail tobias.breidthardt@usb.ch
                351190 Nephron Clin Pract 2013;123:118-122
                © 2013 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.

                : 09 January 2013
                : 04 April 2013
                Page count
                Figures: 2, Tables: 1, Pages: 5
                Original Paper

                Cardiovascular Medicine,Nephrology
                NTpro-BNP,Haemodialysis,Myocardial stunning
                Cardiovascular Medicine, Nephrology
                NTpro-BNP, Haemodialysis, Myocardial stunning


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