natriuretic-peptide--brain and Water-Electrolyte-Imbalance

The majority of patients undergoing peritoneal dialysis (PD) suffer from volume overload and this overhydration is associated with increased mortality. Thus, optimal assessment of volume status in PD is an issue of paramount importance. Patient symptoms and physical signs are often unreliable indexes of true hydration status.. Over the past decades, a quest for a valid, reproducible, and easily applicable technique to assess hydration status is taking place. Among existing techniques, inferior vena cava diameter measurements with echocardiography and natriuretic peptides such as brain natriuretic peptide and N-terminal pro-B-type natriuretic peptide were not extensively examined in PD populations; while having certain advantages, their interpretation are complicated by the underlying cardiac status and are not widely available. Bioelectrical impedance analysis (BIA) techniques are the most studied tool assessing volume overload in PD. Volume overload assessed with BIA has been associated with technique failure and increased mortality in observational studies, but the results of randomized trials on the value of BIA-based strategies to improve volume-related outcomes are contradictory. Lung ultrasound (US) is a recent technique with the ability to identify volume excess in the critical lung area. Preliminary evidence in PD showed that B-lines from lung US correlate with echocardiographic parameters but not with BIA measurements. This review presents the methods currently used to assess fluid status in PD patients and discusses existing data on their validity, applicability, limitations, and associations with intermediate and hard outcomes in this population. Key Message: No method has proved its value as an intervening tool affecting cardiovascular events, technique, and overall survival in PD patients. As BIA and lung US estimate fluid overload in different compartments of the body, they can be complementary tools for volume status assessment.

Topics: Body Composition; Echocardiography; Electric Impedance; Humans; Kidney Failure, Chronic; Lung; Natriuretic Peptide, Brain; Nephrology; Peritoneal Dialysis; Predictive Value of Tests; Prognosis; Risk Assessment; Ultrasonography; Vena Cava, Inferior; Water-Electrolyte Imbalance

Adequate assessment of fluid status is an imperative objective in the management of all types of patients in cardiology, intensive care, and especially nephrology. Fluid overload is one of the most common modifiable risk factors directly associated with hypertension, heart failure, left ventricular hypertrophy, and eventually, higher morbidity and mortality risk in these categories of patients. Different methods are commonly used to determine fluid status (eg, clinical assessment, natriuretic peptide concentrations, echocardiography, inferior vena cava measurements, or bioimpedance analysis). In recent years, lung ultrasonography (LUS), through the assessment of extravascular lung water, has received growing attention in clinical research. This article summarizes available studies that compare LUS with other methods for fluid status assessment in patients with kidney diseases. At the same time, it also presents the association of LUS with different outcomes (physical functioning, mortality, and cardiovascular events) in the same population. It appears that this simple bedside noninvasive technique has significant clinical potential in nephrology.

Topics: Aged; Echocardiography, Doppler; Female; Follow-Up Studies; Heart Failure; Humans; Kidney Failure, Chronic; Male; Middle Aged; Natriuretic Peptide, Brain; Pulmonary Edema; Renal Dialysis; Risk Assessment; Survival Rate; Treatment Outcome; Ultrasonography, Doppler; Water-Electrolyte Imbalance

This review discusses renal sodium handling in heart failure. Increased sodium avidity and tendency to extracellular volume overload, i.e. congestion, are hallmark features of the heart failure syndrome. Particularly in the case of concomitant renal dysfunction, the kidneys often fail to elicit potent natriuresis. Yet, assessment of renal function is generally performed by measuring serum creatinine, which has inherent limitations as a biomarker for the glomerular filtration rate (GFR). Moreover, glomerular filtration only represents part of the nephron's function. Alterations in the fractional reabsorptive rate of sodium are at least equally important in emerging therapy-refractory congestion. Indeed, renal blood flow decreases before the GFR is affected in congestive heart failure. The resulting increased filtration fraction changes Starling forces in peritubular capillaries, which drive sodium reabsorption in the proximal tubules. Congestion further stimulates this process by augmenting renal lymph flow. Consequently, fractional sodium reabsorption in the proximal tubules is significantly increased, limiting sodium delivery to the distal nephron. Orthosympathetic activation probably plays a pivotal role in those deranged intrarenal haemodynamics, which ultimately enhance diuretic resistance, stimulate neurohumoral activation with aldosterone breakthrough, and compromise the counter-regulatory function of natriuretic peptides. Recent evidence even suggests that intrinsic renal derangements might impair natriuresis early on, before clinical congestion or neurohumoral activation are evident. This represents a paradigm shift in heart failure pathophysiology, as it suggests that renal dysfunction-although not by conventional GFR measurements-is driving disease progression. In this respect, a better understanding of renal sodium handling in congestive heart failure is crucial to achieve more tailored decongestive therapy, while preserving renal function.

Topics: Atrial Natriuretic Factor; Diuretics; Glomerular Filtration Rate; Heart Failure; Humans; Kidney; Kidney Glomerulus; Kidney Tubules; Natriuretic Peptide, Brain; Renal Circulation; Renal Insufficiency, Chronic; Sodium; Water-Electrolyte Imbalance

The cardio-renal syndromes (CRS) are the result of complex bidirectional organ cross-talk between the heart and kidney, with tremendous overlap of diseases such as coronary heart disease, heart failure (HF), and renal dysfunction in the same patient. Volume overload plays an important role in the pathophysiology of CRS. The appropriate treatment of overhydration, particularly in HF and in chronic kidney disease, has been associated with improved outcomes and blood pressure control. Clinical examination alone is often insufficient for accurate assessment of volume status because significant volume overload can exist even in the absence of peripheral or pulmonary edema on physical examination or radiography. Bioelectrical impedance techniques increasingly are being used in the management of patients with HF and those on chronic dialysis. These methods provide more objective estimates of volume status in such patients. Used in conjunction with standard clinical assessment and biomarkers such as the natriuretic peptides, bioimpedance analysis may be useful in guiding pharmacologic and ultrafiltration therapies and subsequently restoring such patients to a euvolemic or optivolemic state. In this article, we review the use of these techniques in CRS.

Topics: Acute Disease; Biomarkers; Blood Volume; Body Composition; Cardio-Renal Syndrome; Dielectric Spectroscopy; Electric Impedance; Heart Failure; Hemofiltration; Humans; Natriuretic Peptide, Brain; Renal Insufficiency, Chronic; Water-Electrolyte Imbalance

The assessment of extracellular fluid volume (ECV) and fluid status is both important and challenging in hemodialysis patients. Extracellular fluid is distributed in two major sub-compartments: interstitial fluid and plasma. A variety of methods are used to assess the ECV, with tracer dilution techniques considered gold standard. However, ECV defined as the distribution space of bromide, sodium, chloride, and ferrocyanide appears to be larger than the distribution volume of inulin and sucrose, suggesting a partial distribution into the intracellular volume. Relative blood volume monitoring, measurement of inferior vena cava diameter by ultrasound and biochemical markers are indirect methods, which do not reflect the ECV and fluid status accurately. Bioimpedance spectroscopy (BIS) techniques enable assessment of ECV and intracellular volume. Currently, BIS appears to be the most practical method for assessing ECV volume and fluid status in dialysis patients.

Topics: Blood Volume; Body Fluids; Body Weight; Electric Impedance; Extracellular Fluid; Humans; Kidney Failure, Chronic; Models, Biological; Natriuretic Peptide, Brain; Plasma Volume; Potassium; Renal Dialysis; Sodium; Spectrum Analysis; Ultrasonography; Vena Cava, Inferior; Water-Electrolyte Imbalance

The key management goals for the stabilization of patients admitted for acutely decompensated heart failure (ADHF) include relief of congestion and restoration of hemodynamic stability. Nevertheless, in spite of clinical improvement, many patients are discharged with hemodynamic congestion. In response to volume expansion, the heart secretes the brain natriuretic peptide (BNP) with a biological action that counter-regulates the activation of the renin-angiotensin-aldosterone system. Since BNP is released by increased volume load and wall stretch, and declines after treatment with drugs of proven efficacy, on the basis of an improvement in filling pressures the level of BNP has been proposed as a 'measure' of congestion. The BNP level of a patient who is admitted with ADHF comprises two components: a baseline, euvolemic 'dry' BNP level and a level induced by volume or pressure overload ('wet' BNP level). So, the prognostic value of BNP during hospitalization depends on the time of measurement: from the lowest on admission when congestion is present (wet BNP) to the highest on clinical and instrumental stability (dry BNP), following the achievement of normohydration, as determined by fluid volume measurement. Euvolemia can be set as the primary goal of treatment for ADHF with dry BNP concentration as a target for discharge other than improvement of symptoms, because high BNP levels predict rehospitalization and death. Discharge criteria utilizing both BNP and hydration status measurement which account for the heterogeneity of the patient population and incorporate different strategies of care should be developed. This could in the next future offer an aid in monitoring heart failure patients or actively guiding optimal titration of therapy.

Topics: Biomarkers; Electric Impedance; Heart Failure; Humans; Natriuretic Peptide, Brain; Water-Electrolyte Imbalance

Ever since the publication of the large scale clinical trials of morbid-mortality, the recommendations concerning the medical treatment of cardiac failure are clear with respect to ACE inhibitors, betablockers, angiotensin receptor antagonists and aldosrerone antagonists with established target doses. As far as the prescription of diuretics go, drugs which are effective in a condition associated with a poor quality of life, it is important to use the minimal dosage because of their deleterious stimulant effects on the rennin-angiotensin-aldosterone system and their metabolic side effects. A review of the clinical trials shows that almost all patients were prescribed diuretics; in over 80% of cases, the drugs are loop diuretics with a preference for furosemide, with increasing doses during the follow-up, infrequently associated with thiazide diuretics. In the short term, diuretics reduce the circulating volume and the BNP. In the long term, high doses are associated with a poor prognosis. The clinician then has to decide on the basis of few objective criteria, especially for the reduction of dosage, despite the introduction of the BNP whose role as an aid to prescription remains to be defined. In addition to the simple prescription of drugs, a global approach to patient management is necessary in cardiac failure; in this context, concerning salt- water equilibrium and diuretics, therapeutic education may have a solid role to play to provide an acceptable quality of life including the reduction of the number of frequent hospital admissions.

Topics: Age Factors; Diuretics; Heart Failure; Humans; Natriuretic Peptide, Brain; Water-Electrolyte Imbalance

Diuretics continue to be a mainstay in patients with CHF. Conventional diuretic therapy is associated, however, with potentially deleterious neurohumoral activation and renal impairment. It is not known to what extent these neurohumoral effects are offset by concurrent therapy with ACE-I, beta-blockers, and other agents. In the past, there was no alternative to conventional diuretic therapy, so their potential for adverse outcome in the long term could not be assessed. Enhancement of the natriuretic peptide system could provide us with a better strategy to treat sodium and water retention. In a unique way, the natriuretic peptides combine several of the beneficial actions of the other diuretics, but without the associated cost. Natriuretic peptides, like conventional diuretics, are natriuretic and diuretic. There are important differences, however. First, unlike conventional diuretics, NPs do not activate RAAS. Activation of this system is associated with progression of CHF. Second, NPs inhibit the sympathetic nervous system, the activation of which is associated with heart failure progression, myocyte necrosis and apoptosis, and arrhythmias. Third, unlike conventional diuretics that lead to a decrease in GFR by reflex mechanisms. NPs maintain or even improve GFR. We now appreciate that some "old" drugs may be beneficial to CHF patients in a new way, as is the case with spironolactone. The survival benefit of this aldosterone antagonist is clear: its usefulness, however, may be more a result of both its antifibrotic actions in addition to its tradional role as a potassium-sparing and natriuretic agent. It is hoped that the SARAs will provide the same survival benefit, but with fewer of the sex-steroid side effects. In addition, AVP-receptor antagonists may become useful tools in the treatment of patients with hyponatremia. Likewise, the A1 AR antagonists may find a role in the CHF armamentarium by providing good diuresis and natriuresis while at the same time maintaining GFR through inhibition of TGF. Many questions remain unanswered, and studies are needed to demonstrate that the positive results seen in basic research translate into improved morbidity and mortality.

Topics: Aldosterone; Antidiuretic Hormone Receptor Antagonists; Atrial Natriuretic Factor; Diuresis; Diuretics; Heart Failure; Humans; Kidney; Mineralocorticoid Receptor Antagonists; Natriuresis; Natriuretic Peptide, Brain; Neprilysin; Purinergic P1 Receptor Antagonists; Sodium Chloride; Water-Electrolyte Imbalance

The delicate interplay between vasoconstrictors and vasodilators preserves glomerular filtration in CHF despite marked hypoperfusion. Activation of vasoconstrictive systems seems to depend on the severity and the chronicity of the disease. The importance of renin-angiotensin, sympathetic nerves, vasopressin and counterregulatory ANP, and prostaglandins in CHF has been elucidated. Possible roles of newly identified substances, such as endothelin and EDRF, deserve investigation.

Topics: Animals; Atrial Natriuretic Factor; Dogs; Dopamine; Endothelins; Heart Failure; Kidney; Natriuretic Peptide, Brain; Nerve Tissue Proteins; Nitric Oxide; Prostaglandins; Rats; Renin-Angiotensin System; Sympathetic Nervous System; Vasopressins; Water-Electrolyte Imbalance

Achievement of decongestion in acute heart failure (AHF) is associated with improved survival and cardiovascular outcomes but can be associated with acute declines in estimated glomerular filtration rate (eGFR). We examined whether the rate of in-hospital decongestion is associated with longer term kidney function decline.. Post hoc analysis of trial data.. Patients with ≥2 measures of kidney function (n = 3,500) from the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) trial.. In-hospital rate of change in assessments of volume overload, including B-type natriuretic peptide (BNP), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and clinical congestion score (0-12); and rate of change in hemoconcentration including measures of hematocrit, albumin, and total protein.. Incident chronic kidney disease GFR category 4 or worse (chronic kidney disease [CKD] categories G4-G5; defined by a new eGFR of <30 mL/min/1.73 m. Multivariable cause-specific hazards models.. Over median 10-month follow-up period, faster decreases in volume overload and more rapid increases in hemoconcentration were associated with a decreased risk of incident CKD G4-G5 and eGFR decline of >40%. In adjusted analyses, for every 6% faster decline in BNP per week, there was a 32% lower risk of both incident CKD G4-G5 (HR, 0.68 [95% CI, 0.58-0.79]) and eGFR decline of >40% (HR, 0.68 [95% CI, 0.57-0.80]). For every 1% faster increase per week in absolute hematocrit, there was a lower risk for both incident CKD G4-G5 (HR, 0.73 [95% CI, 0.64-0.84]) and eGFR decline of >40% (HR, 0.82 [95% CI, 0.71-0.95]), with results consistent for other biomarkers.. Possibility of residual confounding.. These results provide reassurance that more rapid decongestion in patients with AHF does not increase the risk of adverse kidney outcomes in patients with heart failure.

Topics: Biomarkers; Glomerular Filtration Rate; Heart Failure; Humans; Kidney; Natriuretic Peptide, Brain; Renal Insufficiency, Chronic; Risk Factors; Water-Electrolyte Imbalance

To describe the baseline characteristics of participants in the Acetazolamide in Decompensated Heart Failure with Volume Overload (ADVOR) trial and compare these with other contemporary diuretic trials in acute heart failure (AHF).. ADVOR recruited 519 patients with AHF, clinically evident volume overload, elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) and maintenance loop diuretic therapy prior to admission. All participants received standardized loop diuretics and were randomized towards once daily intravenous acetazolamide (500 mg) versus placebo, stratified according to study centre and left ventricular ejection fraction (LVEF) (≤40% vs. >40%). The primary endpoint was successful decongestion assessed by a dedicated score indicating no more than trace oedema and no other signs of congestion after three consecutive days of treatment without need for escalating treatment. Mean age was 78 years, 63% were men, mean LVEF was 43%, and median NT-proBNP 6173 pg/ml. The median clinical congestion score was 4 with an EuroQol-5 dimensions health utility index of 0.6. Patients with LVEF ≤40% were more often male, had more ischaemic heart disease, higher levels of NT-proBNP and less atrial fibrillation. Compared with diuretic trials in AHF, patients enrolled in ADVOR were considerably older with higher NT-proBNP levels, reflecting the real-world clinical situation.. ADVOR is the largest randomized diuretic trial in AHF, investigating acetazolamide to improve decongestion on top of standardized loop diuretics. The elderly enrolled population with poor quality of life provides a good representation of the real-world AHF population. The pragmatic design will provide novel insights in the diuretic treatment of patients with AHF.

Topics: Acetazolamide; Aged; Diuretics; Female; Heart Failure; Humans; Male; Natriuretic Peptide, Brain; Peptide Fragments; Quality of Life; Sodium Potassium Chloride Symporter Inhibitors; Stroke Volume; Ventricular Function, Left; Water-Electrolyte Imbalance

Whether acetazolamide, a carbonic anhydrase inhibitor that reduces proximal tubular sodium reabsorption, can improve the efficiency of loop diuretics, potentially leading to more and faster decongestion in patients with acute decompensated heart failure with volume overload, is unclear.. In this multicenter, parallel-group, double-blind, randomized, placebo-controlled trial, we assigned patients with acute decompensated heart failure, clinical signs of volume overload (i.e., edema, pleural effusion, or ascites), and an N-terminal pro-B-type natriuretic peptide level of more than 1000 pg per milliliter or a B-type natriuretic peptide level of more than 250 pg per milliliter to receive either intravenous acetazolamide (500 mg once daily) or placebo added to standardized intravenous loop diuretics (at a dose equivalent to twice the oral maintenance dose). Randomization was stratified according to the left ventricular ejection fraction (≤40% or >40%). The primary end point was successful decongestion, defined as the absence of signs of volume overload, within 3 days after randomization and without an indication for escalation of decongestive therapy. Secondary end points included a composite of death from any cause or rehospitalization for heart failure during 3 months of follow-up. Safety was also assessed.. A total of 519 patients underwent randomization. Successful decongestion occurred in 108 of 256 patients (42.2%) in the acetazolamide group and in 79 of 259 (30.5%) in the placebo group (risk ratio, 1.46; 95% confidence interval [CI], 1.17 to 1.82; P<0.001). Death from any cause or rehospitalization for heart failure occurred in 76 of 256 patients (29.7%) in the acetazolamide group and in 72 of 259 patients (27.8%) in the placebo group (hazard ratio, 1.07; 95% CI, 0.78 to 1.48). Acetazolamide treatment was associated with higher cumulative urine output and natriuresis, findings consistent with better diuretic efficiency. The incidence of worsening kidney function, hypokalemia, hypotension, and adverse events was similar in the two groups.. The addition of acetazolamide to loop diuretic therapy in patients with acute decompensated heart failure resulted in a greater incidence of successful decongestion. (Funded by the Belgian Health Care Knowledge Center; ADVOR ClinicalTrials.gov number, NCT03505788.).

Topics: Acetazolamide; Acute Disease; Carbonic Anhydrase Inhibitors; Diuretics; Double-Blind Method; Heart Failure; Humans; Natriuretic Peptide, Brain; Sodium; Sodium Potassium Chloride Symporter Inhibitors; Stroke Volume; Symptom Flare Up; Treatment Outcome; Ventricular Function, Left; Water-Electrolyte Imbalance

Fluid-induced hypervolemia may stimulate the release of natriuretic peptides and cause degradation (shedding) of the endothelial glycocalyx layer. Sevoflurane is believed to protect the glycocalyx, but the importance of using sevoflurane to prevent shedding during routine surgery is unclear.. The plasma concentrations of brain natriuretic peptide and two biomarkers of glycocalyx shedding, syndecan-1, and heparan sulfate, were measured in 26 patients randomized to receive general anesthesia with sevoflurane or propofol during open abdominal hysterectomy. The fluid therapy consisted of 25 mL/kg (approximately 2 L) of Ringer´s lactate over 30 minutes. Blood hemoglobin and plasma albumin were used to indicate plasma volume expansion and capillary leakage.. The plasma concentrations of brain natriuretic peptide and shedding products showed low levels throughout the surgery (median brain natriuretic peptide, 21 ng/L; syndecan-1, 12.9 ng/mL; and heparan sulfate, 6.5 µg/mL), but the heparan sulfate concentration increased 2 hours post-operatively (to 17.3 µg/mL, P < .005). No differences were noted between the propofol and sevoflurane groups in any of the measured parameters. Albumin was apparently recruited to the bloodstream during the first 20 minutes, when the intravascular retention of infused fluid was almost 100%. The urine flow was <1 mL/min, despite the vigorous volume loading.. No relevant elevations of brain natriuretic peptide or degradation products of the glycocalyx layer were observed when hypervolemia was induced during open abdominal hysterectomy performed with sevoflurane or propofol anesthesia. Plasma volume expansion from Ringer´s lactate was pronounced.

Topics: Adult; Anesthetics, Inhalation; Anesthetics, Intravenous; Endothelium, Vascular; Female; Fluid Therapy; Glycocalyx; Heparitin Sulfate; Humans; Hysterectomy; Latvia; Male; Middle Aged; Natriuretic Peptide, Brain; Propofol; Ringer's Lactate; Sevoflurane; Syndecan-1; Water-Electrolyte Imbalance

Fluid overload is associated with mortality in haemodialysis patients, and 30% of patients remain fluid-overloaded after dialysis. The aim of this study was to evaluate if implementation of Recova. The impact of the implementation was measured as the proportion of participants at an adequate target weight at the end of the study, assessed as change in symptoms, hydration status, and N-terminal pro-brain natriuretic peptide (NT-proBNP). Nurses were instructed to use Recova every 2 weeks, and the process of the intervention was measured as frequencies of fluid status assessments, bioimpedance measurements, and target weight adjustments.. Forty-nine patients at two haemodialysis units were enrolled. In participants with fluid overload (. Implementation of Recova in haemodialysis care increased the monthly frequencies of bioimpedance measurements and target weight adjustments, and it contributed to symptom reduction.. The Uppsala County Council Registry of Clinical Trials: FoU 2019-0001-15.

Topics: Aged; Aged, 80 and over; Algorithms; Blood Pressure; Decision Support Techniques; Dielectric Spectroscopy; Female; Heart Failure; Humans; Kidney Failure, Chronic; Male; Natriuretic Peptide, Brain; Peptide Fragments; Prospective Studies; Renal Dialysis; Water-Electrolyte Imbalance

Open-irrigated radiofrequency catheter ablation (oiRFA) of atrial fibrillation (AF) imposes a volume load and risk of pulmonary edema. We sought to assess the effect of volume administration during ablation on left atrial (LA) pressure and B-type natriuretic peptide (BNP).. LA pressure was measured via transseptal sheath at the beginning and end of 44 LA ablation procedures in 42 patients. BNP plasma levels were measured before and after 10 procedures.. A median of 3,255 (interquartile range [IQR], 2,014)-mL saline was administered during the procedure. During LA ablation, the median fluid balance was +1,438 (IQR, 1,109) mL and LA pressure increased by median 3.7 (IQR, 5.9) mm Hg (P < 0.001). LA pressure did not change in the 19 procedures with furosemide administration (median ΔP = -0.3 [IQR, 7.1] mm Hg, P = 0.334). The correlation of LA pressure and fluid balance was weak (rs = 0.383, P = 0.021). BNP decreased in all four procedures starting in AF or atrial tachycardia and then converting to sinus rhythm (P = 0.068), and increased in all six procedures starting and finishing in sinus rhythm (P = 0.028). After ablation, symptomatic volume overload responding to diuresis occurred in three patients.. A substantial intravascular volume load during oiRFA can be absorbed with little change in LA pressure, such that LA pressure is not a reliable indicator of the fluid balance. Subsequent redistribution of the volume load imposes a risk after the procedure. Conversion to sinus rhythm may improve ability to acutely accommodate the volume load.

Topics: Atrial Fibrillation; Atrial Pressure; Catheter Ablation; Female; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Reproducibility of Results; Sensitivity and Specificity; Therapeutic Irrigation; Treatment Outcome; Water-Electrolyte Imbalance

In primary care the diagnosis of CHF and ECF accumulation is no triviality. We aimed to predict plasma BNP, CHF and ECF accumulation with segmental impedance spectroscopy while using and extending the electrodes of the conventional electrocardiography.. Three combined multiple electrodes were added to the 15 lead ECG for segmental impedance spectroscopy and for measuring the maximal rate of segmental fluid volume change with heart action at the thorax and the legs. The obtained signals were analyzed by partial correlation analyses in comparison with plasma BNP, CHF classes, ejection fraction by echocardiography and cardiac index by double gas re-breathing. 119 subjects (34 healthy volunteers, 50 patients with CHF, NYHA classes II to IV and 35 patients without CHF) were investigated.. The maximal rate of volume change with heart action at the thorax and at the legs, as well as the ECF/ICF ratio at the legs contribute equally and independently to the prediction of BNP and heart failure in an unknown test sample of 49 patients (multiple r=0.88, p<0.001). The ROC-curve for the predicted plasma BNP>400 pg/ml gave an AUC=0.93. The absence or the presence of heart failure could be predicted correctly by a binomial logistic regression in 92.9 and 87.5% of cases, respectively.. The methodology, which is based on inverse coupling of BNP release and of maximal blood acceleration and on sensitive detection of ECF overload, could enable the diagnosis of CHF with useful sensitivity and specificity while writing a routine-ECG.

Topics: Adult; Aged; Algorithms; Cardiography, Impedance; Chronic Disease; Diagnosis, Computer-Assisted; Electroencephalography; Female; Heart Failure; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Reproducibility of Results; Sensitivity and Specificity; Water-Electrolyte Imbalance

Although hypochloremia is strongly associated with adverse prognosis in acute heart failure (AHF), it is unknown whether incorporating hypochloremia into the preexisting risk model improves the model performance. We calculated the Get With The Guidelines-Heart Failure (GWTG-HF) risk score in 1,428 patients with AHF (derivation cohort) and developed 2 risk scores incorporating brain natriuretic peptide (BNP) into the GWTG-HF risk score (GWTG-BNP risk score) and incorporating both BNP and hypochloremia (GWTG-BNP-Cl risk score). Hypochloremia was defined as <98 mmol/L. The external validation and comparison of model performance were performed in an independent group of 1,256 patients with AHF (validation cohort). All models were tested for in-hospital mortality. Hypochloremia was observed in 9.4% and 12.2% of the derivation and validation cohorts, respectively. Hypochloremia was an independent predictor of in-hospital mortality in the derivation cohort (odds ratio 2.02; p = 0.028). In the validation cohort, the GWTG-HF, GWTG-BNP, and GWTG-BNP-Cl risk scores demonstrated good discrimination (area under the curve: 0.742, 0.749, and 0.763, respectively). However, the GWTG-BNP-Cl risk score was more reliable than the GWTG-HF and GWTG-BNP risk scores in risk reclassification (net reclassification improvement: 0.491 and 0.408, respectively; p <0.01 for both). Moreover, this score demonstrated a good calibration of the GWTG-BNP-Cl model (Hosmer-Lemeshow test: p = 0.479). In conclusion, incorporating hypochloremia into the preexisting risk model improves the model performance.

Topics: Acute Disease; Aged; Aged, 80 and over; Chlorides; Female; Heart Failure; Hospital Mortality; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Practice Guidelines as Topic; Risk Factors; Water-Electrolyte Imbalance

High-output congestive heart failure secondary to high-flow arteriovenous fistula (AVF) has been reported in haemodialysis (HD) patients. As high-flow AVF (HFA) would be expected to result in fluid retention, we conducted an observational study to characterize the relationship between AVF flow (Qa) and extracellular water (ECW) in HD patients.. We measured Qa by ultrasound dilution in prevalent HD outpatients with an AVF in two dialysis centres. The ECW:total body water (TBW) ratio was measured both pre- and post-dialysis by multifrequency bioimpedance analysis. Transthoracic echocardiograms (TTEs) were performed as part of routine clinical management.. We included 140 patients, mean age 62.7 ± 15.7 years, 60.7% male, 47.9% diabetic and 22.9% with coronary revascularization. Mean Qa was 1339 ± 761 mL/min and 22 (15.7%) patients had HFA defined as Qa >2.0 L/min. Qa was positively associated with an upper arm AVF (P = 0.005), body mass index (P = 0.012) and N-terminal pro-brain natriuretic peptide (NT-proBNP) (P = 0.047) and negatively associated with diabetes (P < 0.001) and coronary revascularization (P = 0.005). The ECW:TBW ratio was positively associated with age (P < 0.001), Davies comorbidity index (P = 0.034), peripheral vascular disease (P = 0.030) and NT-proBNP (P = 0.002) and negatively associated with serum albumin (P < 0.001). Qa was not associated with the ECW:TBW ratio (P = 0.744). TTE parameters were not associated with Qa.. In our outpatient HD cohort, high AVF flow was not associated with ECW expansion, either pre- or post-dialysis when accounting for potential confounders. By controlling ECW, high access flow should not necessarily be perceived as a threat to cardiovascular physiology.

Topics: Arteriovenous Fistula; Female; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Prognosis; Renal Dialysis; Ventricular Dysfunction, Right; Water-Electrolyte Imbalance

Post-operative atrial fibrillation (POAF) represents a common complication after cardiac valve or coronary artery bypass surgery. While strain of atrial tissue is known to induce atrial fibrillating impulses, less attention has been paid to potentially strain-promoting values during the peri- and post-operative period. This study aimed to determine the association of peri- and post-operative volume substitution with markers of cardiac strain and subsequently the impact on POAF development and promotion.. A total of 123 (45.4%) individuals were found to develop POAF. Fluid balance within the first 24 hours after surgery was significantly higher in patients developing POAF as compared to non-POAF individuals (+1129.6 mL [POAF] vs +544.9 mL [non-POAF], P = .044). Post-operative fluid balance showed a direct and significant correlation with post-operative N-terminal pro-brain natriuretic peptide (NT-ProBNP) values (r = .287; P = .002). Of note, the amount of substituted volume significantly proved to be a strong and independent predictor for POAF with an adjusted odds ratio per one litre of 1.44 (95% CI: 1.09-1.31; P = .009). In addition, we observed that low pre-operative haemoglobin levels at admission were associated with a higher need of intraoperative transfusions and volume-demand.. Substitution of larger transfusion volumes presents a strong and independent predictor for the development of POAF. Via the observed distinct association with NT-proBNP values, it can reasonably be assumed that post-operative atrial fibrillating impulses are triggered via increased global cardiac strain. Optimized pre-operative management of pre-existing anaemia should be considered prior surgical intervention in terms of a personalized patient care.

Topics: Aged; Anemia; Atrial Fibrillation; Blood Transfusion; Cardiac Surgical Procedures; Cardiac Valve Annuloplasty; Coronary Artery Bypass; Female; Fluid Therapy; Heart Valve Prosthesis Implantation; Hemoglobins; Humans; Logistic Models; Male; Middle Aged; Natriuretic Peptide, Brain; Odds Ratio; Peptide Fragments; Postoperative Complications; Water-Electrolyte Balance; Water-Electrolyte Imbalance

To analyze the behavior of B-type natriuretic peptide (BNP) in the presence of defining characteristics (DCs) of the nursing diagnosis Excess fluid volume (00026) in patients hospitalized for acute decompensated heart failure.. Cohort study of patients admitted with acute decompensated heart failure (September 2015 to September 2016) defined by Boston Criteria. Patients hospitalized for up to 36 h with BNP values ≥ 100 pg/ml were included; BNP values at baseline-final assessment were compared by Wilcoxon test, the number of DCs at baseline-final assessment was compared by paired t-test.. Sixty-four patients were included; there was a significant positive correlation between delta of BNP and the number of DCs present at initial clinical assessment.. The behavior of BNP was correlated to the DCs indicating congestion. With clinical compensation, DCs and BNP decreased. The use of this biomarker may provide additional precision to the nursing assessment.

Topics: Aged; Biomarkers; Cohort Studies; Emergency Medical Services; Female; Heart Failure; Humans; Male; Natriuretic Peptide, Brain; Nursing Diagnosis; Sample Size; Stroke Volume; Water-Electrolyte Imbalance

Clinical interpretation of B-type natriuretic peptide (BNP) levels in haemodialysis (HD) patients for fluid management remains elusive.. We conducted a retrospective observational monocentric study. We built a mathematical model to predict BNP levels, using multiple linear regressions. Fifteen clinical/biological characteristics associated with BNP variation were selected. A first cohort of 150 prevalent HD (from September 2015 to March 2016) was used to build several models. The best model proposed was internally validated in an independent cohort of 75 incidents HD (from March 2016 to December 2017).. In cohort 1, mean BNP level was 630 ± 717 ng/mL. Cardiac disease (CD - stable coronary artery disease and/or atrial fibrillation) was present in 45% of patients. The final model includes age, systolic blood pressure, albumin, CD, normo-hydrated weight (NHW) and the fluid overload (FO) assessed by bio-impedancemetry. The correlation between the measured and the predicted log-BNP was 0.567 and 0.543 in cohorts 1 and 2, respectively. Age (β = 3.175e. We developed a mathematical model capable of predicting the BNP level in HD. Our results show the complex contribution of age, CD and FO on BNP level.

Topics: Adult; Age Factors; Aged; Aged, 80 and over; Biomarkers; Cardiovascular Diseases; Female; Humans; Kidney Failure, Chronic; Male; Middle Aged; Models, Biological; Natriuretic Peptide, Brain; Organism Hydration Status; Predictive Value of Tests; Renal Dialysis; Reproducibility of Results; Retrospective Studies; Risk Factors; Treatment Outcome; Water-Electrolyte Balance; Water-Electrolyte Imbalance; Young Adult

The aim of the present study was to evaluate the usefulness of serum B-type natriuretic peptide (BNP) as a biomarker of fluid retention in hypertensive children on peritoneal dialysis (PD).. Hypertensive children on PD were included. The changes (∆) of body weight (BWt), blood pressure (BP) and serum BNP at initial and follow-up periods were reviewed. Data are presented as mean ± standard deviation (median, minimum - maximum). Wilcoxon signed-rank test was used to evaluate the changes in BWt, BP, and BNP. Linear regression analysis was applied for the correlation between the changes of BNP and BP.. A total of 56 hypertensive events were evaluated in 30 patients. Initial findings were BWt 30.5 ± 22.4 (26.5, 3.0-93.5) kg, systolic BP (SBP) 153.3 ± 21.5 (150, 110-241) mmHg, diastolic BP (DBP) 100.1 ± 22.3, (99.5, 49-181) mmHg, BNP 3579.3 ± 6328.9 (1198.5, 305-22 028) pg/mL. Follow-up results were BWt 29.1 ± 21.3 (25.0, 3.12-86) kg, SBP 116.4 ± 17.8 (117.5, 82-150) mmHg, DBP 73.3 ± 14.2 (75.0, 42.0-101.0) mmHg, BNP 63.5 ± 49.2 (60.5, 2-261) pg/mL. ∆SBP (-23.1 ± 13.8, -22.8, -46.9 - 22.5%, P < 0.001), ∆DBP (-24.1 ± 19.2, -24.7, -55.6 - 23.2%, P < 0.001) and ∆BNP (-93.5 ± 8.1, -96.7, -99.9 - -61.0%, P < 0.001) dropped significantly after reduction of ∆BWt (-4.8 ± 4.7, -4.8, -18.7 - 5.6%, P < 0.001). The ∆BNP were significantly correlated with ∆SBP (adjusted R square = 0.221, P < 0.001) and ∆DBP (adjusted R square = 0.203, P < 0.001).. Serum B-type natriuretic peptide should be measured in hypertensive patients on PD to evaluate the volume status.

Topics: Biomarkers; Blood Pressure Determination; Child; Correlation of Data; Female; Fluid Shifts; Humans; Hypertension; Kidney Failure, Chronic; Male; Natriuretic Peptide, Brain; Peritoneal Dialysis; Republic of Korea; Water-Electrolyte Imbalance

Echocardiography is the most valuable tool for assessing cardiac abnormalities of chronic kidney disease (CKD) patients even though it has its limitations, including high equipment cost and the need for specialized personnel. Assessment of volume status is important not only for volume management, but also for prevention of cardiovascular disease of the CKD patients. Recently, bioimpedance is gaining acceptance as a way to quantitatively assess patient hydration status at bedside.. 127 patients who were admitted for planning their first dialysis treatment were enrolled. The echocardiography and bioimpedance spectroscopy (BIS) were performed. The association between echocardiographic data and clinical values such as NT-proBNP and OH/ECW was examined.. OH/ECW, which indicates relative fluid overload, was positively associated with LA dimension (r = 0.25, P = 0.007), LAVI (r = 0.32, P < 0.001), and E/e´ ratio (r = 0.38, P < 0.001). While OH/ECW was not significantly associated with echocardiographic values such as LVEDD, LVEDV, LVMI, and LVEF, NT-proBNP were significantly associated with all echocardiographic parameters. Multivariate logistic regression analysis showed E/e´ ratio (odds ratio, 1.14 [95% confidence interval (CI), 1.01 to 1.29]; P = 0.031), NT-proBNP (odds ratio, 4.78 [95% CI, 1.51 to 15.11]; P = 0.008), and albumin (odds ratio, 0.22 [95% CI, 0.08 to 0.66]; P = 0.007) were significantly associated with OH/ECW.. Since OH/ECW measured by BIS is associated with echocardiographic parameters related to diastolic dysfunction, preliminary screening through laboratory findings, including serum albumin in conjunction with OH/ECW and NT-proBNP, may find patient with risk of diastolic dysfunction. Our study suggests that a timely detection of fluid overload in patients with CKD as well as their proper treatment may help reduce diastolic dysfunction. Further research may be needed to validate the consistency of this association across other stages of CKD.

Topics: Body Water; Echocardiography; Electric Impedance; Extracellular Space; Female; Heart Failure; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Renal Dialysis; Renal Insufficiency, Chronic; Water-Electrolyte Imbalance

Accurate volume status evaluation and differentiation of cardiac and non-cardiac components of overhydration (OH) are fundaments of optimal haemodialysis (HD) management.. This study, by combining bioimpedance measurements, cardiovascular biomarkers and echocardiography, aimed at dissecting OH into its major functional components, and prospectively tested the association between cardiac and non-cardiac components of OH with mortality. In the first part, we validated soluble CD146 (sCD146) as a non-cardiac biomarker of systemic congestion in a cohort of 30 HD patients. In the second part, we performed a prospective 1-year follow-up study in an independent cohort of 144 HD patients.. sCD146 incrementally increased after the short and long intervals after HD (+53 ng/mL, P = 0.006 and  +91 ng/mL, P < 0.001), correlated with OH as determined by bioimpedance and well-diagnosed OH (area under the receiver operating characteristics curve 0.72, P = 0.005). The prevalence of OH was lower for low-sCD146 and low-BNP patients (B-type natriuretic peptide, 29%) compared with subjects with either one or both biomarkers elevated (65-74%, P < 0.001). Notably, most low-BNP but high-sCD146 subjects were overhydrated. Systolic dysfunction was 2- to 3-fold more prevalent among high-BNP compared with low-BNP patients (44-68% versus 21-23%, chi-square P < 0.001), regardless of sCD146. One-year all-cause mortality was markedly higher in patients with high-BNP (P = 0.001) but not with high-sCD146. In multivariate analysis, systolic dysfunction and BNP, but not OH, were associated with lower survival.. The combination of BNP and sCD146 dissects OH into functional components of prognostic value. OH in HD patients is associated with higher mortality only if resulting from cardiac dysfunction.

Topics: Adult; Aged; Analysis of Variance; Biomarkers; CD146 Antigen; Cohort Studies; Female; Follow-Up Studies; Humans; Kidney Failure, Chronic; Male; Middle Aged; Natriuretic Peptide, Brain; Predictive Value of Tests; Prognosis; Proportional Hazards Models; Prospective Studies; Renal Dialysis; ROC Curve; Water-Electrolyte Imbalance

Chemotherapy combining cyclophosphamide, bortezomib and dexamethasone is widely used in light-chain amyloidosis. The benefit is limited in patients with cardiac amyloidosis mainly because of adverse cardiac events. Retrospective analysis of our cohort showed that 39 patients died with 42% during the first month. A new escalation-sequential regimen was set to improve the outcomes. Nine newly-diagnosed patients were prospectively treated with close monitoring of serum N-terminal pro-brain natriuretic peptide, troponin-T and free light chains. The results show that corticoids may destabilise the heart through fluid retention. Thus, a sequential protocol may be a promising approach to treat these patients.

Topics: Aged; Aged, 80 and over; Amyloidosis; Antineoplastic Combined Chemotherapy Protocols; Arrhythmias, Cardiac; Bortezomib; Cyclophosphamide; Death, Sudden, Cardiac; Dexamethasone; Female; Heart Diseases; Humans; Immunoglobulin kappa-Chains; Immunoglobulin lambda-Chains; Immunoglobulin Light Chains; Immunoglobulin Light-chain Amyloidosis; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Retrospective Studies; Troponin T; Water-Electrolyte Imbalance

Many dialysis centres have no formal program for assessing and adjusting post-haemodialysis (HD) target weight. Apart from clinical assessment, there are bioimpedance devices and natriuretic peptides that could potentially aid clinical management. We wished to determine whether pre- or post-HD bioimpedance assessment of extracellular water (ECW) or N terminal probrain natriuretic peptide (NT-proBNP) affected patient outcomes.. Multi-frequency bioimpedance assessments (MFBIA) were made before and after the midweek dialysis session, along with a post-dialysis NT-proBNP measurement.. Data from 362 patients, median age of 63 (50-76) years, 59.7% male, 41.2% Caucasoid, with a median dialysis vintage of 31.4 (13.5-61.7) months were available for review. During a median follow-up of 49.6 (21.9-50.2) months there were 110 (30.4%) deaths. Patients who died had significantly increased ECW, as % over-hydrated both pre-HD 6.6 (5.8-7.6)% vs. survivors 5.1 (4-6.6)%, and post-HD 5.1 (4-6.6)% vs. 0.5 (-1-2.2.0, p<0.001, respectively. They also had higher NT-proBNP 325 (122-791) vs. 102 (48-342) pmol/l, p = 0.002. Using an adjusted Cox model, pre-HD ECW overhydration remained an independent factor associated with mortality (overhydration %: hazard ratio 1.15, 95% limits 1.03-1.28, p = 0.013), with a receiver operator curve (ROC) value of 0.7.. ECW excess is associated with increased mortality for HD patients, with ECW excess pre-dialysis being the strongest association, although these patients also had increased ECW post dialysis. Future trials are required to determine whether achieving euvolaemia as determined by bioimpedance improves patient survival.

Topics: Aged; Body Composition; Electric Impedance; Female; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Proportional Hazards Models; Renal Dialysis; Water-Electrolyte Imbalance

Peritoneal dialysis (PD) patients with preserved residual diuresis have a lower risk of death and complications. Here we analyzed associations between residual diuresis and presence of fluid overload and biomarkers of cardiac strain and nutrition in PD patients.. Among 44 PD patients placed into three subgroups, depending on volume of residual diuresis (group A ≤ 500; group B 600-1900; and group C ≥ 2000 mL/day), we examined: overhydration (OH) assessed by bioimpedance analysis (BIA; yielding OH index OHBIA) and by clinical criteria (edema and hypertension); nutritional status (by subjective global assessment, SGA); metabolic status (electrolytes, serum lipid profile, CRP, and albumin); biomarkers of fluid overload and cardiac strain (N-terminal probrain natriuretic peptide, NT-proBNP, and troponin T, TnT); and, echocardiography and chest X-ray.. With increasing residual diuresis in group A, B and C, fewer patients had signs of overhydration defined as OHBIA > 1.1 L (75.0, 42.9 and 33.3 %) or peripheral edema (25.0, 21.4 and 0 %) and NT-proBNP (15199 ± 16150 vs. 5930 ± 9256 vs. 2600 ± 3907 pg/mL; p < 0.05) and TnT (0.15 ± 0.17 vs. 0.07 ± 0.09 vs. 0.04 ± 0.03 ng/mL; p < 0.05) were significantly lower. Significant differences were found also in ejection fraction, SGA, and total cholesterol, albumin and hemoglobin levels whereas blood pressures and serum CRP did not differ significantly.. Signs of OH and cardiac strain are common in PD patients, even in those with diuresis of 1000-2000 mL/day and with no clinical signs or symptoms, suggesting that even moderate decrease in residual renal function in PD patients associate with OH and other complications.

Topics: Adult; Biomarkers; Cardiovascular Diseases; Echocardiography; Female; Humans; Kidney Failure, Chronic; Kidney Function Tests; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Peritoneal Dialysis; Poland; Renal Elimination; Risk Factors; Statistics as Topic; Water-Electrolyte Imbalance

To evaluate whether changes in hydration status (reflecting fluid retention) would be detected by bioelectrical impedance vector analysis (BIVA) and phase angle during hospitalization for acute decompensated heart failure (ADHF) and after clinical stabilization.. Patients admitted to ADHF were evaluated at admission, discharge and after clinical stabilization (3 mo after discharge) for dyspnea, weight, brain natriuretic peptide, bioelectrical impedance resistance, reactance, and phase angle. Generalized estimating equations and chi-square detected variations among the three time points of evaluation.. Were included 57 patients: Mean age was 61 ± 13 y, 65% were male, LVEF was 25 ± 8%. During hospitalization there were improvements in clinical parameters and increase in resistance/height (from 250 ± 72 to 302 ± 59 Ohms/m, P < 0.001), reactance/height (from 24 ± 10 to 31 ± 9 Ohms/m, P < 0.001), and phase angle (from 5.3 ± 1.6 to 6 ± 1.6°, P = 0.007). From discharge to chronic stability, both clinical and BIVA parameters remained stable. At admission, 61% of patients had significant congestion by BIVA, and they lost more weight and had higher improvement in dyspnea during hospitalization (P < 0.05). At discharge, more patients were in the upper half of the graph (characterizing some degree of dehydration) while at chronic stability normal hydration status was more prevalent (P < 0.001).. BIVA and phase angle were able to detect significant changes in hydration status during ADHF, which paralleled the clinical course of recompensation, both acutely and chronically. The classification of congestion by BIVA at admission identified patients with more pronounced changes in weight and dyspnea during compensation.

Topics: Acute Disease; Aged; Body Composition; Body Weight; Cohort Studies; Dyspnea; Electric Impedance; Female; Follow-Up Studies; Heart Failure; Hospitalization; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Water-Electrolyte Imbalance

Topics: Acid-Base Imbalance; Glycocalyx; Humans; Isotonic Solutions; Natriuretic Peptide, Brain; Water-Electrolyte Imbalance

Determination of fluid overload is important in chronic kidney disease. Early diagnosis and treatment of volume overload may decrease morbidity and mortality. We aimed to determine body composition by using bioelectrical impedance analysis, and studying other clinical characteristics, inferior vena cava diameter, and N-terminal pro-B natriuretic peptide associated with hydration status in chronic kidney disease Stages 3&4 and 5 in patients not undergoing dialysis.. We examined 62 patients with Stages 3&4 and 68 patients with Stage 5 chronic kidney disease. Plasma NT-proBNP was measured and analyzed after log transformation. Inferior vena cave diameter was measured with echocardiography and indexed for body surface area. Hydration status was assessed using multi-frequency bioelectrical impedance analysis. Overhydration was defined as overhydration/extracellular water >0.15.. Overhydration was more frequent in Stage 5 than in Stages 3&4 patients. Systolic and diastolic blood pressure, inferior vena cava index, and log NT-proBNP were higher in overhydrated compared to non-overhydrated patients. A significant positive correlation existed between overhydration/extracellular water and log NT-proBNP, systolic and diastolic blood pressures, and inferior vena cava index. In multiple linear regression analysis, the variables associated with hydration status were male sex, extracellular water/total body water, and extracellular water/intracellular water (greater overhydration), while serum albumin levels had a negative association with overhydration.. Overhydration is more prevalent in Stage 5 chronic kidney disease patients than in Stages 3&4 patients. Bioelectrical impedance analysis, inferior vena cava diameter, and NT-proBNP analysis in chronic kidney disease are useful methods to determine the volume overload.

Topics: Adult; Aged; Blood Pressure; Body Composition; Echocardiography; Electric Impedance; Female; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Renal Insufficiency, Chronic; Serum Albumin; Vena Cava, Inferior; Water-Electrolyte Imbalance

A fall in blood pressure is the most common complication of outpatient hemodialysis. Several factors have been implicated, including serum sodium to dialysate gradient, ultrafiltration rate, and the amount of fluid to be removed during dialysis.. We prospectively audited 400 adult patients attending for their routine midweek hemodialysis session, and recorded changes in mean arterial blood pressure (MAP).. Mean age 58.4 ± 16.6 years, 60.9% male, 30.7% diabetic, 36.8% Caucasoid, single pool Kt/V 1.57 ± 0.4, and median percentage change in MAP -6.7% (-14.1 to + 2.8). The percentage fall in MAP was greatest for those starting with higher MAPs (β 0.448 , F 67.5, p<0.001), greater serum sodium to dialysate sodium gradient (β 0.676, F 5.59, p = 0.019), and age (β 0.163, F 5.15, p = 0.024). In addition, the percentage fall in MAP was greater in those with the lowest segmental extracellular water/total body water (ECW/TBW) ratios in the right arm prior to dialysis (β -477.5, F 7.11, p = 0.008).. Falls in blood pressure are common during dialysis, and greater for those starting dialysis with the highest systolic pressures, greater dialysate to serum sodium concentration gradient, and also those with the least ECW in the arm. As such, segmental bioimpedance may be useful in highlighting patients at greatest risk for a fall in blood pressure with dialysis.

Topics: Adult; Aged; Aged, 80 and over; Biomarkers; Blood Pressure; Blood Pressure Determination; Dialysis Solutions; Electric Impedance; Female; Hemoglobins; Humans; Hypertension; Immunoassay; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Renal Dialysis; Retrospective Studies; Serum Albumin; Sodium; Water-Electrolyte Imbalance

The assessment of proper hydration status in hemodialysis patients is difficult. None of currently available markers or measures is clinically relevant. Recently, human pre-pro-vasopressin (1-164) split product [copeptin (CPP)] - a new surrogate marker of hydration status - was introduced. The aim of the study was to analyze body weight changes in the early post-transplant period in relation to serum CPP levels before kidney transplantation.. Serum CPP and NT-proBNP concentrations and osmolality were measured in 130 kidney recipients directly prior to transplantation and, additionally, in 78 of them at 14th day post-transplant. Hydration status at transplantation was calculated from the difference in the patient's body weight before transplantation and at the discharge.. During the post-transplant hospitalization, the average weight change was -1.6 kg, varying from 10.5 kg loss to weight gain of 5 kg. The overall weight loss was significantly related to pretransplant serum concentration of CPP (r=0.238), but not of NT-proBNP or osmolality. Patients with the lowest initial CPP level (first tertile) had smaller post-transplant weight loss. The early kidney graft function was unrelated to pretransplant CPP. Multivariate regression model revealed that variability of post-transplant weight loss is explained by the number of antihypertensive drugs used prior to transplantation [β=0.213 (0.049-0.377)] and pretransplant CPP values [β=0.233 (0.069-0.397)].. Elevated serum CPP level predicts a rapid weight loss after kidney transplantation and seems to characterize the subgroup of patients with the greatest overhydration. These results suggest the dysregulation of physiological mechanisms of CPP secretion in hemodialysis patients.

Topics: Adult; Biomarkers; Blood Volume; Cohort Studies; Female; Glycopeptides; Humans; Kidney Failure, Chronic; Kidney Transplantation; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Prospective Studies; Renal Dialysis; Water-Electrolyte Imbalance; Weight Loss

Increased natriuretic peptides are associated with increased cardiovascular and all-cause mortality for haemodialysis (HD) patients. However, debate continues whether these biomarkers are increased by extracellular water (ECW) excess and can be used to aid clinical assessment of volume status and help determine target weight.. We measured N terminal probrain natriuretic peptide (NT-proBNP) predialysis in 375 stable haemodialysis outpatients with corresponding pre and postdialysis multifrequency bioelectrical impedance assessments (MFBIA) of (ECW)/total body water (TBW).. Median age 64 (51-75), 63.9% male, 42.9% diabetic, 43.2% Caucasoid, 14.4% with a history of myocardial infarction, 8.4% coronary artery bypass surgery, dialysis vintage 28.2 (12.3-55.5) months. Median predialysis NT-proBNP 283 (123-989) pmol/l, and predialysis ECW/TBW ratio 0.397 ± 0.029. On multivariate analysis, predialysis log NT-proBNP was associated with predialysis systolic blood pressure (β 0.007, p = 0.000), weight (β -0.008, p = 0.001), valvular heart disease (β 0.342, p = 0.015, ECW/TBW (β 1.3, p = 0.019) and log CRP (β 0.145, p = 0.037). Dividing patients into NTproBNP quartiles, %ECW/TBW and relative ECW overhydration were significantly greater for the highest quartile vs. lowest (40.5 ± 4.1 vs. 39.0 ± 1.1, and 1.51 ± 1.24 vs. 0.61 ± 0.69 l, respectively, p < 0.001).. In this study, predialysis NTproBNP values were associated with direct assessments of the extracellular volume excess measured by MFBIA and systolic arterial blood pressure. This suggests that predialysis NTproBNP values can potentially be used to aid clinical assessment of volume status in dialysis patients to determine target weight.

Topics: Aged; Antihypertensive Agents; Biomarkers; Blood Pressure; Coronary Artery Bypass; Diabetes Complications; Electric Impedance; Extracellular Fluid; Female; Humans; Male; Middle Aged; Multivariate Analysis; Myocardial Infarction; Natriuretic Peptide, Brain; Outpatients; Peptide Fragments; Regression Analysis; Renal Dialysis; Water-Electrolyte Imbalance

Chronic fluid overload is associated with higher mortality in dialysis patients; however, the link with cardiovascular morbidity has not formally been established and may be influenced by subclinical inflammation. We hypothesized that a relationship exists between fluid overload and [i] cardiovascular laboratory parameter as well as between fluid overload and [ii] inflammatory laboratory parameters. In addition, we aimed to confirm whether volume status correlates with nutritional status.. We recorded baseline characteristics of 244 hemodialysis patients at three hemodialysis facilities in Vienna (Austria) and determined associations with volume measurements using the body composition monitor (Fresenius/Germany). In one facility comprising 126 patients, we further analyzed cardiovascular, inflammatory and nutritional parameters.. We detected predialysis fluid overload (FO) in 39% of all patients (n = 95) with FO defined as ≥15% of extracellular water (ECW). In this subgroup, the absolute FO was 4.4 +/-1.5 L or 22.9 ± 4.8% of ECW. A sub-analysis of patients from one center showed that FO was negatively associated with body mass index (r = -0.371; p = <0.001), while serum albumin was significantly lower in fluid overloaded patients (p = 0.001). FO was positively associated with D-Dimer (r = 0.316; p = 0.001), troponin T (r = 0.325; p < 0.001), and N-terminal pro-B-type natriuretic peptide (r = 0.436; p < 0.001), but not with investigated inflammatory parameters.. Fluid overload in HD patients was found to be lower in patients with high body mass index, indicating that dry weight was inadequately prescribed and/or difficult to achieve in overweight patients. The association with parameters of cardiovascular compromise and/or damage suggests that fluid overload is a biomarker for cardiovascular risk. Future studies should determine if this applies to patients prior to end-stage renal disease.

Topics: Austria; Biomarkers; Cardiovascular Diseases; Comorbidity; Cross-Sectional Studies; Female; Fibrin Fibrinogen Degradation Products; Humans; Incidence; Kidney Failure, Chronic; Male; Middle Aged; Natriuretic Peptide, Brain; Nutritional Status; Obesity; Peptide Fragments; Renal Dialysis; Reproducibility of Results; Risk Assessment; Sensitivity and Specificity; Serum Albumin; Statistics as Topic; Survival Rate; Water-Electrolyte Imbalance

Cardio-Renal syndrome may occur as a result of either primarily renal or cardiac dysfunction. This complex interaction requires a tailored approach to manage the underlying pathophysiology while optimizing the patient's symptoms and thus providing the best outcomes. Patients often are admitted to the hospital for signs and symptoms of congestion and fluid overload is the most frequent cause of subsequent re-admission. Fluid management is of paramount importance in the strategy of treatment for heart failure patients. Adequate fluid status should be obtained but a target value should be set according to objective indicators and biomarkers. Once the fluid excess is identified, a careful prescription of fluid removal by diuretics or extracorporeal therapies must be made. While delivering these therapies, adequate monitoring should be performed to prevent unwanted effects such as worsening of renal function or other complications. There is a very narrow window of optimal hydration for heart failure patients. Overhydration can result in myocardial stretching and potential decompensation. Inappropriate dehydration or relative reduction of circulating blood volume may result in distant organ damage caused by inadequate perfusion. We suggest consideration of the "5B" approach. This stands for balance of fluids (reflected by body weight), blood pressure, biomarkers, bioimpedance vector analysis, and blood volume. Addressing these parameters ensures that the most important issues affecting symptoms and outcomes are addressed. Furthermore, the patient is receiving the best possible care while avoiding unwanted side effects of the treatment.

Topics: Acute-Phase Proteins; Biomarkers; Blood Pressure; Blood Volume; Body Composition; Cardio-Renal Syndrome; Electric Impedance; Fluid Therapy; Heart Failure; Humans; Lipocalin-2; Lipocalins; Natriuretic Peptide, Brain; Proto-Oncogene Proteins; Water-Electrolyte Balance; Water-Electrolyte Imbalance

Both brain natriuretic peptide (BNP) and volume overload are reported to be powerful predictors of survival for peritoneal dialysis patients. The usefulness of single BNP determinations in helping determine volume status in peritoneal dialysis patients remains controversial, so we reviewed serial BNP and multifrequency bioimpedance measurements to determine whether changes in BNP reflected changes in volume status.. Prospective measurements of fluid volume by multifrequency bioimpedance and serum N-terminal pro-BNP (NTproBNP) were conducted in stable adult peritoneal dialysis outpatients attending for routine assessments of peritoneal dialysis adequacy and transport status.. A total of 189 serial measurements were made in 92 patients, and NTproBNP increased from a median of 162.5 pmol/l (interquartile range 82-385.4) to 195 pmol/l (interquartile range 101.9-348.6; p < 0.05). Changes in NTproBNP correlated with changes in extracellular water (ECW), total body water (TBW) and ECW/TBW (r = 0.38, 0.31 and 0.45, respectively; all p < 0.0001). Patients were divided into quartiles depending upon NTproBNP changes; those with the greatest fall in NTproBNP had significant falls in ECW (p < 0.001), TBW (p = 0.001) and ECW/TBW (p < 0.001) compared to the quartile with the greatest increase in NTproBNP, who also had an increase in systolic blood pressure from 133.5 ± 22.7 to 142.7 ± 28.8 mm Hg (p = 0.0078), whereas it fell in the quartile with the greatest fall in NTproBNP (143.8 ± 24.6 vs. 136.5 ± 18.7 mm Hg).. Serial measurements of NTproBNP correlated with changes in volume assessments made by multifrequency bioimpedance in peritoneal dialysis outpatients. As multifrequency bioimpedance measures total ECW, rather than effective plasma volume, serial NTproBNP determinations may prove an adjunct to the clinical assessment of volume status in peritoneal dialysis patients.

Topics: Body Fluids; Computational Biology; Extracellular Fluid; Female; Humans; Kidney Failure, Chronic; Male; Middle Aged; Natriuretic Peptide, Brain; Outpatients; Peptide Fragments; Peritoneal Dialysis; Predictive Value of Tests; Risk Factors; Water-Electrolyte Imbalance

To analyze usefulness of measurement amino-terminal pro-B type natriuretic peptide of (NT pro-BNP) as the one of parameters of water overload in patients with chronic kidney diseases.. A total number of 277 patients with chronic kidney diseases (CKD) were followed up in the period often years between January 2000 and July 2010. Patients with creatinine clearance of 60 ml/min or less were included in the study. Changes of creatinine clearance, and in last five years changes of NT pro-BNP were followed. Water overload was analyzed using chest x-ray in relation with concentration of NT pro-BNP in the blood.. Decrease of clearance of creatinine ranged from average 54.7 ml/min in the first year to 14.6 ml/min in the fifth year of the monitoring. Average NT pro-BNP level in patients without any sign of water overload was 94 pg/ml (SD 21), mean value in those with Kerley lines was 231 pg/ml/L (SD 64), in those with clear signs of water overload but without pleural effusion it was 525 pg/ml (SD 223), and in those with water retention including pleural effusion it was 1606 pg/ml (SD 1134). Using test of multiple correlation a statistically significant correlation between X-ray signs of water overload and NT pro-BNP concentration was shown, p < 0.05.. Measurement of NT pro-BNP was increased in the beginning of water overload in patients with CKD. Increased value of NT pro-BNP may be found earlier than any other signs of water overload. NT pro-BNP was a useful parameter in estimation of water overload in these patients.

Topics: Biomarkers; Body Water; Chronic Disease; Creatinine; Female; Humans; Kidney Diseases; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Uric Acid; Water-Electrolyte Imbalance

Weight gain with oedema development is a complication of major surgical procedures with an incidence as high as 40%. Fluid retention is not always clinically evident and it is reported despite fluid-restriction regime. The causes are several and not totally clear. We performed a prospective study to assess the amount of fluid accumulation and redistribution observed after major thoracic surgery.. In 49 patients submitted to lobectomy with systematic lymph node dissection for lung cancer, we measured preoperatively and on the postoperative days 1, 2, 4 and 7, body weight, fluid balance, brain natriuretic peptide (BNP) and bioimpedance analysis (BIA)-derived parameters resistance (R) and reactance (X(c)).. The postoperative course was characterised by significant changes. Mean increase in body weight was 2.7 kg ((1.9-3.4); p<0.001) on postoperative day 2. Most of the patients had a negative basal fluid balance (-244 ml (-520 to -50)), whereas, on postoperative day 2, we observed a positive and significant change (+968 ml (646-1456), p<0.001)). Total body R and X(c) fell on the first day (p<0.001), anticipating the changes in weight and fluid balance. BNP increased on day 1, immediately after surgery, and remained significantly above basal values for the entire observation period (p<0.001), in the absence of clinical signs of heart failure.. The three methods used consistently showed a significant fluid retention over the course of the study. BIA was an easy, reproducible and non-invasive method for the estimation and early detection of fluid retention. Increase in BNP may be related to the systemic reaction to stress and to the decreased pulmonary vascular bed. We found no correlation between fluid retention and length of anaesthesia, sex, age, blood loss and body mass index. The clinical and prognostic implication of weight gain may be relevant to patient's health.

Topics: Aged; Biomarkers; Edema; Electric Impedance; Electrodiagnosis; Feasibility Studies; Female; Humans; Lung Neoplasms; Lymph Node Excision; Male; Middle Aged; Natriuretic Peptide, Brain; Pneumonectomy; Prospective Studies; Water-Electrolyte Imbalance; Weight Gain

Topics: Adult; Aged; Aged, 80 and over; Body Fluids; Electrocardiography; Female; Heart Failure; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Predictive Value of Tests; Water-Electrolyte Imbalance

N-terminal probrain type natriuretic peptide (NTproBNP) has been proven to be a valuable biomarker for predicting cardiac events and mortality in the hemodialysis population. However recent reports have suggested that NTproBNP is a marker of volume overload rather than one of cardiac dysfunction. Therefore this study investigated the effect of fluid volume status on NTproBNP.. Volume status was determined pre- and postdialysis in 72 stable hemodialysis outpatients by multifrequency bioimpedance, and the relationship to NTproBNP values was examined.. The mean and median NTproBNP values were 931.9 +/- 230 and 242 (90 to 688) pmol/L, respectively. On simple correlation, NTproBNP was associated with markers of volume overload and cardiac dysfunction. However, on logistical regression analysis, the strongest association was with the predialysis ratio of extracellular water/total body water (beta 26.6, F29.6, P = 0.000), followed by postdialysis mean arterial blood pressure (beta 0.14, F17.1, P = 0.000), dialysate calcium concentration (beta -1.19, F14.1, P = 0.002), and change in extracellular fluid volume with dialysis (beta 0.27, F7.4, P = 0.009). In this study, NTproBNP was not associated with cardiac dysfunction as assessed by transthoracic echo or nuclear medicine scintigraphy but was dependent on factors associated with volume overload. However, because bioimpedance results can also be affected by malnutrition with loss of cell mass, NTproBNP may be elevated not only in patients with volume overload, but also those with malnutrition.

Topics: Adult; Aged; Biomarkers; Blood Pressure; Body Water; Calcium; Electric Impedance; Female; Heart Diseases; Humans; Kidney Diseases; Linear Models; Logistic Models; Male; Malnutrition; Middle Aged; Natriuretic Peptide, Brain; Outpatients; Peptide Fragments; Prognosis; Renal Dialysis; Risk Assessment; Risk Factors; Up-Regulation; Water-Electrolyte Imbalance

Topics: Biomarkers; Blood Pressure; Body Water; Calcium; Electric Impedance; Heart Diseases; Humans; Kidney Diseases; Malnutrition; Natriuretic Peptide, Brain; Peptide Fragments; Prognosis; Renal Dialysis; Risk Assessment; Risk Factors; Up-Regulation; Water-Electrolyte Imbalance

Elevated B-type natriuretic peptide (BNP) levels are established as a marker for volume overload and left ventricular (LV) dysfunction in patients with predominately cardiac diseases. Little is known about markedly elevated BNP values in patients with multiple comorbidities.. A total of 99 patients, admitted to M. D. Anderson Cancer Center, were identified as having a BNP value >1000 pg/mL during the year 2003. Clinical characteristics, including the presence of volume overload and sepsis, as well as echocardiographic parameters were measured. Principal outcome was defined as 30-day mortality.. The median BNP (pg/mL) of the group was 2270 (range, 1010-5000), and there was no association between elevation of the BNP level and the presence of volume overload or LV dysfunction (P = not significant). The large majority of patients (n = 71, 72%) had no volume overload and normal or nearly normal LV function (n = 60, 61%). A majority were also identified as having sepsis (n = 52, 53%). There was no echocardiographic parameter that consistently correlated with BNP levels or volume overload. There was a highly significant association with sepsis and mortality in patients with markedly elevated BNP values, and this conferred a 2.71-fold increased risk of mortality.. In patients admitted with multiple comorbidities and markedly elevated BNP values, there is no significant association with clinical evidence of volume overload or LV dysfunction. An elevated BNP level in patients with sepsis was significantly associated with mortality.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cardiovascular Diseases; Diabetes Complications; Echocardiography; Female; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Neoplasms; Prognosis; Sepsis; Water-Electrolyte Imbalance

Excessive volume resuscitation after injury is associated with severe complications. B-type natriuretic peptide (BNP) is secreted from myocardium under increased wall stretch and is used in medical intensive care units (ICUs) as a noninvasive method to detect heart failure. However, the use of BNP as a marker of fluid overload during resuscitation from injury has not been previously described.. Serum BNP levels were prospectively followed in 134 trauma ICU patients. Levels were obtained at admission and at 12, 24, and 48 hours. Repeated measures analysis of variance was used to test for differences in BNP levels over time. Post hoc pairwise comparisons were made with Bonferroni correction when the omnibus test indicated significance. Chest films were obtained at 24 hours and scored for the presence of pulmonary edema by a radiologist blinded to BNP measurements (n = 45). Twenty-four hour BNP levels for patients with or without radiographic evidence of pulmonary edema were compared using nonparametric analysis (Mann-Whitney U).. Admission BNP levels were low and increased with fluid resuscitation over time in all patients (p = 0.002) as well as in a subgroup of patients <60 years of age (p = 0.003). At 24 hours, 25 patients had no pulmonary edema evident on chest X-ray, whereas 20 were scored indicating that pulmonary edema was present. Patients with evidence of pulmonary edema had higher mean BNP levels at 24 hours (110 +/- 31 pg/mL) than did patients without edema (47.0 +/- 10.8 pg/mL) (p = 0.04).. Serum BNP levels increase with resuscitation after injury and levels are higher in patients who develop pulmonary edema. These findings suggest that BNP might be a marker of excessive volume resuscitation after injury.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Biomarkers; Female; Fluid Therapy; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Prospective Studies; Pulmonary Edema; Resuscitation; Water-Electrolyte Imbalance; Wounds and Injuries

Topics: Adrenal Gland Diseases; Autonomic Nervous System Diseases; Humans; Hyperhidrosis; Hyponatremia; Natriuretic Peptide, Brain; Neuroleptic Malignant Syndrome; Sodium Chloride; Sympathetic Nervous System; Water-Electrolyte Imbalance

To examine whether children with univentricular defects have intrinsic dysfunction in the natriuretic peptide system.. We compared plasma levels of the fluid-regulating hormone vasopressin (antidiuretic hormone), aldosterone, atrial natriuretic peptide, and brain natriuretic peptide in children with congenital univentricular and biventricular defects. We enrolled 27 patients with univentricular defects and 27 patients with biventricular cardiac defects. Children who underwent Fontan and Glenn procedures were considered as patients with univentricular cardiac defects; children who underwent repair of tetralogy of Fallot or subaortic stenosis were considered as controls with biventricular defects.. Preoperative plasma atrial natriuretic peptide, brain natriuretic peptide, antidiuretic hormone, and aldosterone were comparable in both groups. Although plasma cyclic guanosine monophosphate levels were comparable between groups, there was a significant correlation between molar concentrations of plasma cyclic guanosine monophosphate and plasma atrial natriuretic peptide ( r = 0.42) and brain natriuretic peptide ( r = 0.44) in the biventricular group, but not in the univentricular group ( r = 0.19 for atrial natriuretic peptide; r = 0.13 for brain natriuretic peptide). All patients had a significant postoperative increase in plasma antidiuretic hormone. A significant postoperative increase in plasma brain natriuretic peptide was found in the patients with biventricular, but not univentricular, defects. In contrast, a significant increase in plasma aldosterone was observed only in the patients with univentricular defects.. There were distinct differences between univentricular and biventricular groups in their perioperative plasma fluid-regulating hormone responses. Specifically, patients with univentricular defects may have abnormal natriuretic peptide secretion and function. The natriuretic dysfunction may be on the basis of hypoplastic ventricular development.

Topics: Age Factors; Aldosterone; Analysis of Variance; Atrial Natriuretic Factor; Biomarkers; Cardiopulmonary Bypass; Case-Control Studies; Child, Preschool; Cyclic GMP; Down-Regulation; Female; Fontan Procedure; Heart Ventricles; Humans; Infant; Male; Mineralocorticoid Receptor Antagonists; Natriuretic Peptide, Brain; Risk Factors; Second Messenger Systems; Signal Transduction; Time Factors; Up-Regulation; Vasopressins; Water-Electrolyte Imbalance

Topics: Atrial Natriuretic Factor; Heart Failure; Homeostasis; Humans; Myocardium; Natriuretic Peptide, Brain; Nerve Tissue Proteins; Peptide Fragments; Protein Precursors; Water-Electrolyte Imbalance

Heart failure is a leading cause of morbidity and mortality. In the United States, there are more than 5 million patients with heart failure and over 500,000 newly diagnosed cases each year. Numerous advances have been made in our understanding of the pathophysiologic mechanisms contributing to sodium and water retention in this condition. Important alterations in the sympathetic nervous system and the renin-angiotensin-aldosterone system have been described in heart failure, allowing the use of mechanism-specific treatments such as beta-adrenergic receptor antagonism and angiotensin-converting enzyme inhibition. As our understanding of the roles of the natriuretic peptides and the arginine vasopressin-aquaporin-2 system in the pathophysiology of heart failure evolves, treatments directed toward the alterations in these systems in heart failure can be further developed.

Topics: Adrenergic beta-Antagonists; Angiotensin-Converting Enzyme Inhibitors; Atrial Natriuretic Factor; Body Fluids; Heart Failure; Humans; Natriuretic Peptide, Brain; Neurosecretory Systems; Renin-Angiotensin System; Sodium; Sympathetic Nervous System; Vasopressins; Water Intoxication; Water-Electrolyte Imbalance