Prognostic value of B-type natriuretic peptide (BNP) and its potential role in guiding fluid therapy in critically ill septic patients

Zhongheng Zhang, Zhengguang Zhang, Yadong Xue, Xiao Xu, Hongying Ni, Zhongheng Zhang, Zhengguang Zhang, Yadong Xue, Xiao Xu, Hongying Ni

Abstract

Background and objectives: The prognostic role of B-type natriuretic peptide (BNP) in septic patients is controversial. The study aimed to investigate the prognostic value of BNP in critically ill septic patients. Furthermore, because BNP is primarily released from ventricles in response to myocardial stretch, the second aim of the study was to test whether the change in BNP was correlated to the amount of fluid balance.

Methods: This was a prospective observational study conducted in a tertiary 18-bed ICU. Patients fulfilled criteria of sepsis were enrolled. Exclusion criteria included renal dysfunction on ICU entry, age < 18 or >80 years old. BNP was measured on entry (BNP0) and day 3 (BNP1) and daily fluid balance over the three days were recorded. Diagnostic performances of BNP0 and ΔBNP (BNP1-BNP0) were analyzed. The correlation between fluid balance and ΔBNP were tested using Spearman's correlation test.

Results: A total of 67 subjects were eligible for the study during study period. BNP0 was significantly higher in non-survivors than in survivors (738 vs 550 pg/ml, p < 0.01). The area under curves (AUCs) of BNP0 in predicting mortality, duration of mechanical ventilation (MV) > 7 d, length of stay in ICU (LOS(ICU)) > 7 d and hospital (LOS(hospital)) > 12 d were 0.71, 0.79, 0.66 and 0.71, respectively. The AUCs of ΔBNP in predicting duration of MV > 7 d, LOS(ICU) > 7 d and LOS(hospital) > 12 d were 0.80, 0.84 and 0.85, respectively. The amount of fluid balance was correlated to ΔBNP (Spearman's rho = 0.63, p < 0.01), and the correlation remained statistically significant in multivariate model.

Conclusions: BNP measured on ICU entry is associated with mortality, duration of MV, LOS(ICU) and LOS(hospital). ΔBNP is able to predict the LOS(ICU) and LOS(hospital) with satisfactory sensitivity and specificity. ΔBNP is closely correlated to the amount of fluid balance during resuscitation period. However, this could only be considered as a hypothesis-generating pilot study due to its small sample size and the observational nature.

Figures

Figure 1
Figure 1
Flow chart of patients selection.
Figure 2
Figure 2
The correlation between fluid balance and changes in B-type natriuretic peptide (ΔBNP). ΔBNP was significantly correlated to the amount of fluid balance over the first three days (Spearman’s rho = 0.63, p < 0.01).

References

    1. Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29(7):1303–1310. doi: 10.1097/00003246-200107000-00002.
    1. Hotchkiss RS, Karl IE. The pathophysiology and treatment of sepsis. N Engl J Med. 2003;348(2):138–150. doi: 10.1056/NEJMra021333.
    1. Balija TM, Lowry SF. Lipopolysaccharide and sepsis-associated myocardial dysfunction. Curr Opin Infect Dis. 2011;24(3):248–253. doi: 10.1097/QCO.0b013e32834536ce.
    1. Celes MR, Torres-Dueñas D, Prado CM, Campos EC, Moreira JE, Cunha FQ, Rossi MA. Increased sarcolemmal permeability as an early event in experimental septic cardiomyopathy: a potential role for oxidative damage to lipids and proteins. Shock. 2010;33(3):322–331. doi: 10.1097/SHK.0b013e3181b38ef6.
    1. Duncan DJ, Yang Z, Hopkins PM, Steele DS, Harrison SM. TNF-alpha and IL-1beta increase Ca2þ leak from the sarcoplasmic reticulum and susceptibility to arrhythmia in rat ventricular myocytes. Cell Calcium. 2010;47(4):378–386. doi: 10.1016/j.ceca.2010.02.002.
    1. ver Elst KM, Spapen HD, Nguyen DN, Garbar C, Huyghens LP, Gorus FK. Cardiac troponins I and T are biological markers of left ventricular dysfunction in septic shock. Clin Chem. 2000;46(5):650–657.
    1. Maeder M, Fehr T, Rickli H, Ammann P. Sepsis-associated myocardial dysfunction: diagnostic and prognostic impact of cardiac troponins and natriuretic peptides. Chest. 2006;129(5):1349–1366. doi: 10.1378/chest.129.5.1349.
    1. Richards AM, Crozier IG, Yandle TG, Espiner EA, Ikram H, Nicholls MG. Brain natriuretic factor: regional plasma concentrations and correlations with haemodynamic state in cardiac disease. Br Heart J. 1993;69(5):414–417. doi: 10.1136/hrt.69.5.414.
    1. Magga J, Vuolteenaho O, Tokola H, Marttila M, Ruskoaho H. B-type natriuretic peptide: a myocyte-specific marker for characterizing loadinduced alterations in cardiac gene expression. Ann Med. 1998;30(Suppl 1):39–45.
    1. Tang WH, Francis GS, Morrow DA, Newby LK, Cannon CP, Jesse RL, Storrow AB, Christenson RH, Apple FS, Ravkilde J, Wu AH. National Academy of Clinical Biochemistry Laboratory Medicine National Academy of Clinical Biochemistry Laboratory Medicine practice guidelines. Clinical utilization of cardiac biomarker testing in heart failure. Circulation. 2007;116(5):e99–e109. doi: 10.1161/CIRCULATIONAHA.107.185267.
    1. Doust JA, Pietrzak E, Dobson A, Glasziou P. How well does B-type natriuretic peptide predict death and cardiac events in patients with heart failure: systematic review. BMJ. 2005;330(7492):625. doi: 10.1136/bmj.330.7492.625.
    1. Troughton RW, Frampton CM, Yandle TG, Espiner EA, Nicholls MG, Richards AM. Treatment of heart failure guided by plasma aminoterminal brain natriuretic peptide (N-BNP) concentrations. Lancet. 2000;355(9210):1126–1130. doi: 10.1016/S0140-6736(00)02060-2.
    1. Yamanouchi S, Kudo D, Endo T, Kitano Y, Shinozawa Y. Blood N-terminal proBNP as a potential indicator of cardiac preload in patients with high volume load. Tohoku J Exp Med. 2010;221(3):175–180. doi: 10.1620/tjem.221.175.
    1. McLean AS, Huang SJ, Hyams S, Poh G, Nalos M, Pandit R, Balik M, Tang B, Seppelt I. Prognostic values of B-type natriuretic peptide in severe sepsis and septic shock. Crit Care Med. 2007;35(4):1019–1026. doi: 10.1097/01.CCM.0000259469.24364.31.
    1. Wang F, Wu Y, Tang L, Zhu W, Chen F, Xu T, Bo L, Li J, Deng X. Brain natriuretic peptide for prediction of mortality in patients with sepsis: a systematic review and meta-analysis. Crit Care. 2012;16(3):R74. doi: 10.1186/cc11331.
    1. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med. 2003;31(4):1250–1256. doi: 10.1097/01.CCM.0000050454.01978.3B.
    1. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, Levin A. Acute Kidney Injury Network. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11(2):R31. doi: 10.1186/cc5713.
    1. Perman SM, Chang AM, Hollander JE, Gaieski DF, Trzeciak S, Birkhahn R, Otero R, Osborn TM, Moretti E, Nguyen HB, Gunnerson KJ, Milzman D, Goyal M, Cairns CB, Ngo L, Rivers EP, Shapiro NI. Relationship between B-type natriuretic peptide and adverse outcome in patients with clinical evidence of sepsis presenting to the emergency department. Acad Emerg Med. 2011;18(2):219–222.
    1. Chen Y, Li C. Prognostic significance of brain natriuretic peptide obtained in the ED in patients with SIRS or sepsis. Am J Emerg Med. 2009;27(6):701–706. doi: 10.1016/j.ajem.2009.02.001.
    1. Leenders GE, De Boeck BW, Teske AJ, Meine M, Bogaard MD, Prinzen FW, Doevendans PA, Cramer MJ. Septal rebound stretch is a strong predictor of outcome after cardiac resynchronization therapy. J Card Fail. 2012;18(5):404–412. doi: 10.1016/j.cardfail.2012.02.001.
    1. Omland T. Advances in congestive heart failure management in the intensive care unit: B-type natriuretic peptides in evaluation of acute heart failure. Crit Care Med. 2008;36(1 Suppl):S17–S27.
    1. Sturgess DJ, Marwick TH, Joyce C, Jenkins C, Jones M, Masci P, Stewart D, Venkatesh B. Prediction of hospital outcome in septic shock: a prospective comparison of tissue Doppler and cardiac biomarkers. Crit Care. 2010;14(2):R44. doi: 10.1186/cc8931.
    1. Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, DeBoisblanc B, Connors AF Jr, Hite RD, Harabin AL. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;354(24):2564–2575.
    1. Murphy CV, Schramm GE, Doherty JA, Reichley RM, Gajic O, Afessa B, Micek ST, Kollef MH. The importance of fluid management in acute lung injury secondary to septic shock. Chest. 2009;136(1):102–109. doi: 10.1378/chest.08-2706.
    1. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med. 2011;39(2):259–265. doi: 10.1097/CCM.0b013e3181feeb15.
    1. Alsous F, Khamiees M, DeGirolamo A, Amoateng-Adjepong Y, Manthous CA. Negative fluid balance predicts survival in patients with septic shock: a retrospective pilot study. Chest. 2000;117(6):1749–1754. doi: 10.1378/chest.117.6.1749.
    1. Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, Moreno R, Carlet J, Le Gall JR, Payen D. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med. 2006;34(2):344–353. doi: 10.1097/01.CCM.0000194725.48928.3A.
    1. Maisel AS, Clopton P, Krishnaswamy P, Nowak RM, McCord J, Hollander JE. Impact of age, race, and sex on the ability of B-type natriuretic peptide to aid in the emergency diagnosis of heart failure: results from the Breathing Not Properly (BNP) multinational study. Am Heart J. 2004;147(6):1078–1084. doi: 10.1016/j.ahj.2004.01.013.
    1. Nia AM, Gassanov N, Dahlem KM, Caglayan E, Hellmich M, Erdmann E, Er F. Diagnostic accuracy of NT-proBNP ratio (BNP-R) for early diagnosis of tachycardia-mediated cardiomyopathy: a pilot study. Clin Res Cardiol. 2011;100(10):887–896. doi: 10.1007/s00392-011-0319-y.

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa