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NDT Advance Access originally published online on December 18, 2007
Nephrology Dialysis Transplantation 2008 23(4):1370-1377; doi:10.1093/ndt/gfm700
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© The Author [2007]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org


Diagnostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) for left ventricular dysfunction in patients with chronic kidney disease stage 5 on haemodialysis

Sascha David1, Philipp Kümpers1, Vega Seidler1, Frank Biertz2, Hermann Haller1 and Danilo Fliser1

1 Department of Nephrology, Medical School Hannover, Germany 2 Institute of Biometry and Statistics, Medical School Hannover, Germany

Sascha David, Department of Nephrology, Medical School Hannover, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany. Tel: ( +49)-511-532-6319; Fax: ( +49)-511-55-23-66; E-mail: david.sascha{at}mh-hannover.de



   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
Background. Natriuretic peptides such as N-terminal pro-B-type natriuretic peptide (NT-proBNP) have become increasingly important in diagnosing left ventricular dysfunction (LVD), however, in patients with chronic kidney disease (CKD), their use is confounded by concomitant volume overload and reduced renal excretion. We hypothesized that a serum NT-proBNP cut-off value adjusted for patients with CKD could serve as a biochemical marker to detect LVD in patients on haemodialysis treatment regardless of chronic fluid overload.

Methods. We assessed LV function using trans-thoracic echocardiography and indices of hydration status such as extracellular water (ECW) using bioelectrical impedance analysis (BIA) in 62 stable patients on maintenance haemodialysis. NT-proBNP cutoff values for LVD with different specificities and sensitivities were calculated by ROC curves.

Results. We found a significant inverse correlation between LV ejection fraction (EF) and NT-proBNP levels (r = –0.77, P < 0.0001). In the multivariate regression analysis NT-proBNP was the only independent predictor of EF (r = 0.699, P < 0.0001). NT-proBNP levels were significantly higher (P < 0.0001) in patients with LVD (n = 15; 32 760 ± 6605 ng/L) compared to those without LVD (n = 47; 2835 ± 428 ng/L). An NT-proBNP cut-off value of 7168 ng/L resulted in 90% specificity and 79% sensitivity for the presence of LVD, i.e. an EF <45% (AUCROC: 0.95 ± 0.03, P < 0.0001). Furthermore, in patients with LVD we found a significant relationship between serum NT-proBNP and markers of fluid overload such as the ECW/body weight ratio (P < 0.0001) and the grade of peripheral oedema (P = 0.007), but not in patients without LVD.

Conclusion. A serum NT-proBNP cut-off value of ≥7200 ng/L discriminates CKD stage 5 patients without LVD from those with LVD. In those patients with LVD, persistent post-dialytic volume overload correlates with elevated NT-proBNP levels.

Keywords: bioelectrical impedance analysis (BIA); chronic kidney disease (CKD); left ventricular dysfunction (LVD); maintenance haemodialysis (HD); N-terminal pro-B-type natriuretic peptide (NT-proBNP)



   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
Circulating biomarkers play a major role in the early detection of cardiovascular disease such as heart failure. In recent years natriuretic peptides have become promising candidates in this respect [1]; in particularly B-type natriuretic peptides (BNP) have attracted much attention. The circulating half-life of BNP is 23 min, whereas the inactive terminal fragment (NT-proBNP) has a much longer half-life (60–120 min), which is of relevance for its use as a diagnostic tool [1]. The clinical benefit of using these markers to screen for cardiovascular (CV) risk has been well documented in the general population [1–4]. Patients with chronic kidney disease (CKD), including those with stage 5, have one of the highest CV risk scores. In this population, the clinical benefit of NT-proBNP measurements has not been well established [5–7]. The fact that patients with CKD stage 5 have significantly increased BNP and NT-proBNP levels [5,7,8] has been considered a major limitation for its use as a diagnostic tool. Elevated levels were attributed to chronic fluid overload, rendering measurements of NT-proBNP levels unreliable. However, considering the CV burden of patients with CKD [9–16], there is a definite need to explore the diagnostic value of NT-proBNP levels and to establish valid normal ranges in these patients.

Our aim was to evaluate the impact of serum NT-proBNP levels to diagnose left ventricular dysfunction (LVD) in a sizable cohort of stable patients on chronic haemodialysis (HD) without clinical signs of progressive heart failure. In particular, our aim was to determine a cut-off NT-proBNP value above which LVD can be diagnosed regardless of the actual volume status. Moreover, we correlated measurements of post-dialytic (‘dry’) body weight (BW) and NT-proBNP levels. ‘Dry’ BW may be defined as the BW at which the patient is as close as possible to a normal hydration state without symptoms of over- or underfilling [17]. Given that LV dilatation causes a rise in NT-proBNP levels [18,19], we suggest that patients on maintenance HD with LVD and chronic volume overload have the highest serum NT-proBNP concentrations [20,21].



   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
Patients
The study was approved by the Ethics Committee of Hannover Medical School, Germany. We studied 62 stable Caucasian patients with CKD stage 5 who had been on HD for at least 8 weeks prior to the study. All patients were clinically stable and gave informed consent. Patients with acute cardiac disease and/or acute cardiac failure were excluded from the study. The causes of CKD leading to terminal renal failure are shown in Table 1. Fifty-eight patients were dialysed through a native fistula and the remaining four through a central venous catheter. In the screening period, we assessed pre- and post-dialytic mean arterial blood pressure (MAP) and total ultrafiltration volume during an HD session performed after a short interdialytic interval. Blood pressure was measured according to the cuff method of Riva–Rocci and MAP was calculated accordingly. All measurements were performed twice and the means were used for analysis. The presence of oedema was assessed clinically and determined according to the following scheme: grade I—absence of oedema, grade II—mild oedema, grade III—moderate oedema and grade IV—severe oedema (Table 2). Furthermore, the clinical presentation of heart failure was assessed according to the New York Heart Association (NYHA) functional classification system [22]. Clinical data including antihypertensive medication and patients’ erythropoietin-stimulating agents (ESA) were obtained from patients’ records. Due to different treatment regimens an erythropoietin equivalent dose (EPO ED) was defined according to published recommendations [23]. The weekly dose of epoetin alpha (Erypo®) was defined as EPO ED. For darbepoetin alpha (Aranesp®) factor 176 was used in order to calculate the weekly EPO ED.


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  		Table 1 Etiology of chronic kidney disease leading to terminal renal failure

 

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  		Table 2 Four-point scale of the clinical presence of oedema

 
Bioelectrical impedance analysis
We assessed post-dialytic ‘dry’ BW by measuring the amount of extracellular water (ECW), in all patients using multi-frequency bioelectrical impedance analysis (BIA). The BIA system (Fresenius Medical Care, Germany) uses frequencies between 5 and 100 kHz. An excitation current of 800 µA is introduced at both distal electrodes and the voltage drop is detected at the proximal electrodes. Values of the total resistance (Rt), reactance (Rx) and resistance of upper and lower extremities (Ru, Ri) were obtained, and body composition was calculated using specially designed software (Nutriflex 5.1®). Total body water (TBW), extracellular (ECW) and intracellular water (ICW) as well as nutritional parameters were evaluated. This technique has been validated previously [17]. We corrected ECW values for BW (ECW/BW) in order to reduce the variability of the results. According to the ECW/BW ratio, we arbitrarily divided patients into two categories with respect to post-dialytic hydration status: low range (LR) with an ECW/BW ratio smaller than the overall median of 0.188 and a high-range (HR) group with an ECW/BW ratio higher than the overall median of 0.188 (LR <0.188, HR> 0.188 ECW/BW).

Echocardiography
In all patients a trans-thoracic echocardiography was performed on an interdialytic day in the evaluation phase. M-mode and two-dimensional images as well as spectral- and colour-flow Doppler recordings were obtained (ATL, HDI 5000). Two-dimensional imaging examinations were performed in a standardized fashion in parasternal long- and short-axis views and apical 4- and 2-chamber views according to the guidelines of the American Society of Echocardiography [24]. Left ventricular ejection fraction (LVEF) was measured using the Quinones formula from the parasternal view [25] and by the quantitative two-dimensional biplane volumetric Simpson method from 4- and 2-chamber views [24]. This procedure has been performed twice and the mean EF value was used for analysis. The investigators who performed the echocardiography were blinded with respect to the volume status and NT-proBNP level of patients examined. Left ventricular dysfunction (LVD) was defined as LVEF <45%.

Biochemical measurements
We collected blood samples from all patients during the post-dialysis session in order to correct for changes in volume status between dialysis sessions, which might also affect NT-proBNP values. The confounding effect of fluid overload before dialysis resulting in elevated serum NT-proBNP levels has been well documented previously [21]. After centrifugation (1500 rp/min, 6 min), samples were stored at –20°C until further analysis. NT-proBNP was measured using a commercially available electro-chemoluminescence immunoassay (Roche, Basel, Switzerland) that was performed on a Roche E170 modular analytics system. All other biochemical parameters, including serum albumin and high sensitivity C-reactive protein (hsCRP), were measured with routine laboratory methods.

Statistical analysis
We used the SPSS statistic software 11.5 (Lead Technologies Inc., Chicago, USA) for statistical analysis. Data are expressed as mean ± standard error of the mean (SEM). Subgroups were compared using one-way ANOVA. To compare NT-proBNP levels between different hydration groups a post-hoc Scheffe-procedure was applied. We performed correlation analysis between different variables using Spearman's correlation coefficient. In order to assess independent variables associated with LVD, i.e. an EF <45%, we performed a stepwise multivariate regression analysis using variables which were correlated with EF with a P < 0.10 in the univariate analysis, e.g. NT-proBNP, age, haemoglobin, haematocrit, left ventricular hypertrophy (LVH), diastolic dysfunction, hydration status (ECW/BW), grade of oedema, EPO ED and dialysis vintage. Finally, we calculated a receiver operating characteristic (ROC) curve in order to establish an NT-proBNP cut-off value that discriminates HD patients with LVD from those without LVD. An upper left corner location of the curve indicates a good sensitivity and specificity of a given NT-proBNP value for this purpose. A P-value below 0.05 was considered to be statistically significant.



   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
We analysed patient characteristics according to LV function and volume status (Tables 3 and 4). According to the results of the echocardiographic examination, an LV EF <45% was present in 15 patients, whereas 47 did not have LVD. All patients had increased post-dialytic NT-proBNP levels regardless of LV function, i.e. none of the patients had NT-proBNP levels within the age-adjusted reference range. The mean ± SEM NT-proBNP value was 9592 ± 2185 ng/L. Figure 1 presents NT-proBNP box plots in HD patients with LVD (32 760 ± 6605 ng/L) and without LVD (2835 ± 428 ng/L, P < 0.0001). We found a significant inverse correlation between LV EF and post-dialytic NT-proBNP serum levels (r = –0.77, P < 0.0001; Figure 2). Furthermore, a stepwise performed multivariate regression analysis showed NT-proBNP levels to be the only independent predictor for EF (r = 0.699, P < 0.0001, Table 5). All other tested variables were not significant and have been excluded (age, haemoglobin, haematocrit, LVH, diastolic dysfunction, hydration status (ECW/BW), grade of oedema, EPO ED and the dialysis vintage).


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  		Table 3 Clinical characteristics and laboratory data of patients categorized in four groups according to their hydration status and their left ventricular ejection fraction

 

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  		Table 4 Clinical characteristics and laboratory data of patients with left ventricular dysfunction (LVD, n = 15) defined as an ejection fraction (EF) <45% and with normal left ventricular function (nonLVD, n = 47)

 

Figure 1
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  		Fig. 1 Box-plots and whispers of post-dialytic NT-proBNP values in patients with left ventricular dysfunction (LVD) and patients without left ventricular dysfunction (nonLVD), P < 0.0001.

 

Figure 2
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  		Fig. 2 Inverse correlation between left ventricular ejection fraction (EF) and NT-proBNP serum concentration (log-transformed data). The correlation was highly significant (Spearman's correlation: r = –0.77, P < 0.0001).

 

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  		Table 5 Multivariate linear regression analysis (stepwise) with ejection fraction (EF) as the dependent variable. Only NT-proBNP has been identified as an independent predictor of EF

 
By creating ROC curves we identified a cut-off value for NT-proBNP that discriminates between patients with LVD and those without LVD regardless of their fluid status (Figure 3). The AUC was 0.95 ± 0.03 (P < 0.0001). An NT-proBNP cut-off value of 16 829 ng/L resulted in a 100% specificity for the diagnosis of LVD, with a sensitivity of 65%. Therefore, in our patients an NT-proBNP level above 16 829 ng/L is not solely the result of fluid overload, and all patients with such an NT-proBNP concentration showed a reduced EF on echocardiography. The sensitivity of 65% implies that 35% of the patients with an EF of <45% may show serum NT-proBNP concentrations below this level. However, for clinical routine it might be more relevant to use a value with a higher sensitivity at the expense of loss of specificity. A value of ≥7168 ng/L resulted in 90% specificity and an acceptable sensitivity of 79% in diagnosing LVD. Table 6 presents three calculated NT-proBNP values with different sensitivities and specificities.


Figure 3
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  		Fig. 3 Receiver operating characteristic (ROC) curves of serum NT-proBNP concentrations and presence of left ventricular dysfunction (LVD). A cut-off value of 16 829 ng/L has been calculated as 100% specific for the presence of LVD (sensitivity 65%). The upper left corner location of the curves indicates a good sensitivity and specificity of the NT proBNP in diagnosing LVD. The area under the curve (AUC) represents the overall accuracy of the NT-proBNP measurement (AUCROC 0.96 ± 0.03, P < 0.0001).

 

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  		Table 6 Potential NT-proBNP cut-off levels [ng/L] with different sensitivities and specificities for the assessment of left ventricular dysfunction

 
We were able to confirm [26] an inverse correlation between haemoglobin and NT-proBNP levels (r = –0.34, P = 0.01), as well as a correlation between the erythropoietin dose and NT-proBNP levels (r = 0.48, P < 0.0001).

The mean ECW/BW measured with BIA was 0.19 ± 0.005 L/kg. According to the ECW/BW ratio 32 patients were in the HR group (0.22 ± 0.03) and 30 in the LR group (0.16 ± 0.01). Oedema was present to various degrees in 39 patients; the average degree of oedema was 1.7 ± 0.9 on a four-point scale (Table 2). We found a significant correlation between the degree of oedema and the ECW/BW ratio (r = 0.49, P < 0.0001), but no significant correlation between serum–albumin levels and ECW/BW ratio. With respect to this, data on the correlation of post-dialytic NT-proBNP levels with the patients’ hydration status are of interest, and the NT-proBNP distribution for the four different hydration subgroups (separate subgroups for LVD and nonLVD) is demonstrated in Figure 4.


Figure 4
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  		Fig. 4 Relationship between serum NT-proBNP concentrations and hydration status: low range (LR) and high range (HR) subgroups. LVD–-patients with left ventricular dysfunction, non LVD—patients without left ventricular dysfunction, ns—not significant. Data are expressed as mean ± SEM.

 
In patients with LVD, the mean NT-proBNP levels in the HR group were significantly higher (39 614 ± 7064 ng/L) than in the LR group (7629 ± 2568, P <0.0001). In contrast, patients without LVD did not show significant differences in NT-proBNP levels with respect to their hydration status. Despite their NT-proBNP values being considerably higher than the reference values in the healthy population, they were significantly lower than in the LVD group (P < 0.0001). We observed a significant correlation between the grade of oedema and NT-proBNP levels (r = 0.34, P = 0.007). Interestingly, we found no differences in MAP between the different hydration groups (P = 0.138) (Table 3).



   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
In the present study, we investigated whether the natriuretic peptide NT-proBNP may be of help in the assessment of LVD in patients with CKD stage 5 on maintenance HD, since its diagnostic potential has been extensively studied in patients with normal kidney function [1–3,6]. We found clearly elevated NT-proBNP levels in our HD patients; in fact, even patients without a diagnosis of LVD showed values more than tenfold higher than the normal range given by the manufacturer. Our finding is in line with repeatedly reported increased levels of natriuretic peptides as a result of reduced renal excretion and chronic volume overload in CKD patients without LVD [5,6,20,27,28]. We have to point out, however, that a recommendation for specific reference values in order to use NT-proBNP routinely as a diagnostic tool to separate LVD from over-hydration in these patients is not available yet.

With respect to the previously demonstrated impact of NT-proBNP as a predictor of mortality in CKD patients [21], the need to define an NT-proBNP cut-off value for use in clinical practice is mandatory. As we showed in Table 6 different cut-off values have been calculated. Under routine clinical conditions it is better to sacrifice some specificity in order to increase sensitivity. We could demonstrate in our cohort that an NT-proBNP cut-off value of >7200 ng/L could be used for the diagnosis of LVD regardless of the patients’ fluid status, with a sensitivity of about 80% and a specificity of 90%. Further reducing the cut-off level to approximately 5000 ng/L resulted in an increased sensitivity (>90%) and an acceptable specificity of 80% for diagnosing LVD. As there is no harm in detecting some false-positive patients, but some harm in missing them, one might discuss the best relation between specificity and sensitivity. Still, this needs to be confirmed in larger cohorts before suggesting such cut-off values to be used in routine clinical practice. Even more so, as LVD is an important independent CV risk factor in patients on maintenance HD [9–16,29,30], such a study would be highly desirable.

We did not focus on temporary changes of NT-proBNP levels as a result of HD-related ultrafiltration, since this is not helpful in the diagnosis of LVD in patients requiring HD therapy [31]. We solely investigated post-dialytic NT-proBNP levels in order to minimise the chance of fluid overload and ideally assess levels when patients should have reached their ‘dry’ weight. Fluid status was assessed with the BIA method which has been shown to be precise and reproducible for the assessment of the hydration status [32,33]. The fact that it is time and resource intense stops it from being used as a routine procedure and makes it more suitable to assess patients’ nutritional status. Nevertheless, BIA is much better for this purpose than other tools available to establish optimal ‘dry’ BW such as doctor's clinical expertise or measurement of the diameter of the inferior vena cava, whereas patients’ symptoms such as recurrent cramps and episodes of hypotension are mostly subjective and lack a standardized, objective and easily reproducible approach [34–38]. Overall, a gold standard method to determine the ‘dry’ BW is not yet available.

Post-dialytic fluid overload can lead to arterial hypertension [39], peripheral oedema, pulmonary congestion [40] and, in the long term, to LV hypertrophy and LVD [29,41]. We assessed volume status in patients with and without established LVD by correlating their ECW content with post-dialytic serum NT-proBNP levels. We found a definite relationship between fluid status and serum NT-proBNP levels only in the subpopulation with LVD (NT-proBNP levels increased simultaneously with positive indices for over-hydration), while in nonLVD patients this was not evident. An explanation for this phenomenon could be found in the mechanism of NT-proBNP release. Since natriuretic peptides are sensitive to increased intracardiac pressures, they are more sensitive to hydration differences in patients with LVD, in whom the left ventricle cannot maintain normal filling pressures during volume overload. In nonLVD patients, the heart can, despite volume overload, maintain reasonably normal filling pressures; therefore there are no excessive increases in NT-proBNP observed.

Our approach was different in that we separately examined patients with and without LVD as compared to the study of Fagugli et al. who investigated the association of ECW and BNP only in nonLVD patients. Given that most CKD patients on maintenance HD develop LVD, such an approach is not helpful for the discrimination of patients with LVD from those who did not develop this fatal complication [27]. Further, Zeng et al. [42] studied BNP levels in patients on maintenance HD, but there was a lack of attention to the fluid status of the patients. This might explain why the reported BNP levels in their study were markedly lower than the here reported NT-proBNP levels.

The present study has some important limitations. First, measurements of ECW by BIA are established and easily reproducible, however, there is a lack of reliable ECW reference values. The standard reference range is based on the serial measurements of a healthy control population and adjusted according to age groups and gender only. Probably due to a great variation in BW, the span of normal values is up to 10 L. The normal range is therefore not helpful to make assumptions about hypo- or hypervolemia. Second, the uneven distribution of group sizes with respect to LVD is another disturbing aspect resulting from the rather small cohort of stable HD patients. Finally, outliers with very high NT-proBNP levels may have confounded the ROC analysis giving a potentially too high cut-off level.

In summary, we demonstrated that NT-proBNP may be a useful biomarker to identify LVD in a population with CKD stage 5. Further studies are warranted to confirm our observation in larger cohorts and to further validate cut-off values. Moreover, we showed an association of NT-proBNP levels with fluid overload in CKD stage 5 patients, which previously had only been confirmed by patients with LVD but not in patients without LVD.

Conflict of interest statement. None declared.



   References
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 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

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Received for publication: 9. 7.07
Accepted in revised form: 10. 9.07


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