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CLINICAL RESEARCH: HEART FAILURE

Renal Function, Congestive Heart Failure, and Amino-Terminal Pro-Brain Natriuretic Peptide Measurement

Results From the ProBNP Investigation of Dyspnea in the Emergency Department (PRIDE) Study

Saif Anwaruddin, MD^_*, Donald M. Lloyd-Jones, MD, ScM, FACC, Aaron Baggish, MD^_*, Annabel Chen, MD^_*, Daniel Krauser, MD^_*, Roderick Tung, MD^_*, Claudia Chae, MD, MPH, FACC^_* and James L. Januzzi, Jr, MD, FACC^_*,_*

^_* Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois

Manuscript received June 10, 2005; revised manuscript received August 4, 2005, accepted August 9, 2005.

^_* Reprint requests and correspondence: Dr. James L. Januzzi, Jr., Massachusetts General Hospital, Yawkey 5984, 55 Fruit Street, Boston, Massachusetts 02114. (Email: JJanuzzi{at}Partners.org).

OBJECTIVES: We sought to examine the interaction between renal function and amino-terminal pro-brain natriuretic peptide (NT-proBNP) levels.

BACKGROUND: The effects of renal insufficiency on NT-proBNP among patients with and without acute congestive heart failure (CHF) are controversial. We examined the effects of kidney disease on NT-proBNP–based CHF diagnosis and prognosis.

METHODS: A total of 599 dyspneic patients with glomerular filtration rates (GFRs) as low as 14.8 ml/min were analyzed. We used multivariate logistic regression to examine covariates associated with NT-proBNP results and linear regression analysis to analyze associations between NT-proBNP and GFR. Receiver-operating characteristic analysis determined the sensitivity and specificity of NT-proBNP for CHF diagnosis. We also assessed 60-day mortality rates as a function of NT-proBNP concentration.

RESULTS: Glomerular filtration rates ranged from 15 ml/min/1.73 m² to 252 ml/min/1.73m². Renal insufficiency was associated with risk factors for CHF, and patients with renal insufficiency were more likely to have CHF (all p < 0.003). Worse renal function was accompanied by cardiac structural and functional abnormalities on echocardiography. We found that NT-proBNP and GFR were inversely and independently related (p < 0.001) and that NT-proBNP values of > 450 pg/ml for patients ages <50 years and >900 pg/ml for patients 50 years had a sensitivity of 85% and a specificity of 88% for diagnosing acute CHF among subjects with GFR 60 ml/min/1.73 m². Using a cut point of 1,200 pg/ml for subjects with GFR <60 ml/min/1.73 m², we found sensitivity and specificity to be 89% and 72%, respectively. We found that NT-proBNP was the strongest overall independent risk factor for 60-day mortality (hazard ratio 1.57; 95% confidence interval 1.2 to 2.0; p = 0.0004) and remained so even in those with GFR <60 ml/min/1.73 m² (hazard ratio 1.61; 95% confidence interval 1.14 to 2.26; p = 0.006).

CONCLUSIONS: The use of NT-proBNP testing is valuable for the evaluation of the dyspneic patient with suspected CHF, irrespective of renal function.

Abbreviations and Acronyms   BNP = B-type natriuretic peptide   CHF = congestive heart failure   CKD = chronic kidney disease   ED = emergency department   GFR = glomerular filtration rate   IQR = interquartile range   NT-proBNP = amino-terminal pro-brain natriuretic peptide   PRIDE = ProBNP Investigation of Dyspnea in the Emergency Department study   ROC = receiver-operating characteristic

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