B-type natriuretic peptide-directed ultrafiltration improves care in acutely hospitalized dialysis patients

• Published in: Congestive heart failure (Greenwich, Conn.) Vol. 15; no. 3; p. 131
• Main Authors: Tapolyai, Mihály, Uysal, Aşkin, Maeweathers, Gail, Bahta, Elias, Dossabhoy, Neville R
• Format: Journal Article
• Language: English
• Published: United States 01.05.2009
• Subjects: Acute Disease; Aged; Antihypertensive Agents - therapeutic use; Blood Volume; Feasibility Studies; Heart Failure - complications; Heart Failure - physiopathology; Heart Failure - therapy; Hemodiafiltration - methods; Hemodiafiltration - standards; Hospitalization; Hospitals, Veterans; Humans; Hypertension - prevention & control; Kidney Failure, Chronic - complications; Kidney Failure, Chronic - physiopathology; Kidney Failure, Chronic - therapy; Male; Natriuretic Peptide, Brain - blood; Patient Care - standards; Pilot Projects; Prospective Studies; Stroke Volume; Ventricular Function, Left
• ISSN: 1751-7133
• DOI: 10.1111/j.1751-7133.2008.00045.x

In an observational study in 19 consecutive acutely hospitalized dialysis patients, ultrafiltration (UF) volume was determined by B-type natriuretic peptide (BNP) levels. Patients were ultrafiltrated daily until they achieved a target BNP level <500 pg/mL. The UF volumes ranged from 2 to 5 L per session. All patients were male veterans aged 68+/-11 years (mean +/- SD), 74% were diabetic, 47% were African Americans, 58% underwent prevalent dialysis, and 53% had an arteriovenous fistula. Left ventricular ejection fraction on 2-dimensional echocardiography was 43.8%+/-27.9% (n=16). The admission BNP was 2412+/-1479 pg/mL (range, 561-5000 pg/mL) and BNP at hospital discharge was 1245+/-1173 pg/mL (range, 345-5000 pg/mL) (nonparametric Wilcoxon P=.0013). Admission weight was 88.9+/-27.9 kg and at discharge was 78.1+/-25.6 kg (P=.0002). The number of antihypertensive medications taken was 3.8+/-2.0 at admission and 2.3+/-1.7 at discharge (P=.0005). The number of patients with >2 blood pressure medications decreased from 14 to 6 (Fisher exact test, P=.02). The systolic/diastolic/mean arterial blood pressure decreased from admission to discharge (153.6+/-43.8/80.6+/-21.8/102.4+/-27.3 to 132.1+/-27.9/68.9+/-14.6/89.9+/-16.5 mm Hg; P=.0222/.0139/.0329, respectively). Although all patients were volume-overloaded at admission according to BNP criteria (>500), only 42% were identified as having heart failure. BNP-directed UF is safe because it minimizes symptomatic hypotension, identifies occult congestive heart failure in a large number of patients, and significantly reduces blood pressure in addition to reducing body weight and number of medications used.