Page 130 - Biomarkers for risk stratification and guidance in heart failure

Prognostic impact of change in NT-proBNP versus change in eGFR.
INTRODUCTION
Presence of renal dysfunction (RD) is common in patients with heart failure (HF). More than 50% of patients with HF have at least mild RD defined as eGFR <60 ml/min.1 RD in the setting of HF is attributed to biochemical, hormonal, and hemodynamic factors, in association with pharmacological interventions.2 Although the pathophysiologic background for RD in HF patients is complex and only partially understood,3 presence of concomitant renal and cardiac dysfunction is associated with worse outcome. 4,5
In both acute and chronic HF, changes in renal function may occur over time. Reports about the prognostic impact of these changes are conflicting,3,6 but most studies and a recently published meta analysis do demonstrate that worsening renal function (WRF) negatively impacts outcome.7
During the last decade, the B-type natriuretic peptide (BNP) and its cleavage
equivalent N-terminal pro-B-type natriuretic peptide (NT-proBNP) have proven
to be powerful prognostic markers in both acute and chronic HF. In acute HF,
both pre-discharge (NT-pro)BNP concentration and decrease in NT-proBNP
during hospital admission were related to outcome after hospital discharge.8,9
We recently demonstrated that after acute HF admission, change in NT-proBNP concentration one month after hospital discharge was an independent predictor
of mortality, together with change in NT-proBNP during admission and the 6 absolute NT-proBNP concentration one month after hospital discharge.10 Also in
chronic, stable HF, apart from one single measurement, variation in natriuretic
peptides adds to prognostic assessment as well.11
In the setting of treating HF, clinicians may encounter conflicting prognostic information when evaluating changes in renal function and natriuretic peptides over time if they go in opposite directions. Thus, it is unclear if WRF should get more attention than lowering (NT-pro)BNP levels and vice versa. This may be of particular importance early after hospital discharge when changes in medication are very common and risk for readmission or mortality is highest. We therefore assessed the added prognostic value of changes in renal function next to changes in NT-proBNP early after hospital discharge.
129