Department of Nephrology, Graduate School of Medicine, Osaka University, Osaka, Japan; Division of Nephrology, Boston, Massachusetts.
Department of Inter-Organ Communication Research in Kidney Diseases, Graduate School of Medicine, Osaka University, Osaka, Japan.
Am J Kidney Dis. 2023 Nov;82(5):559-568. doi: 10.1053/j.ajkd.2023.05.003. Epub 2023 Jun 23.
RATIONALE & OBJECTIVE: Both hypervolemia and hypovolemia are associated with chronic kidney disease (CKD) progression. Although longitudinal monitoring of B-type natriuretic peptide (BNP) may aid physicians' decision making about the optimization of volume status, its clinical benefit remains uncertain in CKD. This study assessed the association between BNP monitoring and the risk of incident kidney replacement therapy (KRT).
Retrospective cohort study.
SETTING & PARTICIPANTS: A total of 2,998 outpatients with stages 3-5 of nondialyzed CKD referred to the department of nephrology at an academic hospital.
BNP monitoring.
KRT, acute kidney injury (AKI), and heart failure hospitalization.
Marginal structural models, which create a balanced pseudo population at each time point, were applied to account for potential time-dependent confounders. Inverse probability weighted pooled logistic regression models were employed to estimate hazard ratios.
At baseline, the median age and estimated glomerular filtration rate were 66 years and 38.1mL/min/1.73m, respectively. During the follow-up period (median, 5.9 [IQR, 2.8-9.9] years), 449 patients required KRT, 765 had AKI, and 236 were hospitalized for heart failure. After adjustment for time-updated clinical characteristics and physician-specific practice styles, BNP monitoring was associated with lower risks of KRT (HR, 0.44 [95% CI, 0.21-0.92]), AKI (HR, 0.36 [95% CI, 0.18-0.72]), and heart failure hospitalization (HR, 0.37 [95% CI, 0.14-0.95]). The association between BNP monitoring and KRT was attenuated after additional adjustment for AKI or heart failure hospitalization as a time-varying covariate.
Residual confounding by measured and unmeasured variables or indications for BNP measurements.
BNP monitoring was associated with a lower risk of KRT among patients with CKD that did not require dialysis. This association is potentially mediated through a reduced risk of AKI or heart failure hospitalization.
PLAIN-LANGUAGE SUMMARY: Both volume overload and volume depletion are deleterious to kidney function. B-type natriuretic peptide (BNP) is a biomarker that reflects volume status not only in heart failure but also in nondialysis chronic kidney disease (CKD). Although longitudinal BNP monitoring may aid physicians' decision making about the optimization of volume status, its clinical benefit remains uncertain in CKD. In this cohort study analyzing 2,998 patients with nondialyzed CKD, BNP monitoring was associated with a lower risk of kidney replacement therapy, acute kidney injury, and heart failure hospitalization over the follow-up period. The association with kidney replacement therapy may be mediated through a reduced risk of acute kidney injury or heart failure hospitalization. BNP monitoring may aid physicians in optimal fluid management, potentially conferring better kidney outcomes.
血容量过多和血容量不足均与慢性肾脏病（CKD）进展相关。尽管 B 型利钠肽（BNP）的纵向监测可能有助于医生优化血容量状态的决策，但其在 CKD 中的临床获益仍不确定。本研究评估了 BNP 监测与新发肾脏替代治疗（KRT）风险之间的关联。
回顾性队列研究。
共纳入 2998 名在学术医院肾内科就诊的未接受透析的 CKD 3-5 期门诊患者。
BNP 监测。
KRT、急性肾损伤（AKI）和心力衰竭住院。
边际结构模型在每个时间点创建一个平衡的伪人群，以考虑潜在的时间相关混杂因素。采用逆概率加权汇总逻辑回归模型估计风险比。
基线时，中位年龄和估算肾小球滤过率分别为 66 岁和 38.1mL/min/1.73m2。在随访期间（中位时间 5.9[IQR，2.8-9.9]年），449 名患者需要 KRT，765 名患者发生 AKI，236 名患者因心力衰竭住院。在调整时间更新的临床特征和医师特定的实践方式后，BNP 监测与 KRT（HR，0.44[95%CI，0.21-0.92]）、AKI（HR，0.36[95%CI，0.18-0.72]）和心力衰竭住院（HR，0.37[95%CI，0.14-0.95]）风险降低相关。在进一步调整 AKI 或心力衰竭住院作为时变协变量后，BNP 监测与 KRT 之间的关联减弱。
测量和未测量变量的残余混杂或 BNP 测量的指征。
在未接受透析的 CKD 患者中，BNP 监测与 KRT 风险降低相关。这种关联可能是通过降低 AKI 或心力衰竭住院的风险介导的。
