Kidney Diseases

Prognostic Value of B-type Natriuretic Peptide for Assessment of Left Ventricular Function in Patients With Chronic Kidney Disease
Alireza Soleimani,1 Omid Nasiri,2 Hassan Nikoueinejad,3 Mojtaba Yousefzade,4 Fatemeh Foroozanfard,5 Mashaallah Tabatabaizadeh,2 Seyyed Alireza Moraveji,6 Mohsen Rajali4

1Department of Nephrology, Kashan University of Medical Sciences, Kashan, Iran 2Department of Internal Medicine, Kashan University of Medical Sciences, Kashan, Iran 3Department of Immunology, Tehran University of Medical Sciences, Tehran, Iran 4Kashan University of Medical Sciences, Kashan, Iran 5Department of Obstetrics and Gynecology, Kashan University of Medical Sciences, Kashan, Iran 6Department of Epidemiology, Kashan University of Medical Sciences, Kashan, Iran Keywords. chronic kidney disease, heart failure, brain natriuretic peptide

Introduction. Since the level of B-type natriuretic peptide (BNP) increases in heart failure, elevated plasma BNP concentration is used as a predictor in the diagnosis and management of heart failure. Due to the diminished renal clearance of BNP, its level is above normal in kidney failure. This study evaluated the BNP prognostic value for assessing ventricular function in patients with chronic kidney disease. Materials and Methods. All the participants were diagnosed with chronic kidney disease. Echocardiography was employed to assess ejection fraction. Body mass index, serum creatinine, and BNP were measured for all the patients. Prognostic value of BNP was assessed for ventricular function measured by ejection fraction. Results. Forty-four patients, including 34 men and 10 women, participated in the study. Level of BNP had a significant correlation with body mass index, ejection fraction, age, and gender. The sensitivity and specificity of BNP levels of 150 pg/mL and 705 pg/mL were 93.3% and 28.6% and 50.0% and 85.7%, respectively, for the diagnosis of ventricular dysfunction in the patients with chronic kidney disease. Conclusions. These findings suggest that a level of BNP of 705 pg/mL is a rather acceptable predictive factor for heart failure in patients with chronic kidney disease. The participants height and weight, which were associated with BNP as body mass index, contributed to this level.
IJKD 2011;5:242-7 www.ijkd.org

Original Paper

INTRODUCTION Synthesis of B-type natriuretic peptide (BNP) is done mainly by myocytes in the cardiac ventricles in response to excessive cardiac ventricular stretch and pressure overload. B-type natriuretic peptide was originally isolated from porcine brain tissue, but it is also secreted from the heart and the ventricles, in particular.1,2 Age, sex, and body mass

index (BMI) affect plasma BNP concentration 3; therefore, it is much elevated in women and old people, while plasma BNP concentration is lowered in the patients with a high BMI.4-9 Since the level of BNP increases in patients with heart failure, plasma BNP concentration and its serial analysis is used as a predictor not only in the diagnosis, prognosis, and management, but also in assessment

242

Iranian Journal of Kidney Diseases | Volume 5 | Number 4 | July 2011

B-type Natriuretic Peptide in Chronic Kidney DiseaseSoleimani et al of the severity of heart failure. Furthermore, BNP levels are elevated in the plasma of patients with diminished left ventricular ejection fraction (EF), given the clear association between the increase in the BNP concentration and reduction of EF.10-17 The other essential diagnostic value of serum BNP is its ability for assessment of patients with acute dyspnea. 18-22 Plasma BNP concentration can be applied in order to differentiate between dyspnea due to heart failure and dyspnea caused by other diseases.23 Because of helping to shorten the time to initiating appropriate treatment of heart failure as well as the duration of intensive care and hospitalization, 24 the use of BNP as a prognostic and diagnostic value for dyspnea in the emergency departments can be cost-effective and improve clinical outcomes.25 Although most often used in patients with acute dyspnea and those with established heart failure, plasma BNP may have a value in a variety of other settings. Plasma BNP concentration reveals a diagnostic or prognostic value in the patients with stable angina,26 chronic mitral regurgitation,27 restrictive cardiomyopathy (for distinguishing it from constrictive pericarditis, in which wall stretch is minimized by the thickened pericardium), 28 primary or secondary pulmonary hypertension,29 and sepsis.30,31 It is a predictor of mortality rate in heart failure and acute coronary syndromes,17,26,32 and also it was found to be a prognostic marker in patients who undergo cardiac surgery for coronary revascularization and correction of valve defects or inborn dysplasia of the heart.33,34 Plasma BNP concentration is elevated in patients with chronic kidney disease (CKD). 25,35 B-type natriuretic peptide is cleared by the receptor-mediated binding and removal, neutral e n d o p e p t i d a s e , 35,36 a s w e l l a s b y p a s s i v e excretion. Thus, diminished glomerular filtration rate (GFR) in CKD is related to elevated BNP concentrations.5,26 Such elevations may result from volume expansion due to renal retention or from left ventricular hypertrophy, which increases its cardiac release, 35 and monitoring plasma BNP does not appear to facilitate management of these patients.37 Since patients with CKD are at extremely high cardiovascular risk and frequently experience coronary events and heart failure, this increase of BNP levels has initially been considered an unwanted confounder in the diagnosis of congestive heart failure. However most recent studies have shown that BNP is also a suitable diagnostic and prognostic biomarker of heart failure in patients with CKD, 5,36,38-40 requiring, however, higher diagnostic cutoffs, whether or not they have clinically diagnosed heart failure.35-37,41 There is a consensus that the measurement of cardiac peptides is clinically useful and could be a cost-effective method of screening for left ventricular systolic dysfunction in the general population, especially if its use is targeted to individuals at high risk. 42 Although serial echocardiography is an approved method to identify and treat alterations in the left ventricular mass and function in CKD patients, echocardiography services are often available in hospitals and not in daily out-patient clinics. 43 There is much need to some simple and validated methods to clinically diagnose these abnormalities in CKD patients. In this way, BNP has been reproduced by many investigators and seems that it would be more useful in the follow-up of cardiac complications in patients with kidney disease.5,36,38-40 In addition, its serial measurements guides the prognosis and severity of therapy. 14 There is no overall agreement on the accurate cutoff of BNP in diagnosis of left ventricular dysfunction in patients suffering CKD. Therefore, we designed this study to evaluate the variations of serum BNP and to investigate the sensitivity and specificity of serum BNP in the diagnosis of left ventricular dysfunction in CKD patients.

MATERIALS AND METHODS Patients To determine the prognostic value of BNP in assessing ventricular function in the patients with kidney disease, we enrolled 60 patients referred to nephrologists complaining about kidney disease after obtaining informed consent. Patients with valve or congenital disorder (according to their angiography) and those with a level of BNP above 5000 ng/mL were excluded from the study (6 patients). In 5 patients, no serum sample was available for subsequent measurement of BNP. Three patients underwent dialysis and 2 were lost to follow up. Consequently, the remaining 44 patients were included in the study. The causes of CKD were diabetes mellitus (n=31), hypertension (n=9), and chronic

Iranian Journal of Kidney Diseases | Volume 5 | Number 4 | July 2011

243

B-type Natriuretic Peptide in Chronic Kidney DiseaseSoleimani et al glomerulonephritis, obstruction, and renal cell carcinoma (n=4). Our criterion for CKD was a GFR less than 60 mL/min calculated from the equation of Cockcroft-Gault, as follows: [(140 - age) weight in kilogram]/serum creatinine, multiplied by a constant of 1.25 for men and 1.03 for women. The EF based on echocardiography measured using the Simson method was set as an indicator for detecting heart failure; the patients were referred to a cardiologist for echocardiography. Based on the rate of EF, the patients were divided into 2 groups: one with heart failure (EF<45%) and the other without heart failure (EF 45%). Also the patients were classified according to the New York Heart Association Functional Classification.44 Demographic data such as height, weight, age, and gender were also collected. Laboratory Analysis Two milliliters of blood samples taken from each patient and kept at a temperature of 2C to 8C were sent to the laboratory within 24 hours. All the tests were done using double-blinded method in a single laboratory, under supervision of an experienced person, using a single machine. Patients sera were poured into the cuff and plasma level of BNP was measured via a commercially available immunoassay based on the Sandwich technique (Elecys pro-BNP, Roche Diagnostics, Basel, Switzerland) after 25 minutes in the laboratory. A level of BNP less than 100 pg/mL was regarded as normal. Statistical Analysis The data were analyzed by means of the SPSS software (Statistical Package for the Social Sciences, version 16.0, SPSS Inc, Chicago, Ill, USA). Initially, the t test or its nonparametric equivalent, the MannWhitney test, was used for univariable comparisons. Linear regression was employed to study the effects of nuisance variables and modeling, where a P value less than .05 was considered significant. The sensitivity and specificity of the plasma BNP in diagnosing ventricular dysfunction was assessed using a receiver operating characteristic (ROC) curve. The area under the curve represents the overall accuracy of the BNP measurement; the larger the area, the greater the accuracy of plasma BNP. A P value less than .05 was considered to be statistically significant.

RESULTS Forty-four patients, including 34 men (77.3%) and 10 women (22.7%), participated in the study. The mean weight and age of the patients were 68.45 kg and 66.77 years, respectively. The mean BMI and serum creatinine were 25.05 kg/m2 and 1.69 mg/ dL, respectively. The mean EF was 39.36%, and the mean BNP level was 747.69 pg/mL (Table). Thirty-four patients (77.3%) had an abnormal ventricular function (EF<45%), while 10 (22.7%) had a normal ventricular function. In patients with a normal EF, CKD stage was 1 in 5.8%, 2 in 11.8%, 3 in 70.6%, and 4 in 11.8%, and in those with a low EF, zero, 14.8%, 59.3%, and 25.9% had CKD stages 1 to 4, respectively. Based on the New York Heart Association Functional Classification, 35.3% of the patients with a normal EF were in stage 1, 58.8% were in stage 2, 5.9% were in stage 3, and none were in stage 4. Of the patients with a low EF, 18.5%, 40.7%, 29.6%, and 11.1% were in stages 1 to 4 of functional class, respectively. The mean of the age, weight, and height were 66.5 years, 70.4 kg, and 165.8 cm for patients with low EF and 69.4 years, 73.9 kg, and 164.9 cm for those with normal EF, respectively. The mean BNP level was 879.42 pg/mL for patients with low EF, while it was 465.40 pg/mL for those with normal EF ( P =.03). The mean serum creatinine levels were 1.50 mg/dL and 1.76 mg/dL, respectively. There was a significant correlation between BNP and BMI (P=.047). However, BNP level was not significantly associated with gender ( P =.91), serum creatinine (P=.19), or age (P=.94). In the multivariate analysis using a regression model, only BMI and EF were significantly linked with BNP levels. To determine the cutoff of BNP for predicting low EF, the ROC curve was used. The area under the curve was 0.711 (Figure). A BNP level of 584 pg/mL had a sensitivity of 70.0% and a specificity
Characteristics of Patients With Chronic Kidney Disease Variable Age, y Weight, kg Height, cm B-type natriuretic peptide, pg/mL Ejection fraction, % Serum creatinine, mol/L Body mass index, kg/m2 Mean (Range) 66.8 11.9 (42 to 88) 68.4 12.2 (43 to 95) 165.3 8.9 (150 to 185) 747.69 744.67 (26.1 to 3721.2) 39.4 15.7 (15 to 70) 1.69 0.48 (0.9 to 3.3) 25.1 4.0 (14.5 to 34.0)

244

Iranian Journal of Kidney Diseases | Volume 5 | Number 4 | July 2011

B-type Natriuretic Peptide in Chronic Kidney DiseaseSoleimani et al failure on long-term hemodialysis. They found that only BNP levels significantly increased according to the degree of ventricular hypertrophy and/or ventricular function. Therefore, BNP would be more useful for the follow-up of cardiac complications in patients with end-stage renal disease on regular hemodialysis. Nonetheless, the accuracy of BNP in diagnosing left ventricular dysfunction in CKD patients has been inconsistent. Mark and associates reported a cutoff of 42 pmol/L for BNP with a sensitivity of 82.5% and a specificity of 29.6% in CKD patients. 46 Zeng and colleagues 47 and Francesca and coworkers48 determined a cutoff of 152 pg/mL with a sensitivity of 81% and a specificity of 29.6% and a cutoff of 38.9 pmol/L with a sensitivity of 74% and a specificity of 76% in dialysis patients, respectively. The reasons for these discrepancies are some confounders affecting in determining serum BNP, including GFR, albumin, hemoglobin, beta blockade, drug therapy, and age. These confounders limit the application of BNP in the detection and monitoring of cardiac dysfunction in patients with CKD. 46 In the present study, a different level of BNP along with its sensitivity and specificity was determined. The sensitivity and specificity are 93% and 14% for a BNP of 100 pg/mL, respectively. Troughton and coworkers reported a sensitivity and specificity of 90% and 86%, respectively.14 The sensitivity given by these authors was rather identical to that of ours, but their specificity was elevated. In another study conducted by Takami and colleagues, a BNP of 150 pg/mL was inaugurated as a suitable criterion for diagnosing abnormal ventricular function in CKD patients. This level had a sensitivity and specificity of 93% and 28%, respectively.41 Given the role of BNP level in predicting heart and kidney failure, as mentioned in the previous studies, this criterion can be used in the cases above. In our study, a BNP of 705 pg/mL with a sensitivity of 50% and a specificity of 85.7% seemed to be rather acceptable and can be used as an appropriate cutoff to detect ventricular dysfunction in the patients with CKD. However, a BNP of 150 pg/mL, identified in most of the studies, seems to have a poor specificity despite its elevated sensitivity. Since this study was performed on 44 patients, further studies are advised to be done on a larger sample size. Another limitation

The receiver operating characteristic curve in assessing the diagnostic accuracy of B-type natriuretic peptide for left ventricular dysfunction.

of 71.4% and a BNP of 705 pg/mL had a sensitivity of 50.0% and a specificity of 85.7% to predict ventricular dysfunction in the patients with CKD, as measured by EF through echocardiography.

DISCUSSION Our findings suggest that BNP level is a rather acceptable predictive factor for the rate of heart failure in the CKD patients. In the general population, using serum BNP as a screening test in asymptomatic patients, a BNP concentration of 17.9 pg/mL (5.2 pmol/L) or greater, yielded a sensitivity of 77% and a specificity of 87% in all participants for a diagnosis of left ventricular systolic dysfunction.45 In another study of newly diagnosed patients with symptomatic heart failure, a BNP greater than 22.2 pmol/L yielded sensitivity, specificity, and positive predictive value for the diagnosis of heart failure of 97%, 84%, and 70%.45 The findings of our study demonstrated that BNP level in the patients with CKD and abnormal ventricular function was more elevated than that in the CKD patients with a normal ventricular function. Our results were consistent with many such as those obtained by Clerico and colleagues. 16 They measured plasma levels of atrial natriuretic peptide, BNP, pro-atrial natriuretic peptide, and pro-BNP-related peptides in patients with kidney

Iranian Journal of Kidney Diseases | Volume 5 | Number 4 | July 2011

245

B-type Natriuretic Peptide in Chronic Kidney DiseaseSoleimani et al of our study is not considering some confounding factors such as serum albumin, haemoglobin, and beta blockade that may counteract with serum BNP levels.
comparison with Doppler velocity recordings. Circulation. 2002;105:595-601. 11. Stanek B, Frey B, Hlsmann M, et al. Prognostic evaluation of neurohumoral plasma levels before and during beta-blocker therapy in advanced left ventricular dysfunction. J Am Coll Cardiol. 2001;38:436-42. 12. Maeda K, Tsutamoto T, Wada A, et al. High levels of plasma brain natriuretic peptide and interleukin-6 after optimized treatment for heart failure are independent risk factors for morbidity and mortality in patients with congestive heart failure. J Am Coll Cardiol. 2000;36: 1587-93. 13. Yoshimura M, Mizuno Y, Nakayama M, et al. B-type natriuretic peptide as a marker of the effects of enalapril in patients with heart failure. Am J Med. 2002;112:719-20. 14. Troughton RW, Frampton CM, Yandle TG, Espiner EA, Nicholls MG, Richards AM. Treatment of heart failure guided by plasma amino terminal brain natriuretic peptide (N-BNP) concentrations. Lancet. 2000;355:1126-30. 15. Jourdain P, Jondeau G, Funck F, et al. Plasma brain natriuretic peptide-guided therapy to improve outcome in heart failure: the STARS-BNP Multicenter Study. J Am Coll Cardiol. 2007;49:1733-9. 16. Clerico A, Fontana M, Zyw L, Passino C, Emdin M. Comparison of the diagnostic accuracy of brain natriuretic peptide (BNP) and the N-terminal part of the propeptide of BNP immunoassays in chronic and acute heart failure: a systematic review. Clin Chem. 2007;53:813-2. 17. Latini R, Masson S, Anand I, et al. Effects of valsartan on circulating brain natriuretic peptide and nor epinephrine in symptomatic chronic heart failure: the Valsartan Heart Failure Trial (Val-HeFT). Circulation. 2002;106:2454-8. 18. Januzzi JL, van Kimmenade R, Lainchbury J, et al. NTproBNP testing for diagnosis and short-term prognosis in acute destabilized heart failure: an international pooled analysis of 1256 patients: the International Collaborative of NT-proBNP Study. Eur Heart J. 2006;27:330-7. 19. Januzzi JL Jr, Camargo CA, Anwaruddin S, et al. The N-terminal Pro-BNP investigation of dyspnea in the emergency department (PRIDE) study. Am J Cardiol. 2005;95:948-54. 20. Bays-Gens A, Santal-Bel M, Zapico-Muiz E, et al. N-terminal probrain natriuretic peptide (NT-proBNP) in the emergency diagnosis and in-hospital monitoring of patients with dyspnea and ventricular dysfunction. Eur J Heart Fail. 2004;6:301-8. 21. Lainchbury JG, Campbell E, Frampton CM, Yandle TG, Nicholls MG, AM R. Brain natriuretic peptide and n-terminal brain natriuretic peptide in the diagnosis of heart failure in patients with acute shortness of breath. J Am Coll Cardiol. 2003;42:728-35. 22. Chen AA, Wood MJ, Krauser DG, et al. NT-proBNP levels, echocardiographic findings, and outcomes in breathless patients: results from the ProBNP Investigation of Dyspnoea in the Emergency Department (PRIDE) echocardiographic sub study. Eur Heart J. 2006;27:839-45. 23. Maisel AS, Krishnaswamy P, Nowak RM, et al. Breathing Not Properly Multinational Study Investigators. Rapid measurement of B-type natriuretic peptide in the emergency diagnosis of heart failure. N Engl J Med. 2002;347:161-7.

CONCLUSIONS Our findings suggested that level of BNP can be an appropriate predictive factor for \heart failure in the CKD patients. We proposed a BNP of 705 pg/mL with a sensitivity of 50% and specificity 85.7% as an appropriate cutoff to detect ventricular dysfunction in the patients with CKD. CONFLICT OF INTEREST None declared. REFERENCES
1. Iwanaga Y, Nishi I, Furuichi S, et al. B-type natriuretic peptide strongly reflects diastolic wall stress in patients with chronic heart failure: comparison between systolic and diastolic heart failure. J Am Coll Cardiol. 2006;47: 472-8. 2. Nakagawa O, Ogawa Y, Itoh H, et al. Rapid transcriptional activation and early mRNA turnover of brain natriuretic peptide in cardiocyte hypertrophy; evidence for brain natriuretic peptide as an emergency cardiac hormone against ventricular overload. J Clin Invest. 1995;96: 1280-87. 3. Redfield MM, Rodeheffer RJ, Jacobsen SJ, Mahoney DW, Bailey KR, Burnett JC Jr. Plasma brain natriuretic peptide concentration: impact of age and gender. J Am Coll Cardiol. 2002;40:976-82. 4. Das SR, Drazner MH, Dries DL, et al. Impact of body mass and body composition on circulating levels of natriuretic peptides: results from the Dallas Heart Study. Circulation. 2005;112:2163-8. 5. Anwaruddin S, Lloyd-Jones DM, Baggish A, et al. 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. J Am Coll Cardiol 2006;47: 91-7. 6. Mehra MR, Uber PA, Park MH, et al. Obesity and suppressed B-type natriuretic peptide levels in heart failure. J Am Coll Cardiol. 2004;43:1590-5. 7. Wang TJ, Larson MG, Levy D, et al. Impact of obesity on plasma natriuretic peptide levels. Circulation. 2004;109:594-600. 8. McCord J, Mundy BJ, Hudson MP, et al. Relationship between obesity and B-type natriuretic peptide levels. Arch Intern Med. 2004;194:2247-52. 9. Horwich TB, Hamilton MA, GC F. B-type natriuretic peptide levels in obese patients with advanced heart failure. J Am Coll Cardiol. 2006;47:85-90. 10. Lubien E, DeMaria A, Krishnaswamy P, et al. Utility of B-natriuretic peptide in detecting diastolic dysfunction:

246

Iranian Journal of Kidney Diseases | Volume 5 | Number 4 | July 2011

B-type Natriuretic Peptide in Chronic Kidney DiseaseSoleimani et al

24. Mueller C, Scholer A, Laule-Kilian K, et al. Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea. N Engl J Med. 2004;350:647-54. 25. Moe GW, Howlett J, Januzzi JL, Zowall H; Canadian Multicenter Improved Management of Patients With Congestive Heart Failure (IMPROVE-CHF) Study Investigators. N-terminal pro-B-type natriuretic peptide testing improves the management of patients with suspected acute heart failure: primary results of the Canadian prospective randomized multicenter IMPROVECHF study. Circulation. 2007;115:3103-10. 26. Richards M, Nicholls MG, Espiner EA, et al. Comparison of B-type natriuretic peptides for assessment of cardiac function and prognosis in stable ischemic heart disease. J Am Coll Cardiol. 2006;47:52-60. 27. Yusoff R, Clayton N, Keevil B, et al. Utility of plasma N-terminal brain natriuretic peptide as a marker of functional capacity in patients with chronic severe mitral regurgitation. Am J Cardiol. 2006;97:1498-501. 28. Leya F, Arab D, Joyal D, et al. The efficacy of brain natriuretic peptide levels in differentiating constrictive pericarditis from restrictive cardiomyopathy. J Am Coll Cardiol. 2005;45:1900-2. 29. Nagaya N, Nishikimi T, Okano Y, et al. Plasma brain natriuretic peptide levels increase in proportion to the extent of right ventricular dysfunction in pulmonary hypertension. J Am Coll Cardiol. 1998;3:202-8. 30. Leuchte H, Holzapfel M, Baumgartner R, et al. Clinical significance of brain natriuretic peptide in primary pulmonary hypertension. J Am Coll Cardiol. 2004;43. 31. Rudiger A, Gasser S, Fischler M, et al. Comparable increase of B-type natriuretic peptide and amino-terminal pro-B-type natriuretic peptide levels in patients with severe sepsis, septic shock, and acute heart failure. Crit Care Med. 2006;34:2140-4. 32. Koglin J, Pehlivanli S, Schwaiblmair M, Vogeser M, Cremer P, vonScheidt W. Role of brain natriuretic peptide in risk stratification of patients with congestive heart failure. J Am Coll Cardiol. 2001;38:1934-41. 33. Gessler P, Knirsch W, Schmitt B, Rousson V, von Eckardstein A. Prognostic impact of plasma N-terminal pro-brain natriuretic peptide in children with congenital heart defects and open-heart surgery. Pediatrics. 2006;148:372-6. 34. Hutfless R, Kazanegra R, Madani M, et al. Utility of B-type natriuretic peptide in predicting postoperative complications and outcomes in patients undergoing heart surgery. J Am Coll Cardiol. 2004;43:1873-79. 35. Cataliotti A, Malatino LS, Jougasaki M, et al. Circulating natriuretic peptide concentrations in patients with endstage renal disease: role of brain natriuretic peptide as a biomarker for ventricular remodeling. Mayo Clin Proc. 2001;76:1111-9. 36. McCullough PA, Duc P, Omland T, et al. B-type natriuretic peptide and renal function in the diagnosis of heart failure: an analysis from the Breathing Not Properly Multinational Study. Am J Kidney Dis. 2003;41:571-9. 37. Mueller C, Laule-Kilian K, Scholer A, et al. B-type natriuretic peptide for acute dyspnea in patients with kidney disease: Insights from a randomized comparison. Kidney Int. 2005;67:278-84. 38. Luchner A, Hengstenberg C, Lowel H, Riegger GA, Schunkert H, Holmer S. Effect of compensated renal dysfunction on approved heart failure markers: direct comparison of brain natriuretic peptide (BNP) and N-terminal pro-BNP. Hypertension. 2005;46:118-23. 39. Zoccali C, Mallamaci F, Benedetto FA, et al. Cardiac natriuretic peptides are related to left ventricular mass and function and predict mortality in dialysis patients. J Am Soc Nephrol. 2001;12:1508-15. 40. Mark PB, Petrie CJ, AG J. Diagnostic, prognostic, and therapeutic implications of brain natriuretic peptide in dialysis and nondialysis-dependent chronic renal failure. Semin Dial. 2007;20:40-9. 41. Takami Y, Horio T, Iwashima Y, et al. Diagnostic and prognostic value of plasma brain natriuretic peptide in non-dialysis-dependent CRF. Am J Kidney Dis. 2004;44. 42. McDonagh TA, Robb SD, Murdoch DR, et al. Biochemical detection of left-ventricular systolic dysfunction. Lancet. 1998;351:9-13. 43. Smith H, Pickering RM, Struthers A, et al. Biochemical diagnosis of ventricular dysfunction in general practice: Observational study. Br Med J. 2000;320:906-8. 44. The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Little, Brown & Co; 1994. p. 253-6. 45. Cowie MR, Struthers AD, DA W, et al. Value of natriuretic peptides in assessment of patients with possible new heart failure in primary care. The Lancet. 1997;350: 1349-53. 46. Mark PB, Stewart GA, Gansevoort RT, et al. Diagnostic potential of circulating natriuretic peptides in chronic kidney disease. Nephrol Dial Transplant. 2006;21:402-10. 47. Zeng C, Wei T, Jin L, Wang L. Value of B-type natriuretic peptide in diagnosing left ventricular dysfunction in dialysis-dependent patients. Internal medicine journal. 2006;36:552-7. 48. Francesca M, Carmine Z, Giovanni T, et al. Diagnostic potential of cardiac natriuretic peptides in dialysis patients. Kidney International. 2001;59:1559-66.

Correspondence to: Hassan Nikoueinejad, MD, PhD Department of Medical Immunology, School of Public Health, Tehran University of Medical Sciences, PO Box: 6446-14155 Tehran, Iran Tel: +98 913 161 5530 Fax: +98 361 555 6861 E-mail: [email protected] Received August 2010 Revised April 2011 Accepted April 2011

Iranian Journal of Kidney Diseases | Volume 5 | Number 4 | July 2011

247